Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

These authors read far too much into their limited study – Part II

ResearchBlogging.org

Continuing from Part I.

The authors do not find dramatic differences between fentanyl and morphine in their ability to relieve pain in patients who are not hypotensive. In the discussion, they begin to give their reasons for not wanting to use fentanyl.

Why?

I don’t know why they are not fond of fentanyl, but this is what they write in their discussion.

Our study opens the door for debate regarding the value of including fentanyl in limited formularies such as medical helicopters and ambulances given its higher cost and lack of any detectable advantages when compared to morphine. Whereas at our institution fentanyl costs approximately the same as morphine, costs may vary widely in other institutions.[1]

The authors state that their cost is about the same for morphine and for fentanyl, but they think that the possibility that someone somewhere might be paying a lot more for fentanyl is reason enough to limit their choices to morphine.

Both drugs are available as generics, so there does not appear to be any reason to bring a hypothetical difference in price into the discussion. Both generic drugs are affected by the current drug shortages.

If we are much more concerned about giving morphine to hypotensive patients, than we are about giving fentanyl to hypotensive patients, is that worth a bit of a premium in the price of fentanyl?

I think so. More on fentanyl and hypotensive patients in a little bit.

There is also the question of whether including fentanyl in prehospital formularies is worth the risk given its abuse potential among medical staff. Although surveillance data suggest that nationally, fentanyl is one of the least abused drugs in the non-physician population, fentanyl abuse by physicians is a well-recognized concern (24,25).[1]

The first reference does not even mention fentanyl abuse. the second reference appears to be there as a reference for the lack of abuse by non-physicians.

There is no reference for the statement that fentanyl abuse by physicians is a well-recognized concern.

Is fentanyl more of a concern than morphine?

Is fentanyl less of a concern than morphine?

There is nothing in this paper to answer that question. Are the authors using a traditional doctors’ tale an old wives’ tale?

It looks that way.

There was no detectable difference with the limited number of patients, the limited dosing of medication, and the refusal to include patients with a blood pressure that was not at least 10 points above where hypotension begins.

Patients were excluded if they reported an allergy to morphine or fentanyl, or if they were hypotensive before receiving the first dose of the study drug (systolic blood pressure < 100 mm Hg).[1]

It isn’t as if they would have been giving large doses.

It isn’t as if there is a significant concern that fentanyl will cause hypotension.

Fentanyl appears to be one of our most effective treatments for getting rid of hypotension.

There was a 47% chance that a hypotensive patient would no longer be hypotensive after a dose of fentanyl.

the safety of fentanyl as demonstrated in the current study may be related to more conservative dosing in unstable patients, but the parallel message is that experienced EMS crews are able to exercise judgment in determining which patients should receive cautious drug dosing.[2]

Should we assume that there is no judgment going into the dosing of patients?
 

experienced EMS crews are able to exercise judgment in determining which patients should receive cautious drug dosing.
 

When should we expect hypotension after giving a dose of fentanyl?

When the patient is already hypotensive.

I have written more about this study.[3]
 

The study is not a bad idea, since the information on the lack of hypotensive effect of fentanyl[2] was not yet published. However, the conclusions are not justified by the results of this study.

The conclusions may best be described as imaginative.

The authors seem to be experiencing a case of the vapors and might want to consider taking some anti-anxiety medication.

According to the available research, which is much more extensive than this study, fentanyl is very safe, even when the patient is hypotensive.

There is less evidence to demonstrate that the morphine is safe for treating hypotensive patients with pain, but that does not appear to be a concern of the authors, even though the pain of hypotensive patients should be the concern of all of us who treat hypotensive patients.

Is fentanyl expensive?

No.

Is fentanyl effective?

Yes.

Is fentanyl dangerous?

Fentanyl is one of the safest drugs we use.

The ignorance of those on the pushing end of the fentanyl syringe is what is dangerous.

The problem is not the fentanyl, but the ignorance.

Footnotes:

[1] The Effectiveness and Adverse Events of Morphine versus Fentanyl on a Physician-staffed Helicopter.
Smith MD, Wang Y, Cudnik M, Smith DA, Pakiela J, Emerman CL.
J Emerg Med. 2012 Jul;43(1):69-75.
PMID: 21689900 [PubMed – in process]

There is one unusual aspect to the study that does not appear to affect the outcome, but raises questions about how many obstacles to research we create, when the obstacles may not be valid.

The study was fully reviewed by our Institutional Review Board, and given that both treatment arms are considered acceptable practice with equal risk, informed consent was not deemed necessary for this study. Upon completion of participation, each patient was given a verbal and written debriefing of his or her study involvement.[1]

[2] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

[3] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Rogue Medic
Fri, 27 May 2011
Article

Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Rogue Medic
Sun, 05 Jun 2011
Article

Safety of prehospital intravenous fentanyl for adult trauma patients
Rogue Medic
Thu, 03 May 2012
Article

Smith MD, Wang Y, Cudnik M, Smith DA, Pakiela J, & Emerman CL (2012). The Effectiveness and Adverse Events of Morphine versus Fentanyl on a Physician-staffed Helicopter. The Journal of emergency medicine, 43 (1), 69-75 PMID: 21689900

Krauss WC, Shah S, Shah S, & Thomas SH (2011). Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia. The Journal of emergency medicine, 40 (2), 182-7 PMID: 19327928

.

These authors read far too much into their limited study – Part I

ResearchBlogging.org

There is a new study that looks at prehospital fentanyl. It starts out well, it is even randomized, blinded, and prospective, but it loses focus and draws conclusions that are not remotely justified by the study. Starting out well –

In one study looking at patients transported to EDs by ambulance with painful extremity injuries, patients who did not receive analgesics during transport waited approximately 75 min after arrival to the hospital before receiving any analgesic medication (2).[1]

This is a real problem.

Does prehospital fentanyl decrease that delay, or in other ways improve outcomes?

The authors cite several possible benefits – takes effect more quickly, is metabolized more quickly, causes less nausea, and causes less hypotension. However, they seem to ignore the last one – less likely to produce hypotension. In prehospital treatment, this is important.

They do not have many scene transports (only 16%) and they have doctors on the helicopters, so the authors’ flight service appears to take a conservative approach to treatment. On the other hand, their study protocol makes me look like Scrooge.

Each milliliter of study drug contained either 4 mg of morphine or 50 mg of fentanyl. The dosing was kept below the recommended loading doses of each narcotic to aid in blinding and allow for repeat dosing in small aliquots in the concentrations available in our pharmacy.[1]

However, that non sequitur plan appears to have worked even worse than we would expect.

Why not start out with a double dose?

The dose of morphine used in many studies is 1.0 mg/kg followed by doses of 0.05 mg/kg.

The repetition of the dose every 5 minutes should have made this not a problem, but the study protocol had a ridiculous limitation.

Each patient was allowed a maximum of five doses of the study drug.[1]

That is a maximum of 20 mg morphine or 250 µg fentanyl.

Depending on the weight of the patient, I can give more morphine or fentanyl on standing orders than these doctors can. If I reach my standing orders maximum, I can call medical command for orders to give more.

The authors even acknowledge this in their discussion.

Our initial doses correspond to 0.05 mg/kg of morphine and 0.71 mg/kg of fentanyl for a 70-kg adult, whereas others have found that sufficient pain relief required doses of 1.0 mg/kg and 1.6 mg/kg, respectively (7,20).[1]

What is the point of arbitrarily limiting the total dose?

The point certainly does not have anything to do with good patient care, since there is no evidence that any such arbitrary limit in any way improves outcomes.

If anyone knows of any research to suggest that this limitation improves outcomes, please provide it, but I do not know of any justification for this limit.
 


 

An average (mean) of 3 doses of morphine and 3.3 doses of fentanyl. That is 12 mg morphine and 165 µg fentanyl. These are not large doses, but the results show that they only had very limited success in managing pain.

Although they could start treating at a pain level of 1 out of 10, they still stopped at 5 out of ten – a pain level that would be appropriate for me to start treating with morphine or fentanyl, or to continue treating with morphine or fentanyl. I treat moderate to severe pain.

But it gets worse.

Of patients in the study, 57.5% received analgesics before being enrolled, without a significant difference between either arm. Although the medication name was recorded, the dose was not always recorded by the flight crew. Average doses of morphine, Dilaudid, and fentanyl were 4 mg, 1 mg, and 100 mg, respectively, and were similar in both arms, based on available data.[1]

Most of these patients had already received an average of one dose of study drug (or the equivalent amount of hydromorphone [Dilaudid]) prior to being entered in the study, so the pain management should have just been a continuation of treatment, even though the dose they already received had been inappropriately low for a starting dose.

Patients who reported any pain score other than zero were then given the study drug in a 1-mL intravenous bolus. Patients were then reassessed every 5 min (normal flight protocol, with automated monitor and clinical evaluation) during transport with a complete set of vital signs (including pulse oximetry) and another numeric pain score. During each reassessment, a 1-mL bolus of the study drug was given for any pain score > zero.[1]

Except that does not appear to be even close to what happened.

Although the study protocol called for administration of medication every 5 min, a mean of only three doses was given despite a mean patient care time of 40 min.[1]

A change of 13 mm on the visual analog scale and a corresponding change of 1.3 on the NPS have been generally accepted as a clinically significant change in pain relief (8,12,13). We found that both morphine and fentanyl at repeated study doses provided clinically significant pain relief by decreases in mean pain scores of 2.2 and 2.5, respectively.[1]

Yes, the difference was clinically significant, but we can do much better. Here are the details of the pain levels –

The mean pain score at the beginning of enrollment was 8.0 ± 2.0 in the morphine arm and 8.0 ± 1.8 in the fentanyl arm. The mean final pain score was 5.8 ± 2.7 in the morphine arm and 5.5 ± 2.4 in the fentanyl arm. The median initial pain score was 8, with an IQR of 3. There was no difference between the two groups. The median final pain score was 5, with an IQR of 3.5, with no significant difference between the two groups (Table 2).[1]

Starting morphine pain level from 6 to 10 out of 10.   Starting fentanyl pain level from 6.2 to 9.8 out of 10.

Ending morphine pain level from 3.1 to 8.5 out of 10.   Ending fentanyl pain level from 3.1 to 7.9 out of 10.
 


 

This is not even cutting the pain in half – this is only cutting the pain a little.

that is still important, but it could be much better.

61.5% of morphine patients and 69% of fentanyl patients had a significant improvement in pain level (≥2 according to their predefined criteria).

There were no incidences of pruritis or vomiting in either group. There were no episodes of hypotension in either group.[1]

To be continued in Part II.

Footnotes:

[1] The Effectiveness and Adverse Events of Morphine versus Fentanyl on a Physician-staffed Helicopter.
Smith MD, Wang Y, Cudnik M, Smith DA, Pakiela J, Emerman CL.
J Emerg Med. 2012 Jul;43(1):69-75.
PMID: 21689900 [PubMed – in process]

There is one unusual aspect to the study that does not appear to affect the outcome, but raises questions about how many obstacles to research we create, when the obstacles may not be valid.

The study was fully reviewed by our Institutional Review Board, and given that both treatment arms are considered acceptable practice with equal risk, informed consent was not deemed necessary for this study. Upon completion of participation, each patient was given a verbal and written debriefing of his or her study involvement.[1]

Smith MD, Wang Y, Cudnik M, Smith DA, Pakiela J, & Emerman CL (2012). The Effectiveness and Adverse Events of Morphine versus Fentanyl on a Physician-staffed Helicopter. The Journal of emergency medicine, 43 (1), 69-75 PMID: 21689900

.

Pain Management and Comfort Care

Peter Canning has been counting down the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic and he has #1 as not just pain management, but also comfort care.

In spite of all the time I spend writing about pain management, I do not spend much time on other aspects of comfort care.

When I started in EMS, I did not give morphine at all my first year. I gave it only twice for trauma in the next two years, and then in doses too small to provide relief. This is working in a busy system doing 400-500 ALS calls a year. And for vomiting patient, I never once gave an antiemetic.

“I have to hurt looking at you for you to get morphine from me,” an old school medic taught me when I started.

It’s a new day.

Last year I gave Fentanyl over 50 times, more than any other drug except Zofran, which I gave close to 100 times.

As despicable as the old school medic’s comment that he will only treat your pain to make himself feel better, am I any better when I do not give ondansetron (Zofran) for nausea.

Is ondansetron the only anti-nausea medication that we should use?

All I carry is ondansetron, but there are several other medications for nausea – promethazine (Phenergan), prochlorperazine (Compazine), metoclopramide (Reglan), and droperidol (Inapsine). Ondansetron may not be very effective when used for nausea due to vertigo (vestibular causes), but it seems to be effective for other causes of nausea/vomiting and it appears to have fewer side effects than the other anti-emetics.
 


 

A look at the need for further treatment in the emergency department after treatment by rural EMS with ondansetron.[2] As we learn more, we can adjust what we use.

Go read the rest of what Peter wrote.

Footnotes:

[1] #1 Pain Management and Comfort Care
Street Watch: Notes of a Paramedic
Peter Canning
July 17, 2012
Article

[2] Ondansetron as an effective antiemetic in the rural, out-of-hospital setting.
Benner JP, Ferguson JD, Judkins AE, O’Connor RE, Brady WJ.
Am J Emerg Med. 2011 Sep;29(7):818-21. No abstract available.
PMID: 21641151 [PubMed – indexed for MEDLINE]

.

Six EMS Phrases That Should Be Banished

At The EMT Spot, there is an excellent discussion of phrases that are used, and abused, by those of us in EMS. Here are some of these begging to be banished phrases, a few of which I view a bit differently.

“We can do this the easy way or the hard way.”

There are two reasons I dislike this tough-guy approach to patient transport. While the statement is true, it rarely convinces people to go the easy way. Something in our human DNA makes us want to rise to a challenge and this phrase is often interpreted as a challenge.[1]

You are screwed, but since I have a bunch of people to back me up, I Double Dog Dare you. Come at my army, Bro.

This may produce a response, but not a cooperative response.

Are we looking for a cooperative response, or are we looking for an excuse to play rodeo?

“Paramedics save lives. EMT’s save paramedics.”[1]

This is one of the reasons I listen to my partner, when a suggestion is made. Sometimes they see something I do not and sometimes, they will not be distracted by something that distracts me.

I know some medics who claim that everything is their responsibility, so they will not let a basic EMT interfere with their decisions, but this is silly. We still make the final decision, but artificially limiting the information we use to make that decision is not a good idea.

“Based on the mechanism of injury…”

Mechanism of injury should raise our index of suspicion. It should alert us to the possibility of injury. It should not dictate our clinical care.[1]

The Mechanism Of Injury is not the injury.

The Mechanism Of Injury is only a clue to what might be injured.

Might be –

What if . . . ?

We are supposed to ignore assessment of patients –

we are trained to assess patients –

and treat based on our assessment of vehicular damage –

but we are not trained to estimate vehicular damage.

What kind of damage equals what amount of kinetic energy delivered to an occupant?

What if the occupant is restrained?

What if the occupant is restrained and an airbag deployed?

What if the occupant is not restrained and an airbag deployed?

What if the occupant is restrained and no airbag deployed?

These are things that we should consider, but they are rarely part of Mechanism Of Injury considerations.

What about crumple zones?

Crumple zones deform to sacrifice the vehicle to protect the occupants, so they are supposed to result in a totaled vehicle, but occupants who are not injured, or occupants who only have minor injuries.


Image credit.

Do we provide pain management based only on mechanism of injury?

Of course not. That would be bad patient care.

“Pain never killed anyone.”

I hate the guts out of this phrase. And I’m embarrassed to say that it recently came out of the mouth of one of my EMS mentors. I get the truth in the statement and it’s worth considering when we talk about the prioritization of care.[1]

What truth?

For anyone who claims that pain never killed anyone, there is one obvious response –

Prove it.[2]

Why does anyone believe that pain cannot kill?

Wishful thinking?

Ignorance?

Willful self-deception?

We like to be able to justify the damage we do to patients.

It’s only pain.

For most of us, it is only pain when it is someone else’s pain.

We are using cognitive dissonance,[3] when we pretend that we are doing something good for patients when we are torturing them.

It is too dangerous to treat the pain.

Is it dangerous to treat pain if we are not competent at pain management.

If we are not competent at pain management, why should anyone trust us with any patient care?

We do cause harm in EMS, but we come up with excuses that allow us to feel that we are not really causing harm.

I only do good.

I was only following protocol.

Pain never killed anyone.

These are all deceptions.

Why can’t we tell ourselves the truth?

Footnotes:

[1] Six EMS Phrases That Should Be Banished
July 27, 2012
The EMT Spot
Steve Whitehead
Article

[2] EMS Garage Rant – Prehospital Pain Management
Rogue Medic
Fri, 24 Sep 2010
Article

[3] Cognitive dissonance
Wikipedia
Article

.

The 4 ‘Ws’ of Pain Management – a discussion at First Few Moments

On the latest First Few Moments[1], Kyle David Bates hosts Brad Buck, who through an unfortunate Skyping accident we lost, Wilma Vinton, Roland Rolfsen, Dr. Laurie Roming, and me in a discussion of the Who, What, When, and Why of pain management. Being my usual difficult self, I also mention the Where of pain management –

Too often, when I have called for pain medicine orders, the medical command doctor has asked me how far I am from the hospital. How is that relevant? Unless the patient is unstable, I am generally not moving the patient until after the pain is managed. For example, some abdominal pain is made much worse with movement, while other abdominal pain is not affected by movement.

Is it appropriate to move a stable patient before managing their pain, if the movement is going to make the pain worse?

Is EMS transport with insignificant treatment?

No.

Is EMS treatment with insignificant transport?

No. One of the ways we can make pain much worse is by driving carelessly. We do not need to transport quickly. I have transported patients at less than 15 MPH with the emergency lights on – obviously not with the siren on, since that would not be good for the patient.

Is EMS both transport and treatment?

Sometimes EMS is just transport and sometimes EMS is just treatment. Downplaying the treatment and downplaying the transport are both mistakes.

Some points that were mentioned –

1. There is no evidence that anyone can tell the difference between someone who is a drug seeker because of severe pain (kidney stones, tumor, et cetera) or someone who is a drug seeker because the person who is trying to get high.

If we do get any training on this in EMS, it is probably just a bunch of mythology. What are the instructors basing their methods on? How do they know that the patients they claims were faking actually were faking? There is a great article on this topic at Academic Emergency Medicine.[2]

2. Medication is not the only method of pain management.

3. Nitrous oxide and ketamine have different side effects from opioids.

4. Sometimes adding a sedative works much better than just giving more opioid.

5. Even hypotensive patients can be safely treated with pain medicines.
 

There was a 47% chance that a hypotensive patient would no longer be hypotensive after a dose of fentanyl.

the safety of fentanyl as demonstrated in the current study may be related to more conservative dosing in unstable patients, but the parallel message is that experienced EMS crews are able to exercise judgment in determining which patients should receive cautious drug dosing.[3]

Should we assume that there is no judgment going into the dosing of patients?
 

experienced EMS crews are able to exercise judgment in determining which patients should receive cautious drug dosing.
 

When should we expect hypotension after giving a dose of fentanyl?

When the patient is already hypotensive.

I have written more about this study.[4]
 

Go listen to the podcast.

Footnotes:

[1] The 4 ‘Ws’ of Pain Management: a discussion – Episode 40
First Few Moments
13 Jul, 2012
Podcast

[2] Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract available.
PMID: 19298618 [PubMed – indexed for MEDLINE]

Free Full Text at Academic Emergency Medicine

[3] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

[4] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Rogue Medic
Fri, 27 May 2011
Article

Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Rogue Medic
Sun, 05 Jun 2011
Article

Safety of prehospital intravenous fentanyl for adult trauma patients
Rogue Medic
Thu, 03 May 2012
Article

.

Comment on What is a Holistic Pain Management Doctor? from Divemedic

Divemedic of the wonderfully named Confessions of a Street Pharmacist
responds to my criticism of the failure of pain management by someone who preaches that real medicine is evil.[1]

I attended a medical seminar that actually made a few valid points about placebo treatments, which included holistic medicine and “sugar pills.”

Alternative medicine treatments are also placebo treatments, but that oversimplifies things. In addition to placebo, alternative medicine depends on misdiagnosis, reversion to the mean, and spontaneous remission – not just placebo responses.

When we study treatments, we lump too much into the placebo responses.

We include misdiagnosed patients. If I did not have the illness, then I am found to still not have the illness, I did not get better. My diagnosis only became more accurate.

We include patients who will have reversion to the mean – they have deviated from the norm as much as they are going to, so they will only improve.

We include patients who will have spontaneous remission – they are starting to get better on their own.

Improvement does not mean the study drug did it and it does not mean the placebo did it.

These false response groups are in the treatment group and these false response groups are in the placebo group. They are not placebo effects and they are not drug effects.

What is due to placebo and what is due to misdiagnosis?

What is due to placebo and what is due to reversion to the mean?

What is due to placebo and what is due to spontaneous remission (the immune system at work)?

We need better studies to learn a lot more about these effects and about placebo effects.


Image credit.

I have to say that a few good points were made, and I felt they were well grounded in science. For example, the lecturer pointed out that there are many cases where people being treated with placebo medications had better outcomes than people who received no treatment at all.

If we tell our children that we are kissing a boo boo to make it better, we are providing a placebo. We may only be distracting them from the injury, or the illness, until they get better, but having somebody care does seem to make a difference. Being distracted makes the time pass with less discomfort, but that is not magic.

Distraction is the absence of focusing on the illness, or the absence of focusing on the injury. Distraction is not healing.

Distraction is avoiding having the mind add stress to the condition.

And the big problem with placebos is that we tell someone that we are providing a treatment, when we are really deceiving them. We are confounding their expectations.

. . . there are cases where the medication study group is said to be ‘no more effective than the placebo group.’

Those medications that are not shown to be better than placebo are medications that never should have been approved to begin with. Or they are medications that are not approved.

Failing to work better than placebo means that the medication is a placebo.

This would lead one to believe that the power of the mind plays a part in patient outcome, and this should not be summarily dismissed or ignored.

Stress is a bad thing. The brain releases stress hormones. Interrupting that may be what placebos do best.

It is a mistake to give credit to placebo for things that we do not know.

What amount of harm is caused by placebo? If we do not know, then how can we recommend a placebo?

How can we claim to be ethical if we lie to patients?

How do we obtain informed consent for a placebo?

We do need to have a better understanding of what the benefits and harms are of placebo, just as with any other treatment. Until we do, it is not any better than any other new not well understood drug that people get excited about, even though we don’t know enough to make informed decisions.

We all know that the nervous system plays a role in healing, through hormones like cortisol, and other factors that remain undiscovered.

We know that cortisol is harmful. Relaxation seems to decrease the release of cortisol, so the placebo effect may be just a decrease in the power of the mind to harm the body. A lot of the placebo effect may be just turning down the self-destruction of the body, not any actual healing.

As medical practitioners, it is something that I feel we need to investigate. However, it is silly to wed ourselves to any treatment, unless that treatment is the one that is best suited to our patient’s care and recovery.

The way we learn what is best for patients is to study the response of patients to a treatment. If the treatment does not work in controlled circumstances, there is absolutely no reason to believe that some magic kicks in when we are not paying attention.

We need to know more about placebos, but exaggerating the usefulness of deceiving patients is not a good thing.

If we are supposed to obtain informed consent, what are the ethics of misleading patients?

Footnotes:

[1] What is a Holistic Pain Management Doctor?
Rogue Medic
Sat, 16 Jun 2012
Article

.

What is a Holistic Pain Management Doctor?

A woman being treated for a painful condition is refusing pain medicine, because it conflicts with her beliefs. That is her choice, but she is reported to be in school learning to treat people for pain without pain medicine. Her pain is her responsibility, but how much is she responsible for the pain she causes her patients?

Aimee Copeland reportedly “despises” the opiate pain killer morphine, even though it is the most effective treatment for her specific pain.[1]

Does she understand what is an effective treatment for her pain?

Or does she have a different belief system – one that appears to value appearances more than efficacy?

Her beliefs stem from her graduate study in holistic pain management techniques. In Aimee’s eyes, taking painkillers would make her a “traitor to her convictions.”[1]

She is learning to treat pain with what? Wishful thinking? Something else? I don’t know.

How would she treat a patient who does not have such a high tolerance for pain?

She is an adult and apparently has the capacity to make informed decisions for herself, but will she be using this experience to discourage people with severe pain from using pain medicine to treat their pain?

For many in alternative medicine, the explanation for the continual failure of treatments is to blame the patient. You just didn’t believe enough!

They claim that this unethical abuse of patients is somehow more ethical than using treatments that really do work.

Holistic nurses may integrate complementary/alternative modalities (CAM) into clinical practice to treat people’s physiological, psychological, and spiritual needs. Doing so does not negate the validity of conventional medical therapies, but serves to complement, broaden, and enrich the scope of nursing practice and to help individuals access their greatest healing potential.[2]

It does not appear that these holistic pain management practices come close to working, even for her. That failure does not stop her from believing in them. Perhaps she takes large doses of cognitive dissonance.[3]

Cognitive dissonance is the way the mind copes with the conflict, when reality and belief do not agree, and we choose to reject reality.

“The area of her wound, which I saw for the first time on Sunday during a dressing change, is massive,” her father wrote in Friday’s update.

“The nurse who completed Aimee’s dressing change was astonished at Aimee’s insistence to avoid morphine during the procedure, as was her mother and I,” he wrote. “I know the pain was significant, but Aimee’s courage is greater.”[4]

She does not seem to be managing the pain. She only seems to be avoiding the pain medicine.

How helpful will she be in treating pain when it is not her pain?

Will she discourage patients from taking pain medicine?

Will she consider herself a “traitor to her convictions”, if she does not do everything possible to discourage a patient from taking pain medicine?

Since acupuncture, reiki, homeopathy, and other alternative medicine treatments do not consistently do better than comparable placebos, should we describe this as some sort of courage, or should we just point out that this is a misinterpretation of reality?

She could have effective pain relief with pain medicine. Maybe morphine is not the best pain medicine for her, but if morphine is not working well, there are many other med pain medicines available – hydromorphone, fentanyl, alfentanyl, sufentanyl, droperidol, ketamine, propofol, and others.

Why limit the choices to placebos?

More important – why limit patients’ choices?

If she wants the increased stress from untreated pain/placebo treated pain, that is up to her.

How is all of the increased stress from inadequately treated pain in any way holistic?

Footnotes:

[1] Flesh Eating Bacteria Victim Aimee Copeland Refuses Pain Meds
Submitted by Zach Lisabeth on Jun 15, 2012
Opposing Views
Article

[2] What is Holistic Nursing?
American Holistic Nurses Association
Article

[3] Cognitive dissonance
Wikipedia
Article

[4] Woman with flesh-eating disease refusing pain medications
USA Today News
Article

.

How to Torture Patients

Perhaps, you have watched all of the parts of Saw and wished that you could have some of that kind of fun, too. Even though we are supposed to be having the opposite effect on patients, some of us do cause that kind of pain and psychological abuse.

Dr. Weingart gives us a piece of his mind on this topic in Pain and Terror as Effective Pressors.

Does this go well with scrubs, or with an EMS uniform?
 


Image credit.

But what about the hypotension and hypoxia that occur with fentanyl?


Click on images to make them larger.[1] [2]

There is a 97% chance that, after administration of fentanyl to a critical trauma patient who is not hypotensive, the patient will still be not hypotensive.

There is a 47% chance that, after administration of fentanyl to a critical trauma patient who is hypotensive, the patient will stop being hypotensive.

If we did not have so much anxiety about fentanyl, we might consider making it the standard of care for hypotension following trauma.

Should we be double-teaming these patients with both pain and the terror of awareness during intubation with a long-acting paralytic? It probably isn’t any worse than what the traumatically paralyzed patient experiences with intubation, but that should only encourage us to be more aggressive with pain management for these patients. This is not an excuse to be tolerant of iatrogenic pain and anxiety.

Pain management in EMS seems to keep improving, but we still have a long way to go.

Pain management in the ED (Emergency Department) seems to keep improving, but we still have a long way to go.

I currently do have a protocol that allows me to give post-intubation sedation. This was only added to my protocols in the past 5 years, but it is a start. Before that, medics had to be aggressive enough to ask for medical command permission for a treatment that was outside of protocol. Treatments that are outside of protocol are discouraged.

The problem with post-intubation pain (and the expected agitation that goes with pain) this pain management sedation is not a recent development.

In an earlier podcast, Dr. Weingart describes the problems with using sedatives, rather than pain medicine, for post-intubation PAIN.

EMCrit Podcast 7 – Sedation Tirade – and listen to his other sedation podcasts.

Why do we think that a patient does not have pain unless that patient is writhing in pain?

With a paralytic on board, especially a long-acting paralytic, and even more so with a large dose of a long-acting paralytic, these patients will not writhe.

This brings up some questions –

How much evidence do we need that many of our patients are in a lot pain?

How easy is it to ignore the severe pain of our patients?

I do have one criticism.

The dose of sarcasm could be increased. This is no time to be stingy with the sarcasm treatment. I could be wrong.

Go listen to the brief Wee podcast and decide for yourself.

Footnotes:

[1] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

Fentanyl Study: EMS Research Episode 9
EMS Research Podcast
Podcast page

[2] Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Sun, 05 Jun 2011
Rogue Medic
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