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

- Rogue Medic

Public Perception of Pain Management

From the movie Juno comes this interesting line about pain management:

Doctors are sadists who like to play God and watch lesser people scream.

This received one of the biggest laughs of the movie. One thing about comedy is that there needs to be some truth for it to be funny – stretched to the extreme, maybe, but some truth to it.

Why do so many people believe this about doctors?

Is there any evidence to support this apparently widespread belief?

There are medical command physicians who seem to approach prehospital pain management from the Nancy Reagan perspective – Just say No!

Why?

Is there any evidence that opioids or sedatives are dangerous in the hands of trained medics?

A study in Prehospital Emergency Care (the journal of the National Association of EMS Physicians, National Association of State EMS Officials, National Association of EMS Educators, and National Association of EMTs) strongly suggested that opioids, at least, are safely used by appropriately trained medics.

Pridemark paramedics have administered IV fentanyl under standing order protocols since November 2001. The Pridemark pain management program is very aggressive and field crews receive regular continuing education related to pain management and procedural sedation. The pain management protocol states that an initial dose of 1-2 µg/kg fentanyl can be administered for pain with repeat doses at 1 µg/kg, titrated as needed. The protocol does not limit dosing intervals or maximum total dosing and the contraindications for administration include known hypersensitivity, hypotension, respiratory depression, and myasthenia gravis. The only standing order limitation during the study period was that fentanyl administration for abdominal pain required base contact.[1]

Absolutely no requirement to contact OLMC (On Line Medical Command), except for permission to treat abdominal pain.

That seems very risky!

How can medics possibly make reasonable decisions about the proper amount of medication to use?

Fentanyl is a very powerful drug. In some emergency departments the emergency physicians are not permitted to use fentanyl, since the anesthesia department has convinced the directors of the hospital that it is only safe in the hands of anesthesiologists. Certainly, there is no bias possible in that determination.

If fentanyl is not safe when used by attending emergency physicians, how can it possibly be safe in the hands of lowly paramedics?

How can simple paramedics safely administer this powerful drug on almost unlimited standing orders?

I wish that I worked as a lawyer in that crazy system – or as a mortician!

Well, let’s skip down to the results and find out the death toll.

Wait – we need to find out more about the patients first.

There were 2,315 patients who received IV fentanyl in the field; 186 patients were excluded because they received other medications such as other narcotics, sedatives, or nitrates (see Methods), thus leaving 2,129 patients who received IV fentanyl alone.

The average total fentanyl administration was 118 µg (standard deviation [SD] = 67), with a range of 5400 µg. Similarly, for the subgroup of patients who had their ED charts reviewed, the average total fentanyl administration was 118 µg (SD = 67),
The average dose was 118 micrograms?[1]

Are they trying to tell us that paramedics are starting with small doses, reassessing patients, and giving further doses only when necessary?

That just reeks of responsibility.

I don’t believe it.

Bring on the dead bodies, the malpractice, the horror!

Of the 2,315 patients who received fentanyl in the field, 66 patients had a vital sign abnormality. Of those 66 patients, three were excluded because they received a sedative in addition to the fentanyl. There were 46 patients who were excluded because their vital sign abnormalities occurred before the administration of fentanyl.[1]

66 vital sign abnormalities! Almost 3%. That sounds like something to worry about.

Of the 46 patients who had a vital sign abnormality before the administration of fentanyl, 38 patients’ vital signs improved after the administration of fentanyl, eight patients’ vital signs remained the same, and none worsened.[1]

I guess we can’t really blame the fentanyl for the problems if they happened before the fentanyl, but almost all of them improved after the fentanyl – and none of them got worse.

The medicine helped the patient, that is an interesting concept.

Bring on the less than 1% of problems left.

There have to be some serious problems and a few cadavers in there!

The retrospective chart review of 2,129 patients who were administered fentanyl citrate in the field for pain management revealed that only six patients (0.3%) had a field vital sign abnormality possibly attributed to the narcotic administration. No patients required a reversal or recovery intervention during transport.[1]

No problems outside of the hospital?

Just wait, in the hospital they will have problems!

Of the subgroup of 611 patients who had their ED charts reviewed,[1]

They only reviewed 611 ED charts out of 2,129 field administrations that were reviewed.

They must have been trying to cover something up!

Review of all 2,129 ED charts, instead of only the charts of those patients transported to a single facility, might have revealed more patients with complications. However, the sample subgroup was necessary because 2,129 patients were transported to 19 different hospitals and would have required IRB and HIPAA clearance from 19 individual facilities.[1]

Gosh, that makes sense, out of 19 hospitals they chose one that received 29% of the patients.

A nice busy hospital. They won’t put up with any of this EMS mayhem.

Let’s go back and see the carnage that must have overwhelmed the hospital!

Of the subgroup of 611 patients who had their ED charts reviewed, only seven patients (1.1%) had a vital sign abnormality that could be attributed to the field narcotic administration. The higher rate of vital sign abnormalities in the ED (1.1%) compared with the field rate (0.3%) was anticipated given the short transport times compared with the drug’s duration of action. Only one patient (0.2%) required a reversal intervention in the ED.[1]

Now we are getting some place! A victim!

That patient was an 81-year-old woman with a possible hip fracture who received two doses of 100 µg of fentanyl and developed respiratory depression, which prompted the administration of 0.4 mg of naloxone with an immediate reversal of the adverse effect.[1]

Well, maybe somebody died later – or had other serious complications!

No patient required admission for any complications of pain management, and there were no deaths. These findings demonstrate that fentanyl administration in the field is a safe method for pain management.[1]

But what about the scare tactics that are regularly employed to discourage us from using pain medicines?

Hah! I know what they missed.

They used so little that it didn’t cause any problems, but it also didn’t provide any benefit to the patients.

Where’s the benefit?

The pre-and post-pain-management verbal rating scale scores for all patients who received fentanyl were also evaluated. These data showed evidence of a statistically significant change in verbal rating scale scores after pain management. Clinically, this illustrates an improvement in pain from a categorization of severe to mild and thus supports the effectiveness of fentanyl administration.[1]

From severe pain to mild pain.

What more could you ask for?

Now that we have looked at the results it looks as if they behaved responsibly.

I would even say that they make a good case that it could be copied elsewhere.

Perhaps everywhere.

Why pretend that this study is too small to provide meaningful data; or that the methods were so limited that the results are irrelevant; or that this means it is OK, but only with tight OLMC requirements?

What this really tells us is that not only is there no good reason to limit standing orders (maybe for abdominal pain, which required OLMC in this study), but that there is a significant difference that can be made in patient care.

Why do we have medics treating patients with unsupportable limitations on what they can do without OLMC permission?

If the medics are not capable of providing this level of care, why does the medical director allow such dangerous medics to treat patients?

Why are we denying appropriate care to patients?

Why are we providing less-than-adequate care to patients?

There is no good reason.

Footnote:

[1] Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed – indexed for MEDLINE]

I also write about pain maqnagement here:

Pain Management – What is too much?

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Comments

  1. I don’t have anything to say other than “Amen.”

  2. Thank you.The Church of Appropriate Pain Management is always open to believers, converts, curious onlookers,and even those who – for one reason or another – preach that this is a false church.

Trackbacks

  1. […] This is just one example of the appropriately aggressive and safe use of fentanyl in EMS. This is much larger than the rest of the research on the topic combined. I wrote about the study, in more detail, in Public Perception of Pain Management. […]

  2. […] If only medical command were familiar with research on EMS pain management, such as I described in Public Perception of Pain Management. […]

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