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

- Rogue Medic

How EMS Manages Pain

In my last post Burns and Pain and Little Kids, I wrote about a case of bad pain management.

The comments included a lot of discussion of how EMS handles pain management.

I was talking with another medic and the topic of pain management came up. Not the first time that has happened.

One of the problems in EMS is that medics are trained to believe that morphine is some dangerous, magical drug that will sneak in on little cat paws and steal your patient’s breath away. This is told to us by doctors, nurses, and other medics – even non-medical personnel.

We frequently treat respiratory depression in EMS. And we often overreact when we do.

Overreact?

Read Ambulance Driver‘s article on EMS1.comThe Airway Continuum. The comparison between airway management and police use of lethal force is a useful one. Why do we automatically leap to the most invasive approach to airway management?

Conversely, why do we leap to the paranoid expectation of respiratory depression and respiratory arrest, when dealing with pain management?

This is an EMS version of an Urban Legend.

A site that is devoted to finding the truth about urban legends is Snopes.com. We have some people who provide the EMS version of urban legend debunking. AD does that, but he does not go far enough in this article. Not that he might think he exhausted airway management in this one article. AD could go on for days with only a pause for something to whet his whistle. And it would be entertaining, even if he does occasionally plagiarize himself.

Airway management is far more complex than “Intubate ‘Em All and Let Respiratory Sort ‘Em Out.” EMS protocols often do not acknowledge this.

Another problem with the use of morphine is the rush to use naloxone when there is any uncertainty about the patient’s respiratory status. This questionable nature of the respiratory drive should encourage a much more conservative approach. AD discusses this in Naloxone: The Most Abused Drug in EMS.

Pain management is also a far more complex treatment than “One Dose Fits All.” It is also something where “One Drug Fits All,” does not apply. Morphine is commonly used to manage pain, but it is far from a good drug for EMS. The big thing morphine has going for it is Tradition!

But the worst tradition associated with morphine is the dosing. If you are good, you may receive orders to treat an adult with 2 mg morphine. If you are really good you may receive orders to repeat that dose One Time. At least from some OLMC doctors.

The Danger.

The Peril.

The Horror.

There are some big problems with this approach. Pain management is not about rewarding paramedics with aggressive doses for good behavior. These doses that aren’t really even close to aggressive.

Pain management is about providing appropriate care for the patient.

Why is it that paramedics have to fight with some OLMC (On Line Medical Command) physicians for permission to appropriately treat patients?

Why are some doctors such vigorous opponents of appropriate pain management?

Why are some doctors such vigorous opponents of appropriate patient care?

Opponents of appropriate patient care? How can I say that about doctors?

A patient in moderate to severe pain.

A patient with no real contraindications to morphine (if hypotensive, no real contraindications to fentanyl).

A patient who will benefit from the treatment.

A patient too often denied appropriate pain management.

A patient too often denied any pain management.

Now, back to my talk with my friend.

He had a patient with a probable hip fracture. His partner insisted on calling OLMC for orders, even though they have standing orders. OLMC gave orders for 4 mg of morphine – much less than is available on standing orders.

Here are the standing orders for isolated extremity trauma:

ANALGESIC MEDICATION OPTIONS
(Choose one)
Fentanyl 50-100 mcg IV/IO 6,7 (1 mcg/kg)
may repeat ½ dose every 5 minutes until maximum of 3 mcg/kg
OR
Morphine sulfate 2-5 mg IV 6,7
(0.05 mg/kg)
may repeat dose every 5 minutes
until maximum of 0.2 mg/kg
OR
Nitrous Oxide (50:50) by inhalation 8

If we assume that the patient weighs 50 kg (110 pounds), then the standing orders would allow for the patient to receive 10 mg of morphine before having to call command for orders to give any more pain medicine. Not that those orders are likely to take into consideration that the patient is still in pain after 10 mg of morphine – only the “recklessness” of requesting to give more than 10 mg. This is the world of EMS pain management. Pain management isn’t about the patient. Pain management isn’t about appropriate care. Pain management is commonly about treating medical command for discomfort.

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

Look at the standing orders again. In the system where he works, the medical director does not allow them to carry nitrous oxide or fentanyl. The medical director does not appear to have any plans for EMS to carry these drugs. The medical director does not encourage the use of the pain management standing orders.

One way that the medics are discouraged is by being labeled “Too Aggressive.”

I once did some ride time with them and was told that they did not want to hire me because some of the medics I rode with said I was too aggressive and others said I was not aggressive enough.

My interpretation of that was that I am Goldilocks’ porridge. Their interpretation was lacking in literary reference. They probably would have labeled me an Upstart.

You can see where the problem is in EMS. When it comes to pain management, it isn’t about patient care. There are several other things that are considered before the well being of the patient is considered. The other things that are considered can all veto the standing orders.

Then there is the problem of pain that is not due to an extremity injury. If the pain is not from an isolated extremity injury, then the pain is categorized as “too risky” to treat.

Not that this is based on research, these are doctors after all, their expert opinion is to “That’s the most foul, cruel, and bad-tempered medicine you ever set eyes on!” and “Look, that morphine’s got a vicious streak a mile wide! It’s a killer!” and “He’s got huge, sharp… er… He can leap about. Look at the breathing!”

It is true, the bunny in Monty Python and the Holy Grail was a killer. At times morphine can produce respiratory depression that can be a killer, too. Just not when well trained medics use it to appropriately treat their patients’ pain. Titrating the dose to the patient’s pain. The well trained medic is the Holy Hand Grenade of Antioch that counters the respiratory depression from a larger than appropriate dose of morphine, or any opioid.

If only the medical director would insist that the medics be competent in the use of the medications that the medics carry, instead of discouraging the use of the unpopular ones.

.

Comments

  1. The Holy Handgrenade of Antioch? I am so going to use that one!I will never understand why people are so afraid of morhpine. I gave a lady with an obvious hip fx 6mg of MS w/o any trouble and it relieved her pain and anxiety for the bumpy ride to the ED. She did fine, no keeling over, no nothing. If it did anything it made her a little funny cause she said whatever was on her mind. But when I passed on to the nurse what I gave her the nurse about had a stroke. I don’t see the problem. The patient didn’t have any trouble. I guess the point for us as providers is that we should be able to use critical thinking and judgement. We should be well versed in our meds and their effects. The medical directors and in some places the regional council needs to step in and remove the providers that don’t meet the standard. We all have bad days and we all make mistakes. I am talking about the consistent screw-ups, and the ones that all the other firemen or medics are afraid of. This is going to get me started on appropriate assessment and decision making skills. I feel another post coming on. If I was as cool as AD I could plagarize myself!

  2. Admittedly in the UK, but I’m an “Advanced First Aider” with St John Ambulance – a voluntary first aid organisation. I’m not (yet) qualified to crew an ambulance, but even I can give Entonox, and as far as my training goes, there are very few contraindications for its use. What’s the medical director’s logic (and there’s the flaw) in stopping you from carrying it?

  3. Gertrude,Perhaps, after a stroke, that nurse’s brain would function better.Not to wish strokes on nurses, or even to lump most in with this unthinking one.The appropriate response to a dose that one is “uncomfortable” with, is to assess/reassess the patient. The patient’s presentation will tell you if the dose was “excessive.”We need to be requesting that the medical directors remove the turds of EMS. Unfortunately, in many places, being critical of another EMS provider is seen as bad – being publicly, or officially critical, that is, not the slander we exchange whenever two or more EMS providers are together.Medics begin to fear for their own job safety and circle the wagons.

  4. Chris,Entonox (nitrous oxide) is a safe and effective drug that can be safely administered by BLS personnel. In the US, there is a great fear of abuse. Many medical directors would rather deny their patients treatment, than set up a system that provides for accountability when treating patients with nitrous oxide.Then, there is the fear of making everyone giddy in the enclosed environment in the back of an ambulance. Imagine having a functional ventilation system in the back.Logic rarely enters into decisions about pain management.

  5. I agree that there would be much manning of the battle stations if medical directors started culling the herd. Still these people get away with things that would get me canned. I mean I was actually told that Some us of are held to different standards. WHAT?? Seperate but equal? horse hockey is what I say to that. I opened up a fresh can o’ worms on my blog about medic programs. Sadly I don’t think I had a single witty movie reference in the whole thing.

  6. Oooh, you’ve touched on one of my pet peeves.Pain relief is one of the few things that ALS is good for, yet so many doctors quake in fear of even a homeopathic dose of morphine.When ordered to administer 2mg of morphine to a 26 year old with a femur fracture, I told the doc (one I knew well, and even liked), “Soooo…you want me to read him a bedtime story? Because it would do just as good as 2mg of morphine, and involve a helluva lot less paperwork.”There was a long pause, followed by a chuckle. “Forgot who was asking, AD. Give him whatever you think he needs, titrated to comfort.”It’s easy for me to be fearless and borderline insubordinate, because I’ve had the luxury of working in medium sized systems where I knew the vast majority of the ER docs personally.I can’t imagine what it would be like working where you do, when you’re just a voice on the radio to the doctors, most of whom have no idea what you’re capable of doing.

  7. AD, One of the doctors, Dr. No Narcs, would not give any orders for any morphine to anyone, ever. I knew him well, being based at his hospital. Arguing with him has repeatedly proved pointless, but he is the director of the ED.The receiving hospital is as you describe, nobody knows anyone.Usually, I just work my boundless charm on them. :-)I have rarely been turned down for orders and am usually able to talk them into giving orders for more than I need. Better to have the orders and not need that much than to need to keep calling. Being able to cite research is something that has worked pretty well for me. Also, telling the doctor I am aware of the concerns and am prepared to deal with any problems, before the doctor mentions these concerns is something that is apparently reassuring to them. That, being comfortable debating patient care with doctors, an inability to take no for an answer, and the repeated demonstrations of abuse of horseflesh seem to help.

  8. I often toss in Three Stooges references in forum posts, but I’m very, very, impressed that someone actually was able to get a Marx Brothers reference in a blog post. As far as the post itself goes, I agree in part and dissent in part. Before we had protocols to treat non cardiac pain with narcotics, I often regretted not being able to give MS for burn patients. Compared to the pain of a burn, just about everything else is a distant second. Our protocol for pain management in burns is this, Morphine Sulfate 2.0- 10.0 mg SLOW IV PUSH or Fentanyl 1 mcg/kg. to max. 150 mcg. slow IV push or,• If no IV access, Morphine Sulfate 2.0 mg – 10.0 mg IM/SQPersonally, I tend to the top end of the dosing scale. In 28 years in EMS, I’ve never seen anyone stop breathing from a dose of MS. Unlike other parts of the country, we get our medical control from one facility. Our medical director is on staff in the ED as part of his being medical director. Many of the more senior medics are on a first name basis with the attendings. As a result, we are very rarely turned down on the rare occasions when we have to get an order. Since I work in a tiered system, we don’t send ALS on every call. As a result, a majority of the orthopedic injuries that all ALS systems would send a paramedic on, we don’t. Some would say that as a result we under treat pain, and that’s possible. It’s a trade off though. If we were all ALS, I don’t think the skill level of the medics would be nearly as high as it is. Greater good for the greatest number of patients? I think so. Gary

  9. Gary, The Marx Brothers have so much material, that it seems natural to me. Before <a HREF="http://www.imdb.com/title/tt0093779/” REL=”nofollow”>The Princess Bride and SNL, they were providing me with the essential quotes for all occasions.With a 10 mg top of the dosing scale, how do you not regularly max out, unless you are dealing with sun burn? :-)One county I used to work in had no standing orders for pain, but I was often able to convince the doctors to give much higher doses and would give 30 mg once, or twice, a year. The only patient with respiratory depression was less than 50 kg, but by keeping her talking, she was able to avoid any problems from the doses of morphine. Her mother was going to be with her the whole time and I told her to keep her daughter talking and to not trust the staff to monitor her, with such a large amount of morphine on board. It is possible to overshoot a bit, but this should not require ALS reversal of the morphine. Whether it would have resulted in respiratory arrest without this “intervention,” I don’t know. Fentanyl would have been a much more appropriate drug, because it wears off so quickly. Or, did you mean that when adding doctor ordered morphine to the 10 mg standing order dose, you have never seen respiratory arrest?I have no problem with tiered response. I agree that it should lead to better skilled medics. There are several ways of dealing with that, one being to dispatch ALS to ortho calls and encourage BLS to recall ALS quickly, if there does not appear to be a need for pain management. Of course, this would require some critical judgment skill use by BLS, which might make some people uncomfortable. This could allow the medics to develop more experience with pain management.

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