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

- Rogue Medic

The Medical Command Permission Ruse I

Ruse – ▸ noun: a deceptive maneuver.

When using the term Medical Command Permission Ruse, I am using ruse to describe the role of requirements for medical command permission. The ruse is the suggestion that medical command permission requirements protect patients.

Where is there any evidence to support this? The requirement for medical command permission is only a deceptive maneuver to give the appearance of doing something to protect patients. It allows medical directors to protect their ignorance unfounded fears from exposure. If they required competence from paramedics and encouraged appropriate pain management, they should not feel any need for these restrictions.

Have you ever tried to treat a patient with legitimate severe pain, but you were refused orders for morphine?

How does refusing appropriate pain management help the patient’s severe pain?

Have you ever tried to treat a patient with legitimate severe pain, but you were only given orders for 2 mg of morphine?

How does refusing appropriate pain management help the patient’s severe pain?

Have you ever tried to treat a patient with legitimate severe pain, but you were only given orders for 2 mg of morphine with the possibility of one, and only one, repeat of the same dose?

How does refusing appropriate pain management help the patient’s severe pain?

And yet, doctors continue to use these medical command permission requirements to restrict the amount of morphine a patient may receive.

To be fair, there are plenty of medical command physicians who give appropriately aggressive orders for pain management. I have not had many medical command physicians refuse to give orders for morphine for severe pain, but some is still too many.

More often, I have had medical command physicians hesitant to give more than 2 mg of morphine and maybe a repeat if the initial homeopathic dose does not produce a miracle. Perhaps the simple formula below will explain this.

Severe Pain + 2 mg Morphine = Severe Pain.

When treating severe pain in otherwise healthy adults, the starting dose of morphine should be 5 mg or 10 mg, but that is just the starting dose. For one patient who had a couple of fingers amputated, 20 mg of morphine brought his pain all the way down from 10 out of 10 to the almost indistinguishable 9.8 out of 10. He weighed 70 kg, so this was not a size thing.

The only competent way to tell if the dose is appropriate is to reassess.

For that patient, 20 mg of morphine was not close to enough. Unfortunately, the flight nurse and flight medic were not comfortable giving this awake and alert patient with severe pain any treatment for his severe pain because he had already had so much. They should have been more worried about his severe pain being so much.

The only competent way to tell if the dose is appropriate is to reassess the patient, not to reassess the dose or to reassess the protocol.

Discouraging pain management should be an embarrassing part of EMS history, but it still exists and it is still defended. This needs to stop.

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