Continuing from Part I. Unfortunately, with my protocols, an altered level of consciousness prohibits me from giving opioid pain medication on standing orders for burns or for musculoskeletal trauma.
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d. Patient has altered level of consciousness [1]
Isn’t the problem the severity of the pain?
If I have pain that is truly 10 out of 10, is it possible for me to NOT have an altered level of consciousness?
For example, if I were using a wood chipper and had an arm dragged into the blades before I could hit the safety bar (the orange rail around the opening), I would not expect to be able to provide reasonable answers to any of the level of consciousness questions we routinely ask.
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What is my name?
Maybe I can get that one right.
Where am I?
I’m stuck in a chipper. There might be some superfluous adjectives included in my response, but is that question really appropriate at this time?
Do I know what day it is today?
Could today be the day I engage in a bit of justifiable homicide? I ordinarily look at my cell phone to find out the date. My hand appears to be occupied, so I may not have easy access to my phone – assuming that I even want to answer the question.
We do want to know about allergies and medical conditions, but the only reason to ask level of consciousness questions is a misguided effort to treat the protocol at the expense of the patient.
Are there any signs of a head injury? That would be much more useful information than Alert and Oriented Times Three.
The truth of severe pain is that level of consciousness improves AFTER several doses of pain medicine.
We should expect level of consciousness and vital signs to improve after treatment with high doses of medications that would be expected to worsen level of consciousness and vital signs in people who do not have severe pain.
Pain medicine can be morphine, fentanyl, hydromorphone (Dilaudid, Palladone), or other opioid medication. Another possibility to help in extricating me from the wood chipper, that is less likely to produce respiratory depression, is ketamine.
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Imagine that extreme amount of pain, the pain continuing at about the same level, then having to reverse the wood chipper to get my arm out.
Do you imagine that there would be a normal level of consciousness on my part?
Is that an acceptable reason to deny me treatment?
Is that an acceptable reason to deny me treatment that will probably improve my level of consciousness?
Suppose that I had severe burns, rather than musculoskeletal trauma. Would the concern about level of consciousness be any different?
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What do you think?
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Footnotes:
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[1] Musculoskeletal Trauma 6003 and Burns 6071
Pennsylvania Statewide Advanced Life Support Protocols
7007 – ALS – Adult/Peds
Page 73/128 and Page 80/128
Free Full Text PDF of All ALS Protocols
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