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