Pain Management - Is It An Important Focus Of Medical Care?

[ParamedicFNPwantabe]

As a current Paramedic working on transitioning to the dark side I read the following article and thought does nursing or any other medical profession really not understand the importance of pain management or is it really just an EMS problem? Having been a patient as well as an EMT and now a Paramedic I have experienced a number of different attitudes towards patients pain both prehospital and in hospital. So I guess really I am interested on what to expect as I advance in my education and move indoors in regards to pain management.

I also hope the article might also give you as a Nurse an ideal of why the patients you see brought in by ambulance may not all be treated the same way for the same injury or illness.

http://www.associatedcontent.com/article/5930346/is_an_ambulance_an_ambulance_the_differences.html?cat=5

[ZippyGBR, BSN, RN]

I'd be interested to note what 'critical symptomology' is masked by appropriate pain relief ( vs snowing the patient to next february)

From my right-pondian perspective it seems that pain management is a neglected field in the US

All our A+E ambulance crews have access to analgesia - middle tier, volunteer and techs to entonox and (in some places) paracetamol

paramedics and ECPs routinely carry IV tramadol and/or Morphine and increasing numbers of services are carrying oramorph as well , plus they've got entonox and paracetamol ( and possibly a NSAID depending on drug protocols)

all these meds are given on the practitioner's own determination and inthe case of Paramedics it is legally enshrined as part of the legislation that governs Paramedics in the UK.

adequate analgesia is a integral part of patient care.

[linearthinker, DNP, RN]

I do t want a paramedic making any determination about my neuro status. I just want them to drive me to the ED.

[leslie :-D]

Not trying to be rude, but can you name one example of a critical symptom that is masked by appropriate pain management that can NOT be discovered by other means which are routinely also done for the complaint as it presents? Or are we just buying into old-school surgeons "trained hands" BS?

well, other than r/o appendicitis and other gi issues, i am thinking of a hospice pt i had, who has since died.

he was on painkillers for lower back pain, which his pcp generously prescribed.

pt's speech became more slurred and garbled.

this was attributed to heavy doses of painkillers.

turns out this guy had brain tumor.

by time it was officially dx'd, it was too late for treatment.

he died at 37.

leslie

[leslie :-D]

adequate analgesia is a integral part of patient care.

as a hospice nurse, i couldn't agree with you more.

but there are exceptions, when immediate analgesia is not advisable.

that's all i was saying.

leslie

[CrufflerJJ, BSN, RN, EMT-P]

I do t want a paramedic making any determination about my neuro status. I just want them to drive me to the ED.

I don't want a CCRN making any determination about my neuro status. I just want them to hold my hand until I'm evaluated by a physician.

There....doesn't that sound helpful??

I was active in volunteer EMS for 19 years (2 years EMT, 17 years paramedic) before going into nursing. I find it unfortunate that some folks still feel that Paramedics/EMTs are just "ambulance drivers." Yes, their level of training and scope of practice differ from those of a RN. That being said, I would much rather be assessed/stabilized/packaged/transported by a trained EMS person than being merely "driven" to the ED.

Over the years, evidence based practice has played an increasing role in field EMS. This has resulted in a return to the older "load & go" approach to handling serious trauma versus the "stay & play" treatment modality. Even in "load & go", however, assessment and treatment of the pt (to the limits of scope of practice) play a role.

Back to the OP's original post....treatment of pain in the field is important. Depending on region of the country & standing orders under which EMS providers operate, a pt may be given nitrous oxide, morphine, fentanyl, nalbuphine, or any number of other agents. Over the years, I saw my standing orders become more liberal. This was done in order to enable field personnel to provide pain control as early as possible.

Once upon a time, we could only give morphine after calling medical control ("call for orders"), and only in non-abdominal pain pts. This changed after a while to us being able to give the first dose (5mg) of morphine under standing orders even to abd pain pts, then give subsequent doses only after calling the ED doc. Eventually, this changed to us being able to give up to (2) 5mg doses of morphine at a set time interval without calling for orders. This is very handy when treating nasty pain like a compound femur fx. I could give the first dose even before splinting the pt, and a second dose (if needed) during transport.

Ohio permits EMT-Intermediate level personnel (not just paramedics) to give meds including morphine, nalbuphine, ketorolac, meperidine, or other analgesics for pain relief.

Pain control (or if not "control", at least taking the edge off it) is a good thing.

[usalsfyre]

well, other than r/o appendicitis and other gi issues, i am thinking of a hospice pt i had, who has since died.

he was on painkillers for lower back pain, which his pcp generously prescribed.

pt's speech became more slurred and garbled.

this was attributed to heavy doses of painkillers.

turns out this guy had brain tumor.

by time it was officially dx'd, it was too late for treatment.

he died at 37.

leslie

Every appy I've ever seen appropriately medicated for pain (see the snowed in comment above for an example of inapproprite) still went primate feces when you messed with there RLQ. All of them also got an abdominal CT prior to surgery.

As to the second guy, there's a name for not investigating a new onset of change in mental status. It's called malpractice.

To me, as soon as an assesment is done attempt to control pain. Your patient deserves it.

[usalsfyre]

I don't want a CCRN making any determination about my neuro status. I just want them to hold my hand until I'm evaluated by a physician.

There....doesn't that sound helpful??

I was active in volunteer EMS for 19 years (2 years EMT, 17 years paramedic) before going into nursing. I find it unfortunate that some folks still feel that Paramedics/EMTs are just "ambulance drivers." Yes, their level of training and scope of practice differ from those of a RN. That being said, I would much rather be assessed/stabilized/packaged/transported by a trained EMS person than being merely "driven" to the ED.

Over the years, evidence based practice has played an increasing role in field EMS. This has resulted in a return to the older "load & go" approach to handling serious trauma versus the "stay & play" treatment modality. Even in "load & go", however, assessment and treatment of the pt (to the limits of scope of practice) play a role.

Back to the OP's original post....treatment of pain in the field is important. Depending on region of the country & standing orders under which EMS providers operate, a pt may be given nitrous oxide, morphine, fentanyl, nalbuphine, or any number of other agents. Over the years, I saw my standing orders become more liberal. This was done in order to enable field personnel to provide pain control as early as possible.

Once upon a time, we could only give morphine after calling medical control ("call for orders"), and only in non-abdominal pain pts. This changed after a while to us being able to give the first dose (5mg) of morphine under standing orders even to abd pain pts, then give subsequent doses only after calling the ED doc. Eventually, this changed to us being able to give up to (2) 5mg doses of morphine at a set time interval without calling for orders. This is very handy when treating nasty pain like a compound femur fx. I could give the first dose even before splinting the pt, and a second dose (if needed) during transport.

Ohio permits EMT-Intermediate level personnel (not just paramedics) to give meds including morphine, nalbuphine, ketorolac, meperidine, or other analgesics for pain relief.

Pain control (or if not "control", at least taking the edge off it) is a good thing.

Excelent post on the progression of out of hospital care. The only thing is 5mgs of morphine might as well be homeopathic in certain patients, but I'm sure you've seen that in your own practice.

Me I'm choosing to ingnore Mr. "just drive me" as I lack the civility to reply in a public forum.

[steelydanfan]

I"ll give one more before I leave this to others to debate. My daughter in an MVA, a GCS of 4 at the scene... had obvious right sided crush injury which was obviously very painful... rolled car at least three times each time hitting her side... 45 minute car removal due to the crush.. Probable entire right side broken and crushed, no LOC by the time paramedics arrived.

Life flight was called due to seriousness of injuries and she needed intubation (probable head injury).... now we all can argue based upon crushing injury she needed pain meds as it was clearly obvious there was severe pain involved.

Life flight records... Nimbex for intubation..... intubation followed by several more boluses and no pain meds until arrival at a trauma center to scan the brain injury and all the many fractures. First 24 hours in the ICU... nope no pain meds no sedation on a vent to monitor neuro status to determine if a ventricular drain needed to be placed.

Do ya think I was going to scream treat the pain? Heck no, don't mask any neruo signs and as tough as it was with a kid with 5 hip fractures, two spine fractures and a latent ankle one... they knew what they were doing.

So my case sounds rare, but for those of us that work ER and Trauma ICU, pain is an excellent sign and we revel in it and use it to monitor status.

Don't get me wrong, my co-workers, my lovely ICU nurses were crazy about it as was I. But remember that pain is an excellent neuro assessment skill that when masked... eliminates your astute assessment skills. One change in her assessment meant neuro surgery. Pain assessment does have a purpose in a select patient population that is not limited to my personal experience.

Patients and family simply need to be educated that in the first triage and possibly further assessment, pain is pure indicator of treatment and therefor must be left untreated however we may personally disagree.

When you can watch you baby on a vent, pain untreated for a better purpose of diagnosing and catching the smallest change in status, and understand the need for it... you'll accept pain as an acceptable outcome. People just need education through the tough time and more times than not, they'll understand the rationale... the others.... just need to be angry at the situation.

She never remembered the multiple fracture pain,the trauma in the car, or any of the short term recovery, simply the head injury pain which is long lasting and takes a heard of a neuro team AFTER to fix.

Nope, don't and never will agree with this. She could have been given low dose pain mmeds at the minimum. There is no way to tell whether her accelerated heart rate and bp is from pain or internal bleeding, UNLESS YOU TREAT THE PAIN YOU KNOW SHE MUST HAVE. Serial CT scans or a pressure monitor would have given her doctors the info they needed regarding your daughters neuro status without torturing her. Sedation with propofol can be reversed within MINUTES to check neuro status. We don't DO this kind of medicine in this country anymore!

[nursemike, ASN, RN]

Had a pt with lung CA awaiting diagnosis for mets-to-brain vs. CVA. Pt c/o 10/10 pain. Neuro prescribed 1 Lortab 5/500 Q6H. I was charge. Staff nurse paged repeatedly, resident wouldn't budge (attending would have just reamed him and d/c'd the order in the am, anyway, so I understood his predicament).

At 2300, had an onc nurse floated to my floor. Revised the assignments to assure that the pt wasn't the only one in pain.

This post should be in Latin, since we're practiciing in the Middle Ages.

[Altra, BSN, RN]

I do t want a paramedic making any determination about my neuro status. I just want them to drive me to the ED.

Whew ... are you sure you want to "go there" with this comment? Is it helpful?

Altra, CEN, CCRN

[grannyrn65]

I do t want a paramedic making any determination about my neuro status. I just want them to drive me to the ED.

Why call the paramedics then? Some seem to hold paramedics as a life form lower then themselves. I have had the rescue squad respond in three situations where their ability to assess, then call for treatment orders, either saved my life or shorten the length of my disability or hospital stay. I had a fire in my home. The fire department responded. One of them identified himself as a paramedic. He asked me how I was breathing and I told him I was a little SOB but I would be fine. Fortunately, he stayed around, and transported me to the hospital, after I started suffering major respiratory distress. And he gave me a breathing treatment, started an IV and gave me O2. Turns out I was suffering from severe smoke inhalation.

I had an off duty paramedic respond to my car accident, after calling it in. He gave me support until his peers arrived. They gave me life saving care, included pain medication, in the field. They assessed my neuro status, thank heavens. Unlike some, I am glad they are available. I am glad that they are educated to the degree they are. I am glad they perform the assessments and treatments they do. I wouldn't trade them for all the tea in China.:yeah::yeah::yeah::yeah:

GrannyRN65

[linearthinker, DNP, RN]

I don't want a CCRN making any determination about my neuro status. I just want them to hold my hand until I'm evaluated by a physician.

There....doesn't that sound helpful??

I'm scratching my head about this comment. It makes no sense. It isn't within the scope of practice for a RN (or even a CCRN ) to make a determination about someone's neuro status. If you just want me to hold your hand, all you have to do is ask. I think there are many conditons that require the assessment and diagnostic skill of a physician before paraprofessionals of any designation intitate any treatment. Neither you nor I are qualified to make those decisons and it is folly and ego to pretend otherwise.