Is It Still There? Hot Topics in Adequate EMS Pain Management

Itís a little known fact that I can speak a little Spanish. Iím not very good at it, and I have a lot of trouble conjugating verbs into the past and future tenses, but I can carry on a fairly relevant conversation with most Spanish speaking individuals when the need arises. It always throws people off, being as I am the absolute least Hispanic-looking person on the planet with my red hair and pale skin. The Irish are known for many good things, but proficiency in Romantic languages is not really one of them.

However, even though my Spanish wasnít perfect and my patientís English wasnít so good either, I could tell what he was asking me through both of our broken dialects, his hand gesture, and the look of pleading and fear in his eyes when he pointed towards his crotch.

ďIs it still there?Ē

The man on my ambulance cot had just landed a job at a local foundry. In fact, he had just been hired that morning and was being given a tour of the plant when the accident happened. I never saw the inside of the place, but somehow this man had been splashed ďfrom neck to nutsĒ with furiously hot molten aluminum. His question to me was quite valid and pressing. In fact, should something like this ever happen to me, I would probably be begging someone to tell me the same thing.

ďYes Sir, it is. Itís all there and itís goodĒ I assured him. My broken Spanish didnít allow me to tell him the news tactfullyÖ but even if he knew perfect English Iím not quite sure I would have known how to phrase that kind of news very well. I donít often give guys the thumbs-up about their genitals. Itís just not something that often comes up in conversation.

aluminum nuts

I’m just going to leave this here…

Once the patientís most pressing question was answered, my focus moved to treating the totality of his injuries. His airway, breathing and circulation were fine. There appeared to have been no airway burns and his speaking voice was normal. He had no kinematic trauma, as in there had been little to no kinetic energy transferred to his body when he was splashed. Nothing was bleeding, no bones were broken, and there was no penetrating trauma to speak of. His pulse, blood pressure, and respiratory rates were all elevated but that was to be expected. His burns were surprisingly light, as the molten metal had only splashed him with droplets. He was burned pretty badly, but the burns were widely spaced and second degree. His skin was white and waxy where the metal had cooked it. Overwhelmingly, this patientís main emergently acute problem was his intense, searing pain. I can only imagine that the ď1 to 10Ē pain scale didnít allow for the amount of pain this man was experiencing. Iíd put his number squarely above 100 on that scale. Poor guy.

This call happened several years ago and at the time the EMS protocol system I worked in allowed us to give 2mg of morphine for pain before calling medical control. This was a recent change from when we could offer no analgesia without calling in to speak with a physician via the radio. As busy as the hospitals in the metropolitan area were, getting a doc on the line was a crap shoot. They were insanely busy, all the time. They were far too busy to be bothered by a medic on the radio and the nurses, whether though instruction or malice, attempted their best to keep them from speaking to us. Our opinion was that the nurses would always lie to us and say that either no physician was available or just wait a second and state that the physician was denying our request in order to avoid having to get up. We hated them for it when we saw our patients suffering. It was a terrible system, but I never changed it while I worked there.

As the venerable Rogue Medic once said, ď2mg Morphine + Severe Pain = Severe PainĒ and that is very true. He also said that ďMorphine and Fentanyl are safe drugs in the hands of competent paramedicsĒ and that ďNo drug is safe in the hands of incompetent paramedics.Ē Iím pretty sure he also said that ďMedical directors who believe that a call to medical command will protect patients from incompetent medics are deluding themselvesĒ or something like that as well. He says a lot of smart things.

I never got this patientís exact weight but I would imagine that he weighed about the same as me. Depending on the day, I weigh around 100kg and Iíd give the guy about the same. So, with the standing medical orders we had at the time that allowed for 2mg of morphine, I was providing the patient with 0.02mg/kg of morphine for his severe, awful, terrible pain.

And 0.02mg/kg of morphine is a cruel, almost criminally negligent dose. Itís like homeopathy but with less plain olí water. Itís ineffective, and if there was one thing that this poor guy who was fighting off the pain from almost having his male parts burned off by molten metal didnít need, it was a paramedic giving him a near placebo and then hoping he wouldnít notice.

There is a lot of literature out there exploring what the appropriate dose of Morphine might be for patients experiencing extreme, acute pain. A lot of those papers state that ďthere is no scientific consensusĒ saying what the appropriate dose of morphine may be, however Iíve seen a lot of papers recommending a starting IV dose of 0.1mg/kg. Some recommend higher. (1)

So In our case above, a dose of 0.1mg/kg would have been 10mg. For those of you who are bad at math, thatís a whole 8mg higher than my restrictive standing orders allowed me to give this poor guy. I suppose if I would have been allowed to, I would have started out by giving this patient a 10mg loading dose of morphine right off the bat, except for that 0.1mg/kg is not always effective in managing severe pain and may need to be be quickly augmented with more should it be required in order to achieve an individualized, situationally appropriate effective dose. (2)

As the call went on, I was finally able to get a physician on the line and actually give this guy a whopping 6mg of morphine by the time I got him to the trauma center. To this manís credit, he remained very stoic and didnít hardly even whimper during the transport. I give him a lot of credit for being very tough. I wish I could have helped him.

Even still, the same physician who had given the order limiting me to a near-homeopathic dose of pain control for this patient took one look at him when I arrived at the ER and immediately ordered another 10mg of morphine to help this poor man. I give the physician credit, he wasnít the person who had written our ridiculously inadequate protocols for pain control, he just wasnít bound by the same fear-mongering that I was.

In recent years, Iíve worked for areas with much more appropriate standing medical orders for pain control ranging from ďYouíve got Morphine, fentanyl, and Versed. Your patient has pain. Treat itĒ to ďIf you need to give more than 400mcg of Fentanyl or need an adjunct, you can get an order within a minute flat but the ED doctor would like a headís up.Ē Some cautious souls may worry of the side effects of morphine when appropriately-dosed, such as hypotension, nausea, and decreased respiratory drive but these are minor adverse events that are surprisingly rare to a person who had been brought up in the era of morphine-related scare mongering. As our friend the Rogue Medic has said ďNo medication is safe in the hands of an incompetent paramedicĒ and what competent medic doesnít know how to utilize a bag-valve mask, give a fluid bolus, or to squirt in a little Zofran or Narcan if needed? It is rare these days for me not to administer 4mg of Zofran prophylactically for nausea when treating serious pain with narcotic analgesia. The last thing my patients who have serious pain need is to feel like they need to throw up. When needed, I also will administer a benzodiazepine, such as Versed, as an adjunct to the analgesic because not only does it enhance the effect of the narcotic, it also helps make for a much more comfortable experience for the patient.

Are your protocols adequate for treating acute pain? Are your attitudes toward pain control realistic, compassionate, and well-researched? We paramedics need to do a better job of assessing and managing our patientsí pain in the continuum of our care and we are not doing enough. We need to relearn skills such as proper splinting, positioning for comfort, psychological first-aid, and the use of appropriate doses of appropriate medications. We are the healthcare providers who see pain at its most severe, raw, and acute after injuries and illnesses strike. Itís our job to advocate for the best possible care.

Take care of your patients. Treat their pain.

 

 

References:

  1. Morphine Dosing in Acute Pain: How Much Is Enough? Ė Zane RD, MD, FAAEM reviewing Birnbaum A et al. Ann Emerg Med 2007 Apr.
  2. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients.Bijur PE1, Kenny MK, Gallagher EJ. – Ann Emerg Med. 2005 Oct;46(4):362-7.

Resources:

  1. Appropriate Morphine Dosing for Opioid Tolerant Patients Ė Roguemedic.com Ė 09/2010 -†Topics on Pain Management Ė Rogue Medic – http://roguemedic.com/tag/pain-management-2/

  • saboats

    Great piece. 1-2mcg/kg q5mins no max and if you need a sedative, go for it. Ketamine is another great adjunct to opiods and works great; much smaller doses of Fent. are needed = no respiratory issues = no freak out by Doc’s about the amount given.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.
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