Comments on: Would You Like More Pain Medicine?

By: medicscribe

medicscribe — Sun, 27 Jun 2010 22:26:23 +0000

Thanks for the comments. Sorry for the delay in responding. 01.mg/kg is actually “the dose” for morphine. For some reason emergency medicine has been fearful of opiates, but few of these fears have been bourne out in the literature. We severely underdose, we cannot recognize others pain, although we think we can, and there is no study that shows that opiates interfere with examinations or history taking. In our system we can give up to 0.15mg/kg on standing order (0.1mg followed by 0.05 mg/kg). I do this fairly often and have never knocked out a respiratory drive or come close. Most of the research coming out shows very little side effects from morphine and fentanyl not related to pushing the drugs too fast. There are areas where even our liberal guidelines are considered conservative. Slowly but surely the direction is for more pain management.

By: medicscribe

medicscribe — Sun, 27 Jun 2010 22:13:53 +0000

Sorry for the delay in answering. My policy is for acute pain with a visibile cause like a fracture or a burn, i always medicate. For back pain, I usally medicate. I would rather medicate a drug seeker and patient will real pain than not medicate the patient with real pain for fear they were drug seeking.

By: PDXEMT

PDXEMT — Wed, 16 Jun 2010 19:01:25 +0000

Really, really interesting. I like it.

Where does this intersect with the issue of frequently-transported patients with known drug-seeking behavior? I’m talking about the guy we see twice a week that the hospital only sees in triage and never dispenses prescriptions to. Is it part of our job to consider what might be best for the patient in the long run, or should we simply treat pain without prejudice and leave the big decisions to other folks?

I’m not necessarily looking for answers, just tossing thoughts out. This is stuff I wrestle with sometimes; I tend to err on the side of treating pain and endure the raised eyebrows from nurses and pointed comments from docs (one recently showed me a chronic chest pain pt’s chart with all the notes about “drug seeking” and “only admit for positive enzymes”).

By: Rusty

Rusty — Wed, 16 Jun 2010 17:54:08 +0000

It has always been my understanding and practice to make acute pain tolerable in the prehospital setting. 0.1mg/kg is a lot of morphine. Giving morphine until the patient “says no or is asleep” will make it difficult for the hospital to perform their own assessment and gather the patent’s history, not to mention the dangers of knocking out their respiratory drive. Using the 0-10 pain scale, vitals, and overall patient disposition should be sufficient when deciding how much morphine to give. Our protocols state give 4mg initially then titrate, up to 10mg. Very rarely have I seen a patient receive 10mg in an ambulance.

By: medicscribe

medicscribe — Thu, 10 Jun 2010 22:57:10 +0000

That’s one of the reasons Dr. gentile uses Benadryl on all patients. We are not allowed to premedicate for side effects. If they start to have a reaction we can give the Benadryl, we can’t routinely give the Benadryl to every patient, otherwise I would be following Dr. Gentile’s protocol .

Thanks for the tip about my comment settings, I was trying to find away to block all the spam I get that backs up in my to be approved box, I didn’t mean to shut readers out.

Peter