I consider myself on the cutting edge of pain management. I have worked within the state and region to increase the amount of morphine paramedics can give patients on standing order and I am very aggressive with my use of morphine. You have pain, I want to take it away. Instead of screaming with pain, I want you singing “The Farmer in the Dell.” Recently, I helped our region get Toradol so we have an alternative pain med for patients allergic to Morphine, in addition to being able to give toradol to patients with kidney stones for which it is particularly good for pain relief.
So it is with some embarrassment that I make the following confession.
But first a bit of blame.
Many years ago another paramedic told me if a patient is allergic to sulfa, you can’t give them Morphine. Why? Because Morphine is in fact Morphine Sulfate.
Okay, makes sense.
So for all those patients, I said, sorry I can’t give you any morphine because you are allergic to sulfa, I am profoundly sorry.
I had a patient with a hip fracture the other day who was allergic to sulfa and to NSAIDS. I told her I couldn’t give her any pain meds unless I talked to the doctor first. We put her rather painfully onto the scoop stretcher and got her out to the ambulance, where pained by her distress, I decided to call medical control and ask if it was okay if I gave her some morphine. She was unable to tell me what happened when she took sulfa drugs, so if she had a reaction, well, I do carry the full complement of anti-allergic reaction drugs — epi, benadryl, solumedrol, albuterol, 02, fluid.
After describing her injury, pain 10 of 10, vitals, and history, I said, “I’m calling because the patient is allergic to sulfa, but she can’t tell me what happens when she takes sulfa. She is in a terrible amount of pain. 10 of 10 and I was calling to consult whether or not giving her morphine is appropriate.”
Give her the morphine was the answer.
Later I talked briefly to the doc, and told her I had been told long ago, you couldn’t give morphine to a patient with sulfa allergies. She smiled and said, “You can,” and then went back to her charts.
Further research and questions confirmed this. The sulfa in a sulfa allergy is different from the sulfate in Morphine Sulfate.
This all brings up the issue of how we learn in EMS. We are taught certain things in class, but much of what we learn comes from the street, from calls, from conversations. Much of the information we learn is good, some of it is conflicted, and some of it is plain wrong. And some stuff changes.
When I started as a medic before every shift I used to grab a handful of ammonia inhalants. We get called for a drunk or an overdose, an ammonia inhalant goes under the nose and the patient is roused. One day — quite a number of years ago — our clinical coordinator was reviewing the run form of one of my preceptees and discovered a passage in the narrative about rousing the patient with an ammonia inhalant. He wanted to know what was going on. I explained. The guy was drunk. We couldn’t rouse him. We stuck an ammonia inhalant under his nose. He woke up. Do it all the time. Been doing it for years. Then the coordinator said, “That isn’t done anymore.” He explained that it is, in fact, a dangerous practice (see links below).
I have long stopped using ammonia inhalants, but I still occasionally see them show up in the supply room or hear of someone telling about using them. Once even at the hospital, an older nurse woke up my unresponsive patient with one(just like I used to), and said, “he’s just a drunk.”
“You’re not supposed to use those anymore,” I said.
“You’re a funny man,” she said.
One common practice that is apparently passed from EMS person to EMS person is the use of the blue duct tape strap that comes with the popular “head-beds.” People attach one end of the blue tape to the board by the patient’s head at ear/forehead level, then loop the tape down under the patient’s chin, and then crank it back to the board by the other side of the head, often hyperextending the patient’s neck. When a partner of mine does it, I undo it, and if necessary resecure it straight across the head over the soft white strap. Sometimes I will get out the instructions and show it to my partner and explain how it hyperextends the neck when done improperly. The instructions allow for the tape to go either straight across the head or straight across the neck (c-collar). When I started as an EMT in the late 1980’s, I would have been crucified by our then medical director for putting any thick tape across the neck, so to this day I don’t tape the neck.
The use of the tape across the neck then back up to the head is so prevalent, I have almost given up trying to correct people. Another medic who shares my views on the device said he was in the ER the other day and a new EMT looked at his c-spined patient (he had placed the tape over the white strap across the head), and the EMT made a remark about how some idiot had taped the head instead of hooking it down under the chin.
Stuff just gets passed on.
Anyway, a second apology to all those sulfa allergy patients with broken bones who had to suffer through my ignorance. And another apology out there to patients past and future who may be the victims of any other misinformed information I have but am as yet unaware of.