So I have been talking to many people about this hip fracture issue and it is quite a dilemma.
I want to change the dispatch protocols to send ALS to fall with hip pain. They don’t have to go lights and sirens. They can go “cold,” but they should at least be on the way.
But here are the problems:
In one of the areas, we are short medics so medics aren’t wild about going to a hip fracture when the chest pain comes in. Basics are reluctant to call for medics for pain control because they don’t want to tie up medics and probably don’t want to be accused of not being able to handle a hip fracture themselves.
In my job as trauma data collector at the hospital, I review the prehospital, ED and in hospital care for all admitted trauma patients. I have been keeping a spread sheet on the hip fracture calls and it is quite revealing. Without giving away the numbers (which I will need permission to do) the general truths are as follows:
1. Prehospital personnel are not using pain scales and they are not medicating the patients, even when the ambulance is a paramedic ambulance.
2. Hospitals are almost universally medicating these patients, but the time between triage and med administration is quite lengthy as has been borne out in many studies.
3. When patients are medicated prehopsitally, time to administration is extremely short. Prehospital medication results in what I am recording as negative time meaning time before hospital triage. In one case the patient is medicated 52 minutes before hospital triage login. A medic’s choice to medicate a patient in pain can easily mean two hours of pain relief before they would otherwise receive medicine. So for any medic who thinks, I’ll hold off on giving morphine because I’m close to the hospital and the hospital will medicate the patient, I say, go ahead and do it yourself. Your patient will appreciate it.
My hope is that when my little study is done, I can use it as a preeducation program benchmark to compare progress against. I know there is growing movement pushing EDs to emphasise early pain management administration.
In the meantime at one of our regional meetings I hope to raise the issue about how the regional doctors think about the question of using paramedics to manage prehospital pain versus keeping medics available for the next big call.
***
Now for a story. I was corresponding about this issue via email with a doctor when we were toned out — dispatched appropriately to an elderly fall with “excruciating hip pain.” I ended the email saying I was off on a hip call and would report back.
I was expecting us to be sent cold. In this town, as the only ambulance, we are sent to all calls (obviously). We were instead dispatched “hot” but that was clarified because the EMD dispatcher informed us the patient had a head lac (injury to a dangerous area).
On arrival at the retirement community, I put my narcs in my pocket and entered the facility with a backboard, straps and extra blankets for padding. I found the woman in the kitchen area, laying on her back. The head lac was too minor to apply a band aid, but she did appear to have considerable hip pain. “On a scale of zero to ten with ten being the worst pain you ever felt in your life and zero being no pain, how would you rate your pain?”
“I will not tell you! I am not talking to you.”
“Huh?”
“Are you a doctor?”
“No, I’m a paramedic.”
“I’ll have you know I am a nurse and I will speak only to a doctor!”
“Look, I think you broke your hip, and since you are a nurse you no doubt know that pain is not good for you. Before I can give you any pain medicine I need you to give me your pain score.”
“You will under no circumstances give me any medication until I am seen by a doctor!”
“I have standing orders from a doctor to give people pain medicine. As a nurse, how would you feel being questioned by a patient when you wanted to give them pain medicine.”
“I would never give anyone medication under they were first seen by the doctor.”
This went on for a little bit with me getting testier and testier until I realized that she was completely demented and what was I doing trying to argue with someone with dementia.
So I padded her as well as I could and got her on the stretcher and out to the ambulance and on over the bumpy roads all the way to the hospital with her complaining the whole way. “Slow down! Owww! Oww! Would you tell your driver to slow down! Oww! Oww!”
It was funny, but it was also sort of sad. At one point, I said, “I told you it was going to be a rough ride that’s why I wanted to give you some pain medicine.”
“You will under no circumstances give me pain medicine until I am seen by a doctor!”
At triage, I explained why I had not only not medicated her but failed to have a pain score. “She’s a former nurse and will only talk to a doctor,” I said.
The triage nurse smiled and then sauntered over to the patient. “On a scale of 1-10,” she began before the patient cut her off.
“You’re wasting your words. I will only speak with a doctor!”
Later my partner told me the aide who rode in the front with him said she went through this same routine every day when they tried to give her her daily meds. They resorted to using one of the silver-haired male dementia patients as a surrogate. Dr. Welby over there says its okay.
Unfortunately at the hospital, the former nurse was put in the hallway, but Dr. Welby was still back at the home.