Why are doctors so reluctant to give pain meds?

[kinoons]

This may quickly turn into a IMHO question, but...


MD's on the board, why are MD's in general so reluctant to give pain meds in "emergency" situations. ever ask for morphine on anything beyone an isolated extremity fracture or for a suspected AMI and all I get is a polite hell no. Why? Studies (I have them at home, and can post them when I get there if requested) have shown that better diagnoises (wow, thats hard to spell. I still dont think I got it right) can be made when the patient is given a slight amount of pain meds to take the edge off (do not read snow the patient here). Also studies have shown that the longer the patient is in pain the slower they heal.


any ideas?

[Guinastasia]

Probably because morphine is EXTREMELY addictive.

[Biggirl]

I am not a doctor, but I will venture a guess.

First, pain medication is addictive, so doctors are reluctant to give prescriptions for every ache and cut.

Pain is subjective. The patient thinks he is experiencing unbearable agony. The doctor thinks he should just be feeling "mild discomfort."

[kinoons]

Yes, morphine is extreamly addictive, I am aware of that. But at the same time once the doctor knows the cause of the pain patients regularlly get snigifiant doses of morphine or other analgesics. And I am pretty good at telling if someone is in unbearable agony or if it just slightly hurts. Maybe I wasen't quite as clear as I intended to be in the orgional post

in an "emergent" situation when a patient is experiencing what they consider to be snigifiant pain (generally abdomonal) why are MD's so reluctant to give pain meds until the MD knows exactly what is making the patient sick?


Also, who are we to tell someone how much pain they are in? If a patient tells me it hurts a lot, and they would like for the pain to go away, who am I to say no, you don't hurt enough for me to take the pain away?

[Farmer]

Three letters:

H M 0

[kinoons]

I should say the pain med would be given in house. This is not reguarding pescribed pain meds post ER or hospital discharge.

[cornflakes]

IANAD, but I assume that the morphine (demerol, more likely) would be just one more thing that the anesthesiologist would have to contend with. I was hit by a car once and was told that I could not have any painkillers until the doctor saw me (this happened roughly every fifteen minutes when I came to.) I don't know whether the orthopedic surgeon gave me a painkiller; I assume that I went without until I was put under for surgery.

[pluto]

Part of the reason is captured in the old adage for doctors: "First, do no harm."

If they don't know what's wrong with you it could be a mistake to start administering medications. Morphine can be a particular problem because it interferes with your breathing. On top of shock, which is almost always present in traumatic accidents, you could do more harm than good. Also some medications shouldn't be given in combination. If you've already given one it may preclude giving another, more urgently needed medicine. Finally the pain is certainly unwelcome but it won't kill you. They need to treat the disease, not the symptom. So, when in doubt, wait until the patient is stable, your diagnosis is complete and the course of treatment is decided.

Even if it hurts.

[Odesio]

Originally posted by kinoons
This may quickly turn into a IMHO question, but...


MD's on the board, why are MD's in general so reluctant to give pain meds in "emergency" situations.


Because some drugs do not interact well with other drugs. You never know if someone is on medication of some kind, illegal drugs, or perhaps alcohol. Better to be safe then sorry.


Marc

[kinoons]

pain meds are almost excluseively thrown out in trauma, I also understand that. Morphine can effect a persons breathing, but a snigifiant amount has to be given for that to occur. 5mg are not going to depress a patients resp effort, however it will do a great job of taking the edge off of the pain. If morphine is not the answer due to a possible imcompatability, then why not another drug


okay, let me try to narrow this down a little more

why, in an "emergent" medical (not traumatic) emergency envolving abdomonal or lower back pain, in which the patients vital signs are (heres a dangerous statement) relatively "stable" and "normal" is analgesia avoided until the cause of the pain is known? Is the interaction between morphine or other narcotics or analgesia more promoniant than I have been lead to believe in paramedic school?

[RedVelvetSunset]

Originally posted by kinoons
in an "emergent" situation when a patient is experiencing what they consider to be snigifiant pain (generally abdomonal) why are MD's so reluctant to give pain meds until the MD knows exactly what is making the patient sick?


Well, first of all, let me give my credentials. I am a nurse and have had experience in both hospice and ER.

Doctors in ER generally like to make a diagnosis before they perscribe any meds because in an emergency situation, the patient needs to be as alert as possible in order to help with giving pertinent (SP?) information relating to their condition. (When possible, the patient is the best source of information!) Morphine, and other pain medications are mind altering due to the drowsiness one usually experiences after administration. I can tell you of one experience where a resident gave a "small" dose of demerol, because the patient was complaining of pain, and we had a tough time getting a straight answer out of her after that.

Also, there are lots of really good actors out there who have drug problems, and will come in to the emergency room complaining of migraine/back/abdominal pain, and be very good at convincing you that they are hurting, but miraculously, once given a shot, they are ready to get out!

Lastly, strong pain medications, such as demerol, morphine, and the like can alter the results of blood tests, urine tests, etc. (If you are a female of childbearing capabilities, you can bet your ass you won't get anything until they do a pregnancy test!) The cause of the pain determines the proper medication. Certain pain medications react in different ways to specific types of pain. Many of these pain meds are very upsetting to the stomach.

I can give you one piece of advice that was given to me, and I know of several doctors, even, who go y this rule: (Unless it's a terminal situation) "Treat the Cause of the pain...not just the pain itself!"

Red

[kinoons]

Red,


Thats not entirely true. I have several times brough a patient into the ER after asking for pain meds over the raido to here the doc ask the same questions I did, get the same answers, and then give the med.


One example. A 45 yr old female complains of pain in her lower back on the right side. the pain comes and goes in waves but is extreme when it is there. She also complainded of some blood in her urine. I asked for morphene prehospital suspecing a kidney stone and was told no. As soon as she hit the ER the doc asked the questions and gave the order of 5mg morphine

second example. A male, 30, with the same complaint (stones stick in my mind the best) who has had a stone before, and knows exactly what it feels like. he says hes having another. Hes denied Morphine prehospital, and then dosent get any for the next hour and a half in the ER until they do all the tests and get, low and behold, Its a stone!

Also, studies have shown (see 1st post, I'll list the studies when I get home) that a SLIGHT admin of analgesia assists the MD in the assessment of a medical pain patient.

[Guinastasia]

Besides, don't you want to first make sure the patient has no allergies to certain substances?

[MsRobyn]

Also, not all pain meds will work for all types of pain.

This is purely anecdotal, but when I was having acute attacks of cholecystitis (my gallbladder was inflamed), with the exception of the IV Toradol I got in the ER, was Ultram. I'd gotten prescriptions for Darvocet and Percocet, and those did not touch the pain at all. All they did was make me high, then woozy, and they increased the pain because they're constipating. Not fun.

I would also imagine that giving patients pain meds in an ER setting would also cause problems with anesthesia if emergent surgery is needed.

Robin

[Qadgop the Mercotan]

I am an MD, and a lot of the input above is good. As for me, first I have to figure out what I'm treating. If you give enough morphine, the patient will happily agree he's getting much better, just before he expires of a ruptured aorta. If they're in pain cuz a bone is sticking out of their leg, then I tend to give pain relief meds sooner. Even here I have to be careful, if they're going to surgery soon I need to avoid complicating their anesthesia by giving opiates inappropriately. And I always remember that one of the possible side-effects of opiate pain killers is that they may stop breathing (not a desirable outcome).

But pain should be treated. Not always with narcotics, tho. Migraines should almost never be treated with narcotics (and yes, I know it's commonly done, and I've done it too), and one must be very careful treating any type of chronic or recurrent condition with narcs. Often they only potentiate the pain when they wear off, requiring larger and more frequent doses of narcotics.

Addiction rarely results from treatment of legitimate acute pain, in fact not treating acute pain appropriately with narcotics can lead to altered pain responses, and more problems with chronic pain. So we need to treat genuine acute pain of trauma and various other causes, to properly care for the patient.

And so far noone's mentioned regulatory agencies. Physicians have lost their licenses, and been busted by the DEA for prescribing what some bureaucrat feels is "too many narcotics" even when their patient population consists mainly of terminally ill hospice types, or end-stage AIDS. So its damned if you do and damned if you don't, we get castigated by colleagues for not treating pain adequately, and busted by the authorities for treating it adequately.

I have one colleague who was sued by a patient for not giving her enough narcotic meds for her headaches (the patient lost), then 2 years later was sued by her again for "turning her into an addict" with the narcotics he did prescribe her. This one's still pending.

I've also had tons of patients call and say they need more narcotics because their prescription "fell into the sink/dishwasher/toilet" etc. I've never had anyone call me and say they needed more amoxicillin because they dropped it in the toilet. Go figure.

Anyway, it's a complex issue clouded by fear of doing harm, getting scammed, getting busted, getting sued, even getting physically attacked. I just try to figure out what's in the patient's best interest, and I haven't gotten into too much trouble yet.

Enough ranting.
Merry Xmas
Qadgop, MD

[Yeah]

There are many good reasons for not giving pain meds before a diagnosis has been made. Other posters have already given most of them. I think a few have been missed:

1. Many pain killers affect mental status (i.e., make people lethargic or act goofy). This not only makes it difficult to get a good history from the patient (as has alredy been mentioned) but also makes it difficult to evaluate the patient's mental status, an important evaluation to make before arriving at a diagnosis (or diagnoses).

2. "5mg [or morphine] are not going to depress a patients resp effort" in most cases, but what if the patient already received 5 mg in the ambulance or took a handful of Tylenol #3 before coming to the hospital or is drunk?

3. The patient can't really consent to treatment once they are doped up. If they are going to need an operation, you would like to get their consent before giving them mind-altering drugs.

kinoons: "One example. A 45 yr old female complains of pain in her lower back on the right side. the pain comes and goes in waves but is extreme when it is there. She also complainded of some blood in her urine. I asked for morphene prehospital suspecing a kidney stone and was told no. As soon as she hit the ER the doc asked the questions and gave the order of 5mg morphine."

You are correct that in this case and in retrospect the patient would have been better off having had the 5mg during transport. I doubt that the MD would disagree. But as long as it is her ass that is going to get sued if anything bad happens, she really can't afford to rely on your diagnosis.

[handy]

Cause of ADVERSE REACTIONS:

"Adverse reactions caused by morphine are essentially those observed with other opioid
analgesics. They include the following major hazards: respiratory depression, and less
frequently, circulatory depression, apnea, shock and cardiac arrest secondary to
respiratory and/or circulatory depression.

Most Frequently Observed Reactions

Constipation, nausea, vomiting, lightheadedness, dizziness, sedation, dysphoria, euphoria,
and sweating. Some of these effects seem to be more prominent in ambulatory patients and
in those not experiencing severe pain. Some adverse reactions in ambulatory patients may
be alleviated if the patient is in a supine position.

Less Frequently Observed Reactions

Body as a Whole: Edema, antidiuretic effect, chills, muscle tremor, muscle rigidity.

Cardiovascular: Flushing of the face, tachycardia, bradycardia, palpitation, faintness,
syncope, hypotension, hypertension.

Gastrointestinal: Dr. mouth, biliary tract spasm, laryngospasm, anorexia, diarrhea, cramps,
taste alterations."

[RedVelvetSunset]

Originally posted by Qadgop the Mercotan
Anyway, it's a complex issue clouded by fear of doing harm, getting scammed, getting busted, getting sued, even getting physically attacked.[/B]

I couldn't have said it better myself, "Doc". Although, I would have to disagree with the theory that narcotics are not reccommended for migraines.
I suffer from migraines at least once a week, and have gotten physically ill as a result in some cases.
Many times If the Midrin or the Imitrex injection doesn't work, I end up in the hospital, and the one thing that seems to work is Demerol. I must add, that it usually gets to that extreme only when I don't recognize the onset of a migraine and fail to start self-medication in time. But, this is of course, an individual case, and probably not within the "normal scope", and probably is a subject for another thread.

MERRY CHRISTMAS TO ALL!!!!!!!!!

RedVelvetSunset

[MsRobyn]

Originally posted by Qadgop the Mercotan
And so far noone's mentioned regulatory agencies. Physicians have lost their licenses, and been busted by the DEA for prescribing what some bureaucrat feels is "too many narcotics" even when their patient population consists mainly of terminally ill hospice types, or end-stage AIDS. So its damned if you do and damned if you don't, we get castigated by colleagues for not treating pain adequately, and busted by the authorities for treating it adequately.

I've also had tons of patients call and say they need more narcotics because their prescription "fell into the sink/dishwasher/toilet" etc. I've never had anyone call me and say they needed more amoxicillin because they dropped it in the toilet. Go figure.

Anyway, it's a complex issue clouded by fear of doing harm, getting scammed, getting busted, getting sued, even getting physically attacked. I just try to figure out what's in the patient's best interest, and I haven't gotten into too much trouble yet.

Enough ranting.
Merry Xmas
Qadgop, MD

Excellent points. There was a Sixty Minutes show on a few years ago describing physicians in Virginia (IIRC) who were being hassled by regulators for prescribing too much narcotic medication. In Texas, prescription blanks for narcotics are issued to doctors by the state and if the doc needs more, he needs to explain why. Some war on drugs. :rolleyes:

Robin

[kunilou]

And of course, my mother was allergic to opiates (morphine, demerol, the whole spectrum)

Her reaction when the doctor missed that bit of information on her chart and gave her demerol was truly frightening.

[kinoons]

Okay, here are the studies I was refering to. These are taken from my paramedic class, I have not seen the actual studies myself. If anyone knows where I could get ahold of these studies I'd much appericate it. I would love to read them myself

in 1994 a study was done by Lewis, Sasater and brooks that showed:

56% of patients admited to the hospital with painful conditions received no analgesia

Meperidine was given in inadequate doses 55% of the time, and by a non prefered route 60% of the time

Only 31% of chest pain patients received analgesia

of 401 patients in the study with acute fractures, only 30% recieved analgesia in the ED.




The Boston Drug Collaborative Study showed that out of 11,892 patients who recieved opioid analgesc in the hospital, 4 devloped a dependency


the Perry study of 1982 showed that out of 10,000 burn patients (a little off the subject) who recieved an opioid none devloped an addiction


The Zolte and cust study: "Analgesia in the acute abdomen: 1986"; the Attard, Corlett and Kidner study: "Safety of early pain relief for acute abdomonal pain"; and the burke study: "the use of IV MS for early pain relief in patients with acute abdominal pain: 1994"

the three above studies showed that "titrated use of low doses of opioids does not interfere with the diagnostic process"


Two other studies: "Dunphy and Way: Current surgical diagnosis and treatment: 1994" and "Angell: The acute abdomen for the man on the spot: 1979" both showed that opioid use "actually improves the ability to make an accurate diagnosis"


Any thoughts or Ideas. Again if anyone has access to the studies, I would love to get copies of them. This info is taken second hand from my EMT-P class.

[straykat23]

Often when Kervorkian took a life, the patient had complained of extreme pain that was not abated. Each time the medical community said that with proper medication the pain could have been controlled. Huh? After the fact they're all willing to prescribe. This certainly isn't an endorsement for Kervorkian (although I applaud the premise) but an appreciation for those who have lived with indescribable pain.

Ancecdotally? A cousin who was died of leukemia who had to leave her home state (South Dakota) to find a physician inclined to prescribe greater pain medication (Minnesota).

In California we voted passage of a medical marijuana bill. The researchers say that use is 'inconclusive.' Anecdotally again, my Mom found relief only when toking. This bill often gets overruled in court, but with more frequency individuals are winning their cases.

I appreciate all the info about medication given when a patient is in an emergency situation, but what about people who are dying? What difference should it make to anyone? Who owns my body? Me or the 'state?' Shouldn't I be able to make that determination?

[DVous Means]

kinoons, as a fellow EMT, I sympathise with your argument - I have been in the same position on one or two occasions.

However, surely you carry another quick-acting non-opoid analgesic in your ambulance? Because I am not licensed to use morphine (next level up from me), I am limited to using a drug that is more commonly known as an anaesthetic - methoxyflurane. This has been used as a self-administered inhaled analgesic in Australia for almost 20 years, and it is reasonably effective in most cases that I have witnessed.
There are very few side effects, provided you limit the dose to the recommended daily maximum of 6 ml.

Maybe it will only take two tenths out of the pain score of someone with renal colic, but that's better than not having anything available at all.

[RedVelvetSunset]

Kinoons, you said you requested morphine PREHOSPITAL. Well as a nurse who has worked in the ER, I can tell you that I have seen only one case of a doctor who would allow a trauma nurse to administer morphine, sight unseen. (I personally would not feel comfortable administering an opiate narcotic without an MD having seen the patient. Sorry, but it's MY license!) You have to understand that it's very risky to the Doctor to approve someone miles away over a radio to give morphine. Drug reactions aren't restricted to different drugs, but can go as far as specific manufacturers, generic/brand names, etc. I did a home care case with a woman who was allergic to the generic drug warafin but could take the Name brand Coumadin wih no problems. (I don't know why, exactly, but every time the pharmacy screwed up and she didn't catch it and took the generic, she was in the hospital within hours.)
Also, while the studies you mentioned are good, society has limited the doctor's ability in many cases. We live in a country of frivilous (sp?) 'sue-happy' people. So, it's sad to say, but the following quote is probably true:
"Lawyers and H.M.O.'s rule the world!" Add that to the fact that, sadly enough, Er's are usually understaffed and underbudgeted, and you can see why doctors may be reluctant to give pain meds until they are damned certain what they are treating.

Red

[kinoons]

Originally posted by DVous Means
kinoons, as a fellow EMT, I sympathise with your argument - I have been in the same position on one or two occasions.

However, surely you carry another quick-acting non-opoid analgesic in your ambulance? Because I am not licensed to use morphine (next level up from me), I am limited to using a drug that is more commonly known as an anaesthetic - methoxyflurane. This has been used as a self-administered inhaled analgesic in Australia for almost 20 years, and it is reasonably effective in most cases that I have witnessed.
There are very few side effects, provided you limit the dose to the recommended daily maximum of 6 ml.

Maybe it will only take two tenths out of the pain score of someone with renal colic, but that's better than not having anything available at all.

I wish things were as well in New Mexico

as an EMT-I I only have access to morphine, and only after direct radio contact with an MD. Paramedics have access to MS or Demerol(but generally not both. Most services don't carry both on their trucks), valium, and N2O (I have yet to see that on a truck) We carry ASA and acetaminophen for non-analgesic purposes. A paramedic can give MS without an MD's orders in the case of chest pain. Any other instance the drug is desired a paramedic generally has to call for permission as well

Red--

In New Mexico it is actually generally accepted for paramedics and EMT's to call for prehospital MS. We (EMT-I's) almost universally recieve the okay for chest pain and extrimity fractures to give MS. On rare occasions I've seen medics who an MD trusts get permission for MS in other instances.

Maybe I am young and idealistic, but if the studies can show that titrated doses of pain relief does not hinder, and my even assist in the diagnostic process, why are we not giving more out? How can a lawyer or an HMO argue with a process that benifiates the patients?

[Qadgop the Mercotan]

you're right, you're right, pain medicines, especially the opiate ones, could be used better. But ignorance is as tough to battle in the medical profession as it is in the general public. We haven't even managed to convince most docs not to give their patients antibiotics for viral infections! And its the regulators, who are mostly lawyer-driven, that set a lot of policy about punishing people who "overprescribe". And state medical examining boards find that their effectiveness is judged by the people and leaders of their state by the number of doctors it's disciplined, not by whether what they've done makes sense or not. Combine those things with this ludicrous "war on drugs" the government is waging, and the end result is that people who need narcotics will end up being denied them.

[kinoons]

Originally posted by Qadgop the Mercotan



I guess then the medical profession will have to do its best to change slowly over time. Is it that the studies are not widely circulated, or is it that medicine is one of the worst professions to go "thats the way I was taught, thats the way I am going to do it reguardless of what we can prove or disprove" -- I plan to attend medical school post paramedic school. Maybe I can help make a difference. Or is it that the nail that stands up gets hammered down? :)

Thanks everyone for the time and ideas

[DVous Means]

kinoons, perhaps you might like to come to South Australia.

Our paramedics (EMT-P) are licensed to administer morphine under protocol, but I think they are limited to use in trauma. That said, when the protocol requirements have been met, there is no further need to seek medical authority before administration. The same criteria applies for the drugs I am licensed to give (Advanced life Support level - roughly equivalent to your current status).

However, when the situation exceeds the protocol, a medical consult is mandatory before the medication can be used.

[kinoons]

Dvous,

I'd love to come to South Australia regardless if I was practicing medicine or not.

New Mexico has a strange system for medical control (supervision of EMS). Our EMT's have our own licenses, but we have to be "signed off" by a MD who acts as a services medical director. The medical director writes protocols that the EMT follows. Most all services have standing orders for MS in cases of chest pain, (for paramedics, EMT-I's have to call and ask) and some for isolated extremity fractures. Generally the medic will call for anything not falling under chest pain. The services medical director can be very liberal, giving standing orders for several (if not all) medications, or can be VERY conservative (I've seen some services that have to call a doc to start an IV)Everything that is done is under the EMT's own license. The MD's are there for QI and to write protocols. I feel its a good system, as long as you can get a MD that is pro-ems and is willing to work to make the system run well.

[spooje]

Originally posted by RedVelvetSunset
[Also, there are lots of really good actors out there who have drug problems, and will come in to the emergency room complaining of migraine/back/abdominal pain, and be very good at convincing you that they are hurting, but miraculously, once given a shot, they are ready to get out!

I was once one of these 'actors'. Actually, 'junkie' is a better word. Around 1980, it was pretty easy to get pain meds from a doctor, especially in the E.R. BTW, we really were in pain, so it was pretty easy to sell it to a doctor. All we had to do was come up with better sounding reason for the pain than withdrawl. For whatever reason, doctors are much harder to fool these days, I'm told.

[Chas.E]

there is a lengthy article on this very topic in today's NYTimes online edition:

http://www.nytimes.com/2000/12/26/science/26PAIN.html

[Adolph Peewee]

Originally posted by kinoons
Dvous,

I'd love to come to South Australia regardless if I was practicing medicine or not.

New Mexico has a strange system for medical control (supervision of EMS). Our EMT's have our own licenses, but we have to be "signed off" by a MD who acts as a services medical director. The medical director writes protocols that the EMT follows. Most all services have standing orders for MS in cases of chest pain, (for paramedics, EMT-I's have to call and ask) and some for isolated extremity fractures. Generally the medic will call for anything not falling under chest pain. The services medical director can be very liberal, giving standing orders for several (if not all) medications, or can be VERY conservative (I've seen some services that have to call a doc to start an IV)Everything that is done is under the EMT's own license. The MD's are there for QI and to write protocols. I feel its a good system, as long as you can get a MD that is pro-ems and is willing to work to make the system run well.


ah...the joys and advantages of autonomy! Gotta love it! :)

[kinoons]

Originally posted by Adolph Peewee
Originally posted by kinoons
Dvous,

I'd love to come to South Australia regardless if I was practicing medicine or not.

New Mexico has a strange system for medical control (supervision of EMS). Our EMT's have our own licenses, but we have to be "signed off" by a MD who acts as a services medical director. The medical director writes protocols that the EMT follows. Most all services have standing orders for MS in cases of chest pain, (for paramedics, EMT-I's have to call and ask) and some for isolated extremity fractures. Generally the medic will call for anything not falling under chest pain. The services medical director can be very liberal, giving standing orders for several (if not all) medications, or can be VERY conservative (I've seen some services that have to call a doc to start an IV)Everything that is done is under the EMT's own license. The MD's are there for QI and to write protocols. I feel its a good system, as long as you can get a MD that is pro-ems and is willing to work to make the system run well.


ah...the joys and advantages of autonomy! Gotta love it! :)


Joys of autonomy? care to elaborate?

[coming up for air]

I'm serious here: It's the Protestant work ethic. No pain, no gain. The Pilgrims had to suffer, so be a man about it.

[Qadgop the Mercotan]

Originally posted by Chas.E
there is a lengthy article on this very topic in today's NYTimes online edition:

http://www.nytimes.com/2000/12/26/science/26PAIN.html

Read it, agree with it, now if only regulatory agencies would heed it, and all state medical examining boards would require the new recommendations to be read before agreeing to renew each doc's license.

No matter what we do, addicts will still scam docs and get drugs. This should not discourage docs from prescribing narcotics when, based on the knowledge they have on hand at the time, the patient seems to have a legitimate need for pain.

By the way, it is illegal for physicians to prescribe narcotics to maintain someone's addiction, except in some very specific cases. The doc can be(and has been) suspended or revoked for knowingly doing so.

Qadgop, MD

[Adolph Peewee]

Originally posted by kinoons
Originally posted by Adolph Peewee
Originally posted by kinoons
Dvous,

I'd love to come to South Australia regardless if I was practicing medicine or not.

New Mexico has a strange system for medical control (supervision of EMS). Our EMT's have our own licenses, but we have to be "signed off" by a MD who acts as a services medical director. The medical director writes protocols that the EMT follows. Most all services have standing orders for MS in cases of chest pain, (for paramedics, EMT-I's have to call and ask) and some for isolated extremity fractures. Generally the medic will call for anything not falling under chest pain. The services medical director can be very liberal, giving standing orders for several (if not all) medications, or can be VERY conservative (I've seen some services that have to call a doc to start an IV)Everything that is done is under the EMT's own license. The MD's are there for QI and to write protocols. I feel its a good system, as long as you can get a MD that is pro-ems and is willing to work to make the system run well.


ah...the joys and advantages of autonomy! Gotta love it! :)


Joys of autonomy? care to elaborate?


Autonomy: Noun; freedom to determine one's actions; behaviours etc.

however, in DVous Means's case, this autonomy is limited to their skill and training levels. The level above DVous, has a fair bit more autonomy, but this is only given after 3 years of training to enter the level that DVous is currently at, and then requires another 400 hours clinical training with a lot of "on the road" experience after that. Only then can you enjoy that sort of Autonomy.

[toadspittle]

of 401 patients in the study with acute fractures, only 30% recieved analgesia in the ED.

Hey! I was one of those in the 30%.

Ten years ago, I suffered severe fractures of my right ulna and radius (my forearm curved...really gross to look at). I was taken to the ER, sat down on a bed for a good hour, then finally given a shot of some opioid (I don't recall which), since it would be another half hour before they could x-ray me and another few hours before they could reduce the fracture.

So, kudos to them for giving it to me. Unfortunately, it did exactly jack. I noticed no difference whatsoever. Maybe it was just saline, those bastards...

Now, when they took me up to reduce the fracture (I probably should have been cut open and pinned, but the doctor was really good and managed to spare me that), the demarol drip did wonders.

So the moral of my pain anecdote: some pain meds aren't all they're cracked up to be.

Of course, I wouldn't mind a little demarol every now and then...

[Qadgop the Mercotan]

Some months ago the state of Maine mandated that doctors treat pain more aggressively there, under threat to their license, and of prosecution if they did not. Just the other day a news story appeared, saying that Oxycontin, a long-acting opiate, was all the rage in Maine, with a large black market trade going on for it, fueled by people with chronic illnesses like severe arthritis, degenerative joint disease, or migraines, selling their pills for big bucks. The increase in the abuse was linked to the mandate for physicians to prescribe more. The suggested solution was to crack down on those physicians who prescribe it "too freely", whatever that means.

Talk about having your ass in a crack!

Qadgop, MD

[kinoons]

Originally posted by Adolph Peewee
Originally posted by kinoons
Originally posted by Adolph Peewee
Originally posted by kinoons
Dvous,

I'd love to come to South Australia regardless if I was practicing medicine or not.

New Mexico has a strange system for medical control (supervision of EMS). Our EMT's have our own licenses, but we have to be "signed off" by a MD who acts as a services medical director. The medical director writes protocols that the EMT follows. Most all services have standing orders for MS in cases of chest pain, (for paramedics, EMT-I's have to call and ask) and some for isolated extremity fractures. Generally the medic will call for anything not falling under chest pain. The services medical director can be very liberal, giving standing orders for several (if not all) medications, or can be VERY conservative (I've seen some services that have to call a doc to start an IV)Everything that is done is under the EMT's own license. The MD's are there for QI and to write protocols. I feel its a good system, as long as you can get a MD that is pro-ems and is willing to work to make the system run well.


ah...the joys and advantages of autonomy! Gotta love it! :)


Joys of autonomy? care to elaborate?


Autonomy: Noun; freedom to determine one's actions; behaviours etc.

however, in DVous Means's case, this autonomy is limited to their skill and training levels. The level above DVous, has a fair bit more autonomy, but this is only given after 3 years of training to enter the level that DVous is currently at, and then requires another 400 hours clinical training with a lot of "on the road" experience after that. Only then can you enjoy that sort of Autonomy.

The level of autonomy varies widely from state to state, country to country -- Sense Adolph Peewee practices in a prehospital setting in another country. I am curious what level of autonomy he has compaired to what I can do in New Mexico

[kinoons]

Originally posted by Qadgop the Mercotan
Some months ago the state of Maine mandated that doctors treat pain more aggressively there, under threat to their license, and of prosecution if they did not. Just the other day a news story appeared, saying that Oxycontin, a long-acting opiate, was all the rage in Maine, with a large black market trade going on for it, fueled by people with chronic illnesses like severe arthritis, degenerative joint disease, or migraines, selling their pills for big bucks. The increase in the abuse was linked to the mandate for physicians to prescribe more. The suggested solution was to crack down on those physicians who prescribe it "too freely", whatever that means.

Talk about having your ass in a crack!

Qadgop, MD


Damn, no joke. Sounds like a nice case of damned if you do and damned if you don't. Sounds like the debate on pain medication will probally never end