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?
Probably because morphine is EXTREMELY addictive.
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.”
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?
Three letters:
H M 0I should say the pain med would be given in house. This is not reguarding pescribed pain meds post ER or hospital discharge.
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.
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.
**
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
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?
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
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.
Besides, don’t you want to first make sure the patient has no allergies to certain substances?
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
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
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:
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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).
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“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?
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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.
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."
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
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
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.