There is a great post at StreetWatch on prehospital pain management and one of the obstacles to good patient care.
Peter writes about the way that they finally were able to approve standing orders for pain medicines.
The reason we had to contact medical control when I started was a state law that required “simultaneous communication” with a physician in order to dispense controlled substances. That was interpreted to mean on-line control. After I discovered other states did not have a similar provision and that controlled substances were allowed to be given on standing order in those states, I went about changing our state’s law. I met with the DEA (who are charged with overseeing federal and state controlled substances laws), and with the state medical advisory committee. I eventually testified before the legislature on the issue and they changed the law to allow standing orders. Then once that was allowed, within our region, we started at 5 mg of morphine on standing order and then in time upped it to 10 mg and then to the 15 mg we currently have as well as broadening the indications for pain management to include abdominal pain.[1]
Peter did not just wait for the doctors to get around to doing what is right for patients. This is pain management. How often do we see doctors going out of their way to do the right thing for the patient? I don’t know what your answer is, but my experience has been that it is not enough.
If I were to use two words to describe the management of pain in EMS, those words would be not enough.
There are some great doctors, who do a lot to improve EMS, but those same doctors are also generally trying to accomplish a dozen different things at once. None of those dozen things may be unimportant, or only a few of them are likely to be unimportant.
We need to do what we can, on our own, to get other doctors to change our protocols to allow us to provide appropriate patient care.
If we continue to rely on whatever the doctors let us do, our patients will continue to be limited to not enough.
Do we want to provide excellent patient care?
Or.
Do we want to keep our heads down and avoid doing anything that might attract attention from an administrator, or from a medical director, or from any doctor at any hospital we might transport to – no matter how much we have to hurt patients do do this?
We can change things, so that we do not have to hurt our patients.
And many prefer not to exercise their imaginations at all. They choose to remain comfortably within the bounds of their own experience, never troubling to wonder how it would feel to have been born other than they are. They can refuse to hear screams or to peer inside cages; they can close their minds and hearts to any suffering that does not touch them personally; they can refuse to know.[2]
There is plenty of research that shows that EMS can do an excellent job of managing pain on standing orders.
There is no research to support any kind of need for on line medical command permission for any pain medicine.
There is no good reason for us to continually be giving doses that are not enough.
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if the patient is still awake, breathing and in pain, just because I have hit my standing order limit, doesn’t mean I shouldn’t call in for more. All I have to do is pick up the radio and ask to talk to a doc. How hard is that?[1]
This is also important.
Limits on standing orders are not limits on patient care. We can always call medical command for orders to give more.
What’s the worst that can happen?
A doctor tells me that the patient cannot be in pain after that much morphine/fentanyl. Then we transport to the hospital and I get the doctor to come over and assess the patient himself and the doctor learns that a patient can be in a lot of pain after that much morphine/fentanyl. The doctor is then better able to understand what appropriate pain management is.
If the worst that can happen is that the doctors think I care too much about treating pain, is that a bad thing?
It is important to point this out to the doctor. Unless you have some sort of remote medical command system, the doctor is the one who does not believe that the patient is in pain after whatever treatment was given on standing orders.
It is medical command doctor’s job to demonstrate to us that this patient is not still in significant pain.
If this doctor is comfortable denying treatment to this patient, the doctor needs to see what the patient is really like – if we are to change things so that we can provide appropriate pain management.
We should not be disrespectful.
Doctors are generally great about answering questions. When I ask doctors about what is going on with a patient, unless they are extremely busy, they take some time to answer me. By getting doctors to try to explain how patients in severe pain do not actually have severe pain, we should be able to get these doctors to realize that their orders are not enough.
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There is plenty of research that shows that EMS can do an excellent job of managing pain on standing orders.
There is no research to support any kind of need for on line medical command permission for any pain medicine.
There is no good reason for us to continually be giving doses that are not enough.
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Footnotes:
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[1] You Gave Her 20 Milligrams?!!
StreetWatch
Article
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[2] Text of J.K. Rowling’s speech
‘The Fringe Benefits of Failure, and the Importance of Imagination’
Harvard Commencement 2008
Harvard Gazette
Text
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