ABCD: Assess for BS and choose Cookbook or Discretion

“Can you tolerate being bamboozled by your patients from time to time?”

In this discussion, I think there is some context that is a bit lacking that needs to be laid down first. Specifically, what is our starting point?

If you work in a system with conservative pain management, then the concern is you’re not administering enough pain medication to enough patients. Conversely, if you work in a system with liberal pain management, then the concern is which patients you’re giving it to.

While I generally agree with the idea of aggressive pre-hospital pain management, I feel that this seemingly new trend towards very liberal, blanket pain management is just too much. It seems like a classic case of over-correction (of the past practice of very conservative pain management). I’m not referring to the safety issues of the various medications that we could use, although balancing risks (potential adverse events) and benefits (relieving bullshit pain) should always cross a provider’s mind, and I’m not referring to the basic, noble idea of relieving somebody’s pain, but rather, I’m displeased by the inappropriate selection of patients for IV pain medications. It’s almost as if people aren’t even thinking about who they’re administering medications to.

Lost in this rush to medicate everybody are basic techniques that work, such as proper splinting, traction, ice and psychological coaching. People tend to forget to use any of these methods before starting IVs and pushing medications or even after they’ve given the medications. I’m not much into cliches, but “BLS before ALS” isn’t necessarily a bad thing here. Besides, I don’t like seeing crews spend time starting IVs on calls before, say, for instance, properly splinting a fractured leg when even the patient tells them the pain is tolerable; it seems like misplaced priorities.

There are always going to be drug seekers, and there are always going to be people who are truly in pain. Our egos take a hit when they fool us, but it doesn’t really matter because it’s ultimately not really our job to decide who falls into which category. Besides, it’s not our dope.

But, at the same time, in many cases, it’s painfully (unintended pun) clear whether patients are full of shit or not. I do not agree with either extreme – either we act like the candy man and give everyone pain medications or we don’t give anyone anything. If it’s not clear if someone’s seeking or truly in pain, certainly there’s nothing wrong with medicating them.

Coincidentally, ERP had 2 posts not long ago, one after the other, in which he encountered a patient who deserved all the narcotics he could handle and 2 other patients who were so clearly seeking. He also posts about drug seekers quite often, and they’re pretty funny.

Am I, as a transport medic with short contact times, going to give IV pain medications to the lady who calls every day for the same pain? Probably not.

The guy who falls asleep on the gurney after complaining of 20/10 pain? Probably not.

The patient against whom EDs have restraining orders because of drug-seeking behavior? Probably not.

“Where the fuck is my fucking dilaudid?” Probably not.

The patient calling from a ED lobby complaining of whatever pain wanting to go to a different hospital? Probably not.

The patient who doesn’t even want medications, even if a bone is sticking out of their body? Probably not.

The patient with a broken finger or an ankle sprain? Probably not.

Menstrual cramps? Probably not.

Toothache? Probably not.

These are just hasty examples, so don’t anyone get all literal on me.

Besides, in these parts, EDs are often way too busy and many ambulance patients are sent to the lobby. EDs absolutely hate it when you bring them someone they want to put in the lobby appropriately but can’t because you’ve inappropriately medicated them, especially when they are already scrambling to find beds for legitimate patients who have been waiting in the lobby. Right or wrong – I’m all for a smooth transition. If that means helping to maintain the actual-sicker-people-first order at the ED, if that means trying to be more in tune with what the EDs want so I don’t have to wait with the patient for a bed for an hour or two and instead be available again in the system for the greater good, i.e. overall system status, then I will do exactly that. It’s a trade-off. Nothing is perfect. In a perfect world, everyone gets everything they want. But this is an imperfect world, and when there are no units available, you do what you can. It’s almost like a mini-MCI in your daily routine, spread out over a larger area and a longer timeframe.

Fundamentally, it’s no different than the concerns about liability The Happy Medic and EMS 2.0 folks raise:

Imagine I take Erma Fishbiscuit in because her dial a nurse told her to call 911 to arrange her colonoscopy.  Erma demands transport and I am bound by law to oblige her, regardless of her lack of need of an ALS ambulance.  We take her because of a perceived liability, that if we don’t take her and she sues us we will not like it one bit.

5 minutes after getting Erma loaded up a code 3 CPR in progress comes in next door to Erma and a 6 month old child dies before ALS can arrive on scene.  Are we liable for not having more ambulances?  Which liability is greater?  Which liability makes national headlines?

Or:

“Your honor, we had no ambulances because Mr Johnson’s neighbor made us take her in for a sore throat.”

Let’s say I cater to the patient’s demands for pain medications, even though it’s totally silly (and we can name countless examples), because only the patient’s opinion and perception of pain matter, as some people have suggested. (Since when do we provide patient care based solely on whatever other people tell us?) We wait a long period of time for a bed, unable to respond to other calls for service, when without pain medications, this patient could have easily and safely (and deservedly) gone to the lobby. Multiply this by whatever number you want representing other units in the system, because, let’s face facts, some type of “complaint of pain” is frequently one of the most common category of response. I just don’t see blindly medicating everyone as being responsible.

Spending time transporting the sore throat and as a result being late to the VF code is not really all that different from spending time sitting in triage and being late to the VF code. Since the ED staff routinely asks for our input when deciding who goes to the lobby, I’m unwilling to handicap them by making a lobby patient into a room patient because of IV access and medications.

There are also folks out there who say we can’t be 100% correct in sorting out the bullshit, so we shouldn’t be judging at all, in case we miss a legitimate patient, and we should instead be indiscriminately handing out pain medications like candy. I don’t agree with that at all. Following that logic, we’d be:

  • Giving Albuterol to anxiety/hypervents because we might miss bronchospasm.
  • Putting everyone in C-spine, never mind that it’s probably one of the 2 remaining bastions of old wives’ tales in patient management.
  • Bringing all chest pains to cath labs because we might miss a STEMI, especially given the low sensitivity of most algorithms.
  • Bringing all ALOCs to stroke centers because we might miss a hot stroke. (If you think cath labs and stroke centers don’t mind false activations, think again.)
  • Giving D50 to all ALOCs even without hypoglycemia. (Wait, didn’t we do this 20 years ago… oh, right…)
  • Let’s not even mention trauma centers.

Since missing any of the aforementioned conditions is actually more serious than missing a true candidate for pain medications, I would say that a few patients who didn’t get any pain medications when they could have used some isn’t the end of the world as some folks have suggested. In other words, I’ll readily accept responsibility for not going to the cath lab when I should have, but I’ll be less willing to take the blame for not administering pain medications when I could have. Yes, it’s easy to say when I’m not the one in pain – and I have experienced pain (while sucking it up big time) – but medicine by nature is never 100% and it’s not going to change. I would prefer that I be 100% correct, but that’s not going to happen.

I feel that anyone with half a brain can reliably and consistently figure out who is truly in pain and uncomfortable and who is not. We should emphasize thinking before we do something.

4 thoughts on “ABCD: Assess for BS and choose Cookbook or Discretion”

  1. At the risk of incurring the wrath of Rogue Medic and others, pain management for ortho injuries is not a primary function of ALS personnel. In a tiered system, such as mine, we don’t dispatch ALS units for that kind of injury and as you suggest our BLS crews generally manage quite well with splinting, elevation, compression, and ice packs.

    We do use pain management, and lots of it, for burn patients.

    You bring up a good point about a patient with an ankle Fx who could sit in a wheel chair becoming a patient that needs to be put into a room immediately because we gave them pain medication in the field.

    1. our BLS crews generally manage quite well with splinting, elevation, compression, and ice packs.

      According to who? The system or the patient?

      If we advertise EMS as “bringing the Emergency Room to the patient,” why do we refuse to do it for some patients?

  2. while i in principle agree with the everyone-gets-a-lot-narcs crowd, i get the impression that overlooked is how every little detail is different with every patient on every single call that goes down in every little neighborhood of every region, served by different providers and hospitals, all functioning as part of different systems.

  3. Discretion is called for. But I’ll never understand the retard who doesn’t even consider the patient’s welfare.

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