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Home > List Archives

pain and suffering

Andrew J Bowman trauma-list@trauma.org
Sun, 13 Apr 2003 13:23:12 -0500


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Nick,

Thanks for your feedback.  The "pain management" protocol used by the =
outlying service in question allows for titrated morphine for the =
treatment of ISOLATED extremity injury.  It is clearly stated as such IN =
the protocol.  However, we still receive patients who have received 10mg =
or more of MS for their multi-system trauma.  Their medical director has =
been informed but nothing has changed.

Yes, altered LOC is one of many s/s of head injury.  But if the patient =
was alert before and now is altered after MS, is it JUST the MS or an =
expanding lesion, or brain ischemia, or hypoxia???

By the way, you practice paramedicine under the your medical director, =
just like I practice nursing and paramedicine (I am a paramedic and a =
nurse) in my respective environments.  To practice medicine requires an =
MD behind your name, not on the name of the person above you.

Andrew
  ----- Original Message -----=20
  From: Nick Nudell=20
  To: trauma-list@trauma.org=20
  Sent: Saturday, April 12, 2003 7:01 PM
  Subject: Re: pain and suffering


  Andrew

  The purpose of protocols is to remove the 'borderline vitals' factors =
so that standardized treatment may be provided. Either the BP was over =
100 or under it (or whatever the particular vital you are speaking =
about).

  I have not seen 10mg of MS IV do horrible things to vitals... no, I =
see pain causing sympathetic rises in vitals which are then mediated by =
the removal of the pain. They are not hypotensive because of the MS but =
because of the lack of pain. As for altered, if you do a proper =
assessment you should be able to determine if the patient is altered. =
Does it matter if the altered has come from the MS or a head injury? The =
fact the patient is altered is only ONE of many signs/symptoms that =
would be used to diagnose a head injury, so really that is a moot point.

  I am a paramedic, I DO practice medicine, under the delegated practice =
of my medical director. If you have a problem with the treatment =
provided by your local paramedics, I would suggest that you document the =
problem, provide some evidence for your problem and approach the medical =
director who has approved the protocols that you have the problem with. =
Period. End of Story.

  Nick


  ____________________________________________
  Nick Nudell, NREMT-P, CCEMT-P
  California
  nudell@prehospital-perspective.com

  "Perception is reality" - Wise Old Paramedic




    ----- Original Message -----=20
    From: Andrew J Bowman=20
    To: trauma-list@trauma.org=20
    Sent: Saturday, April 12, 2003 6:38 AM
    Subject: Re: pain and suffering


    I have no problem with medics making decisions, they make sound ones =
everyday.  I have a problem with medics who break protocol (just like I =
have a problem with nurses who break protocol).  The problem I describe =
is a multisystem trauma patient with borderline vitals who gets 10mg of =
MS IV.

    Then when they hit the ER, are they altered because of the MS or =
brain injury?  Are they hypotensive because of the MS or bleeding?

    Medics do great job, but they should not be practicing medicine, if =
they feel a patient would benefit from an intervention that is not =
covered by their protocol then that is why they have radios and cell =
phones, to call in and discuss/request from the ED physician getting the =
patient.

    Andrew
      ----- Original Message -----=20
      From: michael riordan=20
      To: trauma-list@trauma.org=20
      Sent: Saturday, April 12, 2003 1:32 AM
      Subject: pain and suffering


      Andrew,

       I seem to recall you posted a like thread like this before. You =
seem to have a problem with paramedics making a decision. Do you think =
every trauma patient in the field will become hypotensive after morphine =
is given? Or is it that it only happens with paramedics?=20

      Luckily in Australia we dont have such regressive thinking. IC =
paras dont need to consult. We would more likely get strange looks at =
the ED if we took a patient into hospital in pain (from whatever) that =
should have been reduced. =20

      What is wrong with giving morphine to a patient in pain? =
Especially from trauma. Especially in outlying areas. You would prefer =
some one to be in pain until the hospital? I cannot fathom the logic.=20

      Michael

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<DIV><STRONG><FONT size=3D2>Nick,</FONT></STRONG></DIV>
<DIV><STRONG><FONT size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT size=3D2>Thanks for your feedback.&nbsp; The "pain =
management"=20
protocol used by the outlying service in question&nbsp;allows for =
titrated=20
morphine for the treatment of ISOLATED extremity injury.&nbsp; It is =
clearly=20
stated as such IN the protocol.&nbsp; However, we still receive patients =
who=20
have received 10mg or more of MS for their multi-system trauma.&nbsp; =
Their=20
medical director has been informed but nothing has=20
changed.</FONT></STRONG></DIV>
<DIV><STRONG><FONT size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT size=3D2>Yes, altered LOC is one of many s/s of head=20
injury.&nbsp; But if the patient was alert before and now is altered =
after MS,=20
is it JUST the MS or an expanding lesion, or brain ischemia, or=20
hypoxia???</FONT></STRONG></DIV>
<DIV><STRONG><FONT size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT size=3D2>By the way, you practice paramedicine under =
the your=20
medical director, just like I practice nursing and paramedicine (I am a=20
paramedic and a nurse) in my respective environments.&nbsp; To practice =
medicine=20
requires an MD behind your name, not on the name of the person above=20
you.</FONT></STRONG></DIV>
<DIV><STRONG><FONT size=3D2></FONT></STRONG>&nbsp;</DIV>
<DIV><STRONG><FONT size=3D2>Andrew</FONT></STRONG></DIV>
<BLOCKQUOTE dir=3Dltr=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3Dparamednick@comcast.net =
href=3D"mailto:paramednick@comcast.net">Nick=20
  Nudell</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Saturday, April 12, 2003 =
7:01=20
  PM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: pain and =
suffering</DIV>
  <DIV><BR></DIV>
  <DIV><FONT size=3D2>Andrew</FONT></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT size=3D2>The purpose of protocols is to remove the =
'borderline=20
  vitals' factors so that standardized treatment may be provided. Either =
the BP=20
  was over 100 or under it (or whatever the particular vital you are =
speaking=20
  about).</FONT></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT size=3D2>I have not seen 10mg of MS IV do horrible things =
to=20
  vitals... no, I see pain causing sympathetic rises in vitals which are =
then=20
  mediated by the removal of the pain. They are not hypotensive because =
of the=20
  MS but because of the lack of pain. As for altered, if you do a proper =

  assessment you should be able to determine if the patient is altered. =
Does it=20
  matter if the altered has come from the MS or a head injury? The fact =
the=20
  patient is altered is only ONE of many signs/symptoms that would be =
used to=20
  diagnose a head injury, so really that is a moot point.</FONT></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT size=3D2>I am a paramedic, I DO practice medicine, under =
the=20
  delegated practice of my medical director. If you have a problem with =
the=20
  treatment provided by your local paramedics, I would suggest that you =
document=20
  the problem, provide some evidence for your problem and approach the =
medical=20
  director who has approved the protocols that you have the problem =
with.=20
  Period. End of Story.</FONT></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT size=3D2>Nick</FONT></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><BR><FONT =
size=3D2>____________________________________________<BR>Nick=20
  Nudell, NREMT-P, CCEMT-P<BR>California<BR></FONT><A=20
  href=3D"mailto:nudell@prehospital-perspective.com"><FONT=20
  size=3D2>nudell@prehospital-perspective.com</FONT></A></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT size=3D2>"Perception is reality" - Wise Old =
Paramedic</FONT></DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV><FONT size=3D2></FONT>&nbsp;</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>&nbsp;</DIV>
  <BLOCKQUOTE dir=3Dltr=20
  style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
    <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
    <DIV=20
    style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
    <A title=3Dsumieb@compuserve.com =
href=3D"mailto:sumieb@compuserve.com">Andrew J=20
    Bowman</A> </DIV>
    <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
    href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
    <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Saturday, April 12, =
2003 6:38=20
    AM</DIV>
    <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: pain and =
suffering</DIV>
    <DIV><BR></DIV>
    <DIV><STRONG><FONT face=3DTahoma size=3D2>I have no problem with =
medics making=20
    decisions, they make sound ones everyday.&nbsp; I have a problem =
with medics=20
    who break protocol (just like I have a problem with nurses who break =

    protocol).&nbsp; The problem I describe is a multisystem trauma =
patient with=20
    borderline vitals who gets 10mg of MS IV.</FONT></STRONG></DIV>
    <DIV><STRONG><FONT face=3DTahoma =
size=3D2></FONT></STRONG>&nbsp;</DIV>
    <DIV><STRONG><FONT face=3DTahoma size=3D2>Then when they hit the ER, =
are they=20
    altered because of the MS or brain injury?&nbsp; Are they =
hypotensive=20
    because of the MS or bleeding?</FONT></STRONG></DIV>
    <DIV><STRONG><FONT face=3DTahoma =
size=3D2></FONT></STRONG>&nbsp;</DIV>
    <DIV><STRONG><FONT face=3DTahoma size=3D2>Medics do great job, but =
they should=20
    not be practicing medicine, if they feel a patient would benefit =
from an=20
    intervention that is not covered by their protocol then that is why =
they=20
    have radios and cell phones, to call in and discuss/request from the =
ED=20
    physician getting the patient.</FONT></STRONG></DIV>
    <DIV><STRONG><FONT face=3DTahoma =
size=3D2></FONT></STRONG>&nbsp;</DIV>
    <DIV><STRONG><FONT face=3DTahoma =
size=3D2>Andrew</FONT></STRONG></DIV>
    <BLOCKQUOTE dir=3Dltr=20
    style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
      <DIV style=3D"FONT: 10pt arial">----- Original Message ----- =
</DIV>
      <DIV=20
      style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
      <A title=3Driordanms@optusnet.com.au=20
      href=3D"mailto:riordanms@optusnet.com.au">michael riordan</A> =
</DIV>
      <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
      href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
      <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Saturday, April 12, =
2003 1:32=20
      AM</DIV>
      <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> pain and =
suffering</DIV>
      <DIV><BR></DIV>
      <DIV><FONT face=3DArial size=3D2>Andrew,</FONT></DIV>
      <DIV>&nbsp;</DIV>
      <DIV><FONT face=3DArial size=3D2>&nbsp;I seem to recall =
you&nbsp;posted a like=20
      thread like this before. You seem to have a problem with =
paramedics making=20
      a decision.&nbsp;Do you&nbsp;think every trauma patient in the =
field will=20
      become hypotensive after morphine is given? Or is it that it only =
happens=20
      with paramedics? </FONT></DIV>
      <DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
      <DIV><FONT face=3DArial size=3D2>Luckily in Australia we dont have =
such=20
      regressive thinking. IC paras dont need to consult. We would more =
likely=20
      get strange looks at the ED if we took a patient into hospital in =
pain=20
      (from whatever) that should have been reduced.&nbsp; </FONT></DIV>
      <DIV>&nbsp;</DIV>
      <DIV><FONT face=3DArial size=3D2>What is wrong with giving =
morphine to a=20
      patient in pain? Especially from trauma. Especially in outlying =
areas. You=20
      would prefer some one to be in pain until the hospital? I cannot =
fathom=20
      the logic. </FONT></DIV>
      <DIV>&nbsp;</DIV>
      <DIV><FONT face=3DArial=20
size=3D2>Michael</FONT></DIV></BLOCKQUOTE></BLOCKQUOTE></BLOCKQUOTE></BOD=
Y></HTML>

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