# Pain Management



## Red Flag 1 (Oct 23, 2013)

u


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## amlove21 (Oct 23, 2013)

Ketamine. Ketamine is the wonder drug de rigueur over here. From DUSTOFF to Marine MEDEVAC folks to ground units everywhere, it's quickly become the gold standard for pain management. Even ANSF/ANCOP folks we are picking up already have ketamine on board, and I am telling you- you want to completely manage a dudes pain and knock him down and make him manageable? Ketamine. Just adjust the dosing. 

The classic retort of "well, yea, but the re-emergence" has been, IMO, wildly over-reported. This is one of those clinical things that is listed and repeated ad nauseam to be truth when the ground truth is it's much less pronounced than it's made out to be. 

It's easy to administer (IM works remarkably well, even in patients with hemodynamic instability), it's really, really hard to mistakenly give a dose that's going to hurt/kill someone, and even if you do give a massive dose, it's not going to knock someone's resp drive out. They'll just trip harder. 

I loved it before, and now seeing it's use and benefit here in theatre, I can't speak highly enough of it. 

I have actually seen some great pain reduction with Toradol (Ketorlac) as well. Non narcotic, single dose 30mg, IM/IV. Easy to give, pretty good pain reduction for an NSAID, very safe.


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## policemedic (Oct 23, 2013)

I'd love to have Ketamine available in the field.  As it stands now PA paramedics are limited to opiates (MS/fentanyl/dilaudid) for pain management.  Nitrous oxide is on the state list, but I don't know of a service that uses it.  Trucks stock benzos, and some have etomidate specifically for airway management so sedation is possible.  Benzocaine and tetracaine are also on the list, but obviously those aren't going to be used for significant pain.

The biggest issue I have with pain management in civilian EMS is that very few regions/services have a specific pain management protocol.  Of those, even fewer allow appropriate dosing.  When we call for orders and request a specific pain management regimen we often deal with a resident instead of an attending who is either afraid to give an order that will allow for substantial pain relief, or believes myths like you shouldn't administer pain meds to a pt w/abdominal pain prior to physician exam. 

@Firemedic and I worked at a service where I was able to get a pain management policy instituted.  It was essentially weight-based MS04 titrated to effect.  We were the only service in several regions that could do it without asking for orders.

Pain management is given short thrift in prehospital care in this state.


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## TLDR20 (Oct 23, 2013)

Ketamine and fentanyl. We are looking at intra nasal K but i don't know the final judgement on that.


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## amlove21 (Oct 24, 2013)

We don't even bother with a "true" RSI here. If we need to secure an airway (most likely cric) someone, we use ketamine, liquid fentanyl, and maybe Succ if we have time. Almost every time, ketamine/fentanyl and a drip for maintenance is enough.


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## Muppet (Oct 24, 2013)

policemedic said:


> I'd love to have Ketamine available in the field.  As it stands now PA paramedics are limited to opiates (MS/fentanyl/dilaudid) for pain management.  Nitrous oxide is on the state list, but I don't know of a service that uses it.  Trucks stock benzos, and some have etomidate specifically for airway management so sedation is possible.  Benzocaine and tetracaine are also on the list, but obviously those aren't going to be used for significant pain.
> 
> The biggest issue I have with pain management in civilian EMS is that very few regions/services have a specific pain management protocol.  Of those, even fewer allow appropriate dosing.  When we call for orders and request a specific pain management regimen we often deal with a resident instead of an attending who is either afraid to give an order that will allow for substantial pain relief, or believes myths like you shouldn't administer pain meds to a pt w/abdominal pain prior to physician exam.
> 
> ...


 
FUCK P.A. bro. I am tired of this commonwealth...What Policemedic said though...

F.M.


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## Red Flag 1 (Oct 24, 2013)

too.


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## Muppet (Oct 24, 2013)

We (out medic unit) uses Fentanyl. All extremity injuries get that. Like Policemedic said, lots of docs are afraid to use it for abd. pain. Hell, I could have a old lady fall, hip f/x, femur f/x, hook her up with 100mcg. Fent. and the Level-2 trauma E.D. near here in this county will bitch and complain, stating that the ortho docs hate pre-hospital pain meds. (fuck them) and medics that give it "ruin" the pt's mentation when going to assess pt's. Well, my retort when a doc bitches... I do not give it for multi-systems trauma (though you can in low doses) and this particular pt. did not strike her head, had no L.O.C.,had no neck / back pain (not needing a long board), hence the reason we give Fent. I also tell the docs...If you don't like it, complain to my medical director (a very pro active EMS doc) and also complain to the state (which writes the SOP's). I would love to have Ketamine.

F.M.


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## Red Flag 1 (Dec 15, 2013)

field?


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## dirtmover (Dec 24, 2013)

Our medics aren't allowed to carry Ketamine as per the doctor we fall under.  Hell she won't even allow them to have a fucking suture kit.  It really sucks because as the bases close down we have less access to get that care for a soldier,  case in point we had a soldier cut him self in the forearm with a gerber blood squirted pretty far.  We were lucky that the PA in Farah wasn't due to fly out until the next day, he got some stitches that day but it was several days before we got back to Shindand.


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## policemedic (Dec 24, 2013)

dirtmover said:


> Our medics aren't allowed to carry Ketamine as per the doctor we fall under.  Hell she won't even allow them to have a fucking suture kit.  It really sucks because as the bases close down we have less access to get that care for a soldier,  case in point we had a soldier cut him self in the forearm with a gerber blood squirted pretty far.  We were lucky that the PA in Farah wasn't due to fly out until the next day, he got some stitches that day but it was several days before we got back to Shindand.



Your medics won't like hearing it, but your doc (BN surgeon?) is absolutely right.  The typical, (only) schoolhouse trained 68W should not be managing a medication like ketamine nor be considering laceration repair.  I honestly think 68Ws are permitted to do too much as it is.


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## policemedic (Dec 24, 2013)

Red Flag 1 said:


> Has anyone used, or are there discussions about using Ofirmev (acetaminophen) in the field?



I'm behind on this, but no, I've not heard anything.  But then again, it's only been available for what, 2 years?


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## dirtmover (Dec 24, 2013)

Our doc is at the BDE level.  Our medics where trained on the proper usage and dosage in some class that they went to at Ft Sam so that they would have the option of being able to use it.  There are other conventional units that are allowing their medics to have Ketamine.  This is the first time that our medics haven't been able to carry suture kits.


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## policemedic (Dec 24, 2013)

Has your doc tested your medics for competency?  That might be part of the issue.

I wasn't comfortable with the level of training I saw coming out the 68W schoolhouse.  This often extended to 68Ws with combat experience.  It's a matter of reach exceeding grasp.  For example, being unable to satisfactorily answer questions about drugs they were taught to use, or list contraindications to flu vaccine they were giving out.


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## dirtmover (Dec 24, 2013)

Ok I see where you are coming from Policemedic.  When I had talked to the Dr. I had suggest that could do a class on sutures but I don't think she liked the idea of leaving KAF for more than a couple of days. lol


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## TLDR20 (Dec 24, 2013)

Or maybe you guys have a bunch of fucked up medics. I have seen the 68W product and it is not a good one. Further just because someone thinks they can suture, sure as shit doesn't mean they can suture, and one class on Ketamine does not an expert make. While Ketamine is an easy drug to understand, there is a lot going on physiologically that is beyond a 68W's grasp.


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## dirtmover (Dec 24, 2013)

I'm not saying that the class was the end all be all...my understanding of the class was that it was required for them to pass in order to be able to carry their narcotics kit to include Ketamine.  I never went to the class myself.  I know in the past we have had our BN PA give them classes on suturing to make sure that they understood what to do.  We have three line medics that actually know their stuff and one that is working towards getting her RN.  I am not saying that we have the top 3 medics that are God's gift to the medical core but they are competent and are knowledgeable of the limits.  I by no means saying that they are at the level that the SOF people get but they are far from the bottom of the barrel. 

The only reason why I made the comment that I did was that if they meet the Army's requirement to be able to utilize Ketamine then why don't they get the option to do so.  My initial post was unclear and poorly written to convey my intent.


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## TLDR20 (Dec 24, 2013)

dirtmover said:


> The only reason why I made the comment that I did was that if they meet the Army's requirement to be able to utilize Ketamine then why don't they get the option to do so.  My initial post was unclear and poorly written to convey my intent.



They work under the Bn PA or docs license. Not the Army's. That individual has the right to dictate protocol/formulary.


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## policemedic (Dec 24, 2013)

Regarding suturing, I wonder how many 68Ws could intelligently discuss the types of stitches, indications for each, local infiltration versus nerve blocks, antibiotic coverage, and possess a sufficient knowledge of anatomy and physiology to execute the techniques safely. 

Whenever a new technique is being considered for addition to a person's scope of practice, the first question that must be answered is why that person needs to do the skill.  I submit that delayed primary closure by a properly trained provider is often a perfectly valid clinical choice. Why do your medics think they need to suture?

Like @TLDR20 said it's not the physical skill that's the problem per se but the lack of in-depth knowledge that is dangerous. 

I can have a somewhat intelligent conversation about the chemistry of explosives. But I don't mess with bombs; that's beyond my skill set and I call the bomb Kitteh.  The same is true of medicine; one must know one's limits.   For this reason, I never sutured hands or faces (and fully understood why I shouldn't).


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## pardus (Dec 24, 2013)

Suturing is really outside the scope of what a 68W does/needs to do.


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## Muppet (Dec 24, 2013)

When I was @ Bragg, part of our (the medics in batt) had to pull coverage in the 82nd. Abn. clinic (Roscoe Robinson) on Long Street. We also had to pull coverage in WOMAC ED and the ambulance service (someway something was instituted with them). This is where I learned sick call procedures, suturing...It so happenned out Batt P.A. was one of the docs in charge of training us up and like many said here, we had to know patho-phys of everything we did before Doc T. would sign us off. By this time I was certed as a paramedic and for the most part, our medic stuff was used on the MICU. I learned alot fro Doc T. (former 18D from group and "other places" / now a P.A.). He really trained us up but I think that was not commonplace then / prolly now also? Don't know. I also remember CLS learning I.V.'s form which the doc was not too happy. All the guys measured their medic's skill on a damned I.V. That really pissed me off and this was in the 90's.

F.M.


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## pardus (Dec 24, 2013)

Firemedic said:


> When I was @ Bragg, part of our (the medics in batt) had to pull coverage in the 82nd. Abn. clinic (Roscoe Robinson) on Long Street. We also had to pull coverage in WOMAC ED and the ambulance service (someway something was instituted with them). This is where I learned sick call procedures, suturing...It so happenned out Batt P.A. was one of the docs in charge of training us up and like many said here, we had to know patho-phys of everything we did before Doc T. would sign us off. By this time I was certed as a paramedic and for the most part, our medic stuff was used on the MICU. I learned alot fro Doc T. (former 18D from group and "other places" / now a P.A.). He really trained us up but I think that was not commonplace then / prolly now also? *Don't know. I also remember CLS learning I.V.'s form which the doc was not too happy. All the guys measured their medic's skill on a damned I.V. That really pissed me off and this was in the 90's.*
> 
> F.M.



CLS don't do IV's anymore, and we have much less emphasis on them now. When I first started all you heard was IV, IV, IV. Hell doing a successful IV was a requirement to graduate from basic training in Benning when I went through.


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## policemedic (Dec 24, 2013)

pardus said:


> CLS don't do IV's anymore, and we have much less emphasis on them now. When I first started all you heard was IV, IV, IV. Hell doing a successful IV was a requirement to graduate from basic training in Benning when I went through.



Yes, because people die without an inch long plastic straw in their vein dagnabbit!  Never mind understanding what you're running through the line and what it will do to the patient…..


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## pardus (Dec 24, 2013)

policemedic said:


> Yes, because people die without an inch long plastic straw in their vein dagnabbit!  Never mind understanding what you're running through the line and what it will do to the patient…..



Ive just joined a new unit and they are still talking about saline IV's for trauma. I'm gently prodding them about colloids only for trauma _if_ it is indicated.


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## racing_kitty (Dec 24, 2013)

policemedic said:


> Yes, because people die without an inch long plastic straw in their vein dagnabbit!  Never mind understanding what you're running through the line and what it will do to the patient…..



The only good IV training did my peers and me was after Monday morning runs that were preceded by particularly raucous weekends. I don't think barracks IV parties were the original intent of CLS. I wasn't the least bit disappointed when IV training went away.


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