The next topic for discussion in the naemsp dialog will be Prehospital

Ann Emerg Med. 2007 Mar;49(3):335-40. Epub 2006 Oct 25.
Derek Isenberg, MD, NREMT-P

Medical Director

Mercy EMS

Mercy Catholic Medical Center

Department of Emergency Medicine

501 South 54th Street

Philadelphia, PA 19143

215.748.9740

215.748.9208 (fax))

Hi
About Fentanyl,

We can not say that fentanyl is better than morphine. There is not study to

confirm that.

morphine (2005) ; sufenta vs morphine (2010)). The last one (in press)

compared morphine and sufentanil (titrated, IV) in trauma patients in

prehospital setting. This study showed that the rate of relief patient was

better only one time, at 9 minutes after injection in sufentanil group. But

3, 6, 12 and 15 minutes there was no difference. However morphine was better

in the next hours (6 hours follow up). Bounes et al Ann Emerg Med 2010 (in

press).
Kind regards

Centre National de Ressources de lutte contre la Douleur - CNRD.

H pital Armand Trousseau

26, av Arnold Netter

75571 Paris cedex 12

Secretariat: 01 44 73 54 21

Site internet: www.cnrd.fr

Hi Paul, yes this is a subject that interests me - from a clinical

reasoning aspect and also from a attitudinal perspective. There is

limited research into paramedic attittudes towards analgesia - Jones &

Machen 2003; Hennes, Kim & Pirrallo 2005 are a couple that spring to

mind that explored this somewhat. I think that there is a lack of

education about pain theory - physiology, patient-focused assessment

of pain, and appropriate pain management. It is unfortunate that many

services have limited pain management options, further 'boxing'

paramedics thinking towards the management of pain.

I'm looking foward to reading the rest of this discussion!
Sarah Werner

Sarah Werner

CEU Tutor, Advanced Paramedic

St John, New Zealand

In New Zealand, we have used 50% nitrous oxide / 50% oxygen (Entonox)

for many years with good effect. In 2007 we introduced methoxyflurane,

but in some areas the economics of using methoxyflurane has meant that

Entonox has replaced methoxyflurane... Our procedures (which have a

good amount of latitude in them) indicate Entonox for mild-moderate

pain. Entonox is safe to use, the cylinder can be last more than one

patient, and patients acheive good short term relief - if properly

instructed in the use, have an adequate tidal volume for inhalation,

and the patient has the ability to comprehend and self-administer.

Methoxyflurane is indicated in our procedures for moderate to severe

pain. Both can be administered at BLS level, hopefully meaning that

our patients get short-term analgesia, with the option of ILS / ALS

backup for parenteral analgesia (we have morphine, ketamine and

midazolam available for use).
Sarah Werner

CEU Tutor, Advanced Paramedic

St John, New Zealand

The discussion has gotten quiet and we have had the topic open for

over a month now, so I'm going to ask if any of our invited

participants or others have any closing remarks or summations , to

please post them today or tomorrow.
Thanks,
--- Mic

Mic Gunderson

Editor / Moderator, NAEMSP Dialog;

President, IPS

Pain. We've talked about it a lot, discussed "evidence" and clinical practice.What we have all said it that EMS providers should have options for treating pain. Some alternatives won't be medications, and while some of the medications will be injectable, some should be either oral, inhaled or intranasal. Some of the medications options studied in other parts of the world will not be options in the US. Providers must focus on the pain as their patients report it, but this may not always mean administering medication.
So what are my last thoughts as we close the thread?
For physician medical directors: Give your providers the tools and training to do the job. Advanced providers should have access to opiate analgesia for their patients. Fentanyl offers the option of intranasal as well as IV or IM administration. Consider working with your regulators to allow standing order administration of narcotics within specific practice parameters--physician online medical command does not decrease the opportunity for diversion, it merely delays care for patients. Good medical oversight, CQI and narcotics record keeping reduce the chance for diversion.
For managers: Have strict but reasonable narcotic oversight. Administrative requirements should not prevent care. Study diversions that have occurred elsewhere and use them as lessons. Make sure there are programs available for providers in crisis, before they dip into the narcotics.
For providers: Focus on pain, evaluate your patients for pain, treat appropriately and document accordingly, and most of all, treat your patients as you would want to be treated.
Be safe.
MD

Michael W. Dailey, MD FACEP

Director of Prehospital Care and Education

Associate Professor of Emergency Medicine

Albany Medical Center

518/ 262-3773

and for all: remember that sometimes the best anodyne for pain is a smooth

ride, a gentle smile, and a warm hand to hold.
ck

Charles S. Krin, DO

Retired FP/EP/EMS physician; educator and author

Requirements for on line medical command permission only deprive the

patient of appropriate care.
There is nothing about being a doctor on the other end of a radio or

phone call that improves the safety of the use of opioids to treat

pain.
As Dr. Daily wrote: "Give your providers the tools and training to do the job."

If medical directors lack confidence in the abilities of their

paramedics, then the answer is to better educate those paramedics.

This is not really difficult. Possible means of education include

observing/participating in procedural sedation in the emergency

department. This would not be a preparation for paramedics performing

procedural sedation, but for educating paramedics about the assessment

of respiratory depression.

burn center to get some experience with the treatment of severe pain

with large doses of opioids. Again, not to prepare them to use such

large doses (unless they have patients with similar burns), but to

learn to assess the patient's response to pain medicine and to assess

for respiratory depression.

Waveform capnography is the best safety net in all of EMS.

Even if you never give a patient anything stronger than an aspirin,

competence with waveform capnography is essential for competence in

EMS.
Is there any good reason a patient in pain should have to wait until

arriving at the emergency department to receive adequate pain

management.
There is no maximum dose of any opioid (except for meperidine/

pethidine, but that is the wrong drug to use), the maximum dose is

whatever the patient says produces relief or whatever produces

unacceptable side effects before relief of pain.

patient.

the patient.

with opioids without determining if the paramedic can titrate opioids

to pain relief or to side effects?
Tim Noonan.

http://roguemedic.com/

Dear all

Paul M Middleton

Director, Ambulance Research Institute

Medical Director, Ambulance Service of NSW

Not sure if this had been posted yet as part of the discussion, but here is link to NAEMSP position statement:

http://www.naemsp.org/pdf/Prehospital_Pain_Management.pdf
Brendan Kearney, MPA, EMT-P

Superintendent in Chief

Boston Emergency Medical Services

767 Albany Street * Boston * MA 02118

Phone: (617) 343-2367 * Fax: (617) 343-1199

Email: Kear...@bostonems.org * Website: http://www.cityofboston.gov/ems/

I completely agree with Gene and Michael. We must come together as a

professional body and approach the states with restrictive protocols

in an attempt to give them advice and encourage them to examine this

extremely important issue.
One way for providers and services to justify these changes is to

actively assess all patients for pain and provide medical directors

and state officials with real data of the need. This issue can not be

addressed with anecdotal accounts.

Medical Director

HealthEast Medical Transportation

St. Paul, MN

- The lack of appropriate pain management is the problem.

believe the start to a solution is an understanding as to why we are

so poor at pain management.
For the provider:
- De-emphasize the need to identify who is really in pain and who is

just seeking pain medications.

- Treat all pain, whether it be BLS or ALS treatment.

- Gauge the pain off of the subjective information provided by the

patient (i.e. severity scale)
For the services:
- Train your people that a narcotic dependency is not a prehospital

contraindication for pain management.

- QA these 'pain calls' as if it were an AMI patient who hadn't

received aspirin.

- Provide as many pain management options as possible with appropriate

education and protocols regarding each one.

- Follow the evidence.

opinion as a result of being proven wrong...

Lee County EMS

EMS Educator - Edison State College

Paramedicine101.com

EMSworld.com

Lee County, Florida

I would like to agree with Adam's spot on list and add one more. Remove

barriers to the giving of analgesic medications. Requiring that certain

medications be in a safe in the truck instead of routinely carried to the

patients side with the rest of the drug box, has been demonstrated to reduce

usage. The need to chase down a particular attending for a signature when

drugs are given and then replace meds by catching the pharmacist at a

certain time by going down two flights of stairs through a tunnel and over a

bridge to find the pharmacy are all barriers to appropriate use of

analgesics.

Education Coordinator

77-D Willow Street

New Haven, CT 06511

(203)562-3320 ext. 202

(203)562-9070 fax

www.sponsorhospital.org

dtau...@sponsorhospital.org

Just before this session on pain management comes to a close, I'd like

to ask that if anyone has articles, other documents or links that they

think might be helpful to others seeking information on the topic, to

please send those items to me directly at mic.gunder...@gmail.com.

They will be considered for use on the pain management resource page

that will be also contain a condensed version of the pain management

discussion thread. The intent is to have each of these resource pages

become a place where those looking for information to use in updating

their protocols, policies and procedures can tap into the collective

wisdom and resources of the list members and invited participants.

Several changes are underway because the structure of Google Groups is

changing. The discussion threads will remain here but the file storage

and page capabilities will be removed. As a result, the Dialog

resource pages with the condensed discussion threads and associated

document files and links will be relocated to a new Google Site page.

Bendall, Bryan Bledsoe, Michael Dailey, Michel Galnski, Paul

Middleton, Paul Simpson and Keith Wesley.
Finally, thanks to all of you for your participation and letting your colleagues know about this resource. We are now up to 257 members. Please continue to let people

know about it. The more EMS professionals we have here, the more

collective experience and wisdom we will be able to tap into and the

wider the information will be disseminated.

Editor/Moderator