230 lb guy slips in the shower, lands on his shoulder. When we get there he is in extreme pain and has an obviously deformed shoulder. It is either fractured, dislocated or both.
What do you do for pain?
Morphine.
Okay, now here's the catch. The location is a drug and alcohol rehab clinic, the patient is an ex-heroin user on methadone, who is there for cocaine/ETOH abuse.
I discuss the drug options with him. All I have is morphine. Does he have a problem with getting morphine seeing as he is going through rehab? And I tell him even if I give it to him, it may not touch him due to his past use. He's no doubt developed a certain tolerence.
He says he hurts bad. 10 out 10 on the pain scale. I can see that. I give him 5 milligrams, then another five milligrams.
10 of 10 goes down to an 8 of 10.
I call medical control for permission to give him another ten. I do it with some hesitation because I know when I tell them about his drug history they will probably deny me out of reflex.
Another 10 milligrams is a lot to ask for, but that's how much he needs. They say no. From the nurse's voice relaying the doctor's decision I feel they are saying "What are you crazy?"
At triage I show the nurse his deformed shoulder. "Just because he has a drug history, doesn't mean he shouldn't get pain relief," I say.
She smiles and says, "yes, dear." She and I are friends.
I talk to a doctor about it later. He says he is reluctant to give anyone 20 milligrams of morphine. But I argue that 10 is the standard weight based dose for someone of my patient's size just to start.
Another 10 is a lot, he says.
I argue that people are drastically undermedicated in ERs.
He doesn't disagree.
And I say because the patient has used opiates in the past he should get more medication, not less.
That could be true, the doctor says, but he says he would be relucatnt to give that much to someone he hasn't personally seen.
And I add just because I was only five minutes out doesn't mean the patient will he get meds in five minutes at the ER. It will be more like 40 minutes.
Well, that's not always true, the doctor says.
But as I am walking out -- this after I have brought another patient in -- this one for seizures, my patient with the messed up shoulder is just now an hour later getting more medicine. They give him 10 milligrams of morphine. Thank you.
I don't dispute a doctor's right to deny someone the extra morphine, but if we want to take people's pain away -- which is the goal -- we have to be more aggressive than we are.
I have been on a crusade to adequately medicate my patients. I considered it, but did not not let the patient's drug past affect me. Pain is pain.
***
I once had a patient who spilled boiling water on her arm. Entire arm one big painful raw blistering second degree burn. I gave her ten of morphine and called for orders for more. I was denied. When the doctor saw her as I was wheeling the patient in -- she was poor and black, the doctor said the ten probably didn't work because she was a drug addict. The doctor kept on walking down the hall. That really torqued me. She needed more pain relief right then.
Even if she was a drug addict, she was in obvious pain. Burns are very, very painful. And even if she was a drug seeking drug addict, if she poured boiling water on her arms to get a shot at getting high(unlikely and very stupid), then she deserves to get her prize.
What would you do to get morphine? I'd pour boiling water on my arm. Okay, I'll give it to you then.
Same with the guy, if somehow he concocted to break his shoulder so he could get a fix, well, he earned it. We set the bar high, and by golly, he jumped over it.
***
National Association of EMS Physicians Prehospital Pain Management Position Paper
"In spite of frequent contact with patients who have a painful condition, multiple investigators have demonstrated that prehospital personnel and emergency physicians fail to recognize and properly treat pain." - National Association of EMS Physicians Prehospital Pain Management Position Paper
Pain and Comfort, The Pathophysiology of Pain and Prehospital Treatment Options, JEMS 2003
"It's unethical to withhold appropriate analgesia based solely upon addiction concerns." - Jeff Meyers, DO, NREMT-P, JEMS 2003
