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Fool Me Once, Shame On You…

… fool me twice, shame on me.

I’m a pretty liberal guy when it comes to pain relief. My philosophy is simple: if you’re hurting, I try to make it stop. Acute pain is not a character builder, and it is one of the few conditions most paramedics are well-equipped to manage. I don’t like to see someone hurting if there is something I can do about it.

Now, if I broke out the fentanyl for everybody who complains of pain, I’d never have any narcotics in my pouch, and The Borg would be scheduling me for more “random” drug tests. But I do try to administer analgesics to the people who need it, without judging the patient. You can’t always tell by a patient’s vital signs if they’re in pain; a chronic pain patient will often have “normal” vital signs, and be experiencing pain that would have the rest of us curled up and whimpering in the corner, sucking our thumb and begging for Dilaudid.

But still, a seasoned medic with even a smidgen of compassion left develops a pretty good feel for who is legitimately in pain or not. Still, I try not to consider the patient’s motives when they call me. If they say they are in pain, I generally take them at face value. If I’m on the fence on whether to administer analgesics or not, I’ll generally ask the patient, “Would you like me to give you something for the pain?”

You’d be surprised how many people refuse the narcotics, including some people in no-shit pain.

I don’t particularly care if someone is drug-seeking, either. It’s not like I’m paying for the fentanyl, and even if they are drug-seeking, the doses we give are unlikely to get a chronic narcotic user high. Besides, withdrawl symptoms are very real, and unpleasant.

All that is to say, I try not to judge. One person’s agony is another’s minor discomfort,  and once you start making judgments on whether a patient is worthy of you relieving their suffering, you start killing the compassion that brought you into the profession, one call at a time. It’s only a matter of time before the career you loved, and the provider you were, is just a distant memory.

So yeah, I’d much prefer to be a chump than an asshole.

Musculoskeletal pain? I’ll medicate you.

Kidney stones? Hellz to the yeah.

Granny fell and broke her hip? Granny gets her pain relief before I even move her off the floor, because splinting and packaging itself is painful. And it doesn’t much matter to me if her house is across the street from the ambulance bay at the local ED.

Burns? Here comes the magic fentanyl fairy, baby. Relief is only a couple of minutes away.

Sickle cell crisis? Your normal saline bolus will likely be provided with a narcotic chaser.

Undifferentiated abdominal pain? Oh hell yeah, and don’t give me any crap about analgesics complicating the surgeon’s assessment in the ED. That’s mostly myth anyway, and hasn’t been valid for 20 years, if it ever was. This is the age of diagnostic imaging. No surgeon is going to cut into a patient these days based on physical exam alone.

Chronic pain condition and you’re out of your prescription painkillers? I’m the medic you want, and I don’t particularly care how good or bad your story is. Maybe you legitimately haven’t been able to refill your prescriptions, or maybe Sumdood stole them, or maybe you stumbled while reading your daily Bible verse on the way to your volunteer job feeding homeless people and rescuing kittens, and an entire month’s supply of oxycodone fell into the gutter. If I think you’re hurting, the reason why doesn’t much matter to me.

So yeah, I’ll pretty much medicate the ever-loving snot out of you if I think you’re hurting, and ignore the eye-rolling I get from the nurses at the Emergency Department…

… right up to the first time I catch you lying to me.

You’d be better off just telling me, “Dude, I’m hooked on the pills, and I’m jonesing right now. I’d give my left nut just to stop shaking and vomiting.”

For that, you earn my respect and my sympathy. No testicular sacrifice necessary.

But when you tell me you haven’t been to the hospital in a month, and five minutes later (and 50 mcg of fentanyl), I discover we last transported you to one hospital less than 12 hours ago, and you now want to go to another one…

… your candy train just ground to a screeching halt with this medic, sister.

Don’t lie to me to get drugs. Fool me once, shame on you. Fool me twice, shame on me.



Comments - Add Yours

  • Robert Martin

    That’s pretty much my school of thought on the matter.

  • R

    Yes!!! Having an addition or narcotic dependency issue doesn’t mean that they don’t feel pain or experience very unpleasant withdrawal symptoms that can be medicated. If you want to up your game figure out which hospitals have treatment programs and transport to them.

    If your state has a public narcan/naloxone program it’s probably worth figuring out the details so you can educate patients and their families about them too.

  • n4zhg

    Frankly, the best thing that could be done is to end this stupid “war” on drugs. Drugs won.

  • BobF

    Worst decision ever: Balled into fetal position with kidney stone (didn’t know that’s what it was), away from home, EMT offers pain killer en route to hospital. Hero me says no, let’s wait. Stupid. Dumb. BAAAAD decision. Arrive ER. ER says no, it will interfere with diagnosis. If I could have moved they would have needed Law Enforcement. One laser lithotripsy later… There were actually two. One embedded and one hung up there blocking the plumbing. East Jefferson.

  • Shawn

    Holy shit… I think it’s time for a QA audit of this guys runs , sure we have our seekers out there and we do have true medical emergencies however if your giving narcs out like candy I think that your paying very close attention to the condition not too much the patient’s physical or actual need. Not to mention if your giving narcs to everybody for any pain condition the DEA is not too far from your tail remember your paramedic not a doctor

    • PharmD

      That is the absolute worst reasoning I’ve ever heard on this issue. If there is a legitimate medical need for a drug, it should never be withheld. Pain of any kind is a legitimate medical need, and if you just so happen to get 6 pain-related issues in a shift, that’s not your fault. The DEA isn’t there to prevent the use of drugs for legitimate reasons, and if you document that your patient is in pain, they have no reason to go after you. I’m also confused about why you brought up the fact that paramedics aren’t physicians… That has absolutely no bearing on the situation. As a QA/QI officer and pharmacy director, if I read your report and it says the patient is in pain, and you didn’t address it, you can bet you’ll hear from me. I absolutely agree with AD on this one.

    • Ambulance_Driver

      First, learn how to spell and use punctuation before you criticize.

      Second, the doctor that writes my protocols has no problem with it, seeing as how, you know, I’m FOLLOWING the protocols.
      And if you’re the one deciding the patient’s “need,” I don’t want you working on me.
      Fourth, you have no idea what you’re talking about.

    • wvditchdoc

      Wow, way to show your ignorance on the matter Shawn. Not impressed…..

    • Forwards1ca

      Wow, just wow. I have never read anything more asinine in my life. Your thoughts about the pain don’t matter my friend. All that matters it the patients subjective opinion of the pain. If you’re withholding pain medication because you don’t think they are really in that much pain, you have absolutely no business working in health care in ANY capacity.

    • txmedic

      The DEA does not care about paramedics giving fentanyl to people in pain. There is a reason ambulances are stocked with it. A doctor is responsible for giving protcols to be followed for pt conditions. One of the protocols we have is pain management.

  • Fletch

    It must be lovely to work in a system with such liberal protocols as to allow all of this.

  • ER PA

    I have to agree. Everyone should get the benefit of the doubt. But once I am lied to, I remember. No more narcs unless your arm is literally broken in 2.

    And if we want to have a functioning healthcare system in another 10 years (that isn’t more bankrupt than it already is) please educate your patients during their ride about what constitutes an emergency!

    Also, I’m an advocate for medics evaluating a patient on scene and triaging, treating, medicating, and referring on site (like they are now doing in Australia). Let’s stop being a “cabulance” for Rx refills, runny noses, and ankle sprains.

    • Ambulance_Driver

      Oh, I’m with you there, ER PA.

  • PeriMedic

    Agree 100%. I have had major pain in my life and didn’t “look” like I was in pain. You tell me you’re hurting, you get relief. I’m not here to judge you, but I’m here to help you.

  • Gary Griffin

    Someday I’m going to patent my Painometer. I’ll be so stinking rich I’ll even be able to but politicians in Russia. Gary

  • David Newton

    I agree, I do not treat someone with a good story, I treat my patient. I treat that patient that is in distress from pain, but not the ones that just tells me how much pain they have with no distress.

  • Bob Sullivan

    Amen Kelly. I have a similar philosophy about pain medication and am quite liberal with Fentanyl. What do you think pain management in tiered systems, where paramedics are only sent on potentially life threatening emergencies? Most hip fractures, isolated extremity injuries, and abdominal pain would be BLS calls. My experience is that many paramedics do not think pain control should be the only reason for an ALS transport, which makes EMTs reluctant to request them. Do you think that the frequent need for pain control justifies sending a paramedic on ever call?

    • Ambulance_Driver

      I think Entonox is a perfect solution for such situations. Should be easy enough to train EMTs to hand a patient a mask through which they can self-administer their pain relief.

  • G Jeff

    I agree with you 100% Kelly, nice write up. It kills me working and teaching here in Saudi where “pain relief” usually equates to either Panadol or a bite stick. I’m still fighting the abdominal pain issue as well, not usually with real docs, just the BMBS, but sometimes, even the real docs.

  • Cynthia Gray Barkes

    20 years ago my mother in law fell off a ladder and broke her hip. I did not make it to the ER until 4 hours after she was brought in. At that time she had been given NOTHING for pain. I raised cain and within 10 minutes she had IV pain relief. How they could leave a 65 year old 100 pound women crying softly cause she was in so much pain but did not want to “bother” anyone in that much pain amazes me to this day

  • mkimbee

    My thoughts exactly!