Changing My Mind (And My Practice)

I had the opportunity to change my mind recently.

I give a lot of analgesics to a lot of patients. Like, a lot. Back in the day, I used to be much more stingy.  In the first agency I worked for, documenting and restocking opiates was a monumental hassle.  In addition, in the late nineties during the formative stages of my career, physicians were pretty stingy with analgesic orders.  It wasn’t uncommon at all to get an order for 2 milligrams of morphine.  Like the Rogue Medic says, “Severe pain plus two milligrams of morphine equals severe pain.” So it worked out that a patient needed to have large BSA second-degree burns for me to go through the hassle of opiate administration.

I’m not trying to make excuses for poor care; I’m just explaining how I used to do things.

Over time, that changed. First, my current agency makes it very easy to administer narcotic analgesics. There is essentially no cost to me in time or effort. In addition, over the past decade or so, protocols have relaxed to the point of being able to give reasonable doses of the medications. Fentanyl was added. Also, I realized a couple things. EMS Rule #1 says to make people better than how you found them. Concentrating on helping people as your metric of success makes your job more mentally and emotionally enjoyable. Don’t concentrate on difficult ALS calls or wild, rare procedures as your metric of success. Just concentrate on helping patients. One of the easiest ways to help a patient is to give them pain medications when they are in pain.

I believe patients when they say that they are in pain. There is no cost to me to give a “seeker” some medications.  There is no cost to me to give meds to a patient who isn’t in “real” pain. After all, who am I to say what is real pain and what isn't? I don’t care if my patient is a sissy. Who am I to decide if pain is "severe enough" to warrant Fentanyl? I don’t care if their vital signs don’t reflect numbers that I expect for a patient in pain. If a patient says they are in pain, I offer analgesia.* If they accept, I give it.  It is a simple way to chalk the call up in my win column, and I have been doing this for several years without problems.

In contrast, I rarely give antiemetics like ondansetron or droperidol. The protocols I grew up with indicated those medications for intractable vomiting. Essentially, if I couldn’t provide care over the noise of someone screaming for their friend Ralph, I would give them medications that would allow me to do my job. The protocols changed at some point, where they now indicate antiemetics for nausea. Not intractable vomiting, but just nausea.

Dammit, Becky! How many times do I have to tell you! I don't know who this Ralph guy is!
By Usien (Own work) [Public Domain], via Wikimedia Commons

A couple of weeks ago, I told a trainee to hold off of giving Zofran to a patient. The patient complained of nausea, but I wanted to see at least a little retch before treating the nausea. Come on, give me a wet-sounding burp, at least. It wasn’t like the patient was puking, or even had been puking. Their vital signs were normal and everything. Dude's stomach was just a little queasy.

On my way home, thinking about that call, I found myself experiencing cognitive dissonance. If it makes sense to give analgesics more freely, based solely on a patient's report of their subjective pain perception, why doesn’t the same logic apply to antiemetics? The answer that I came up with is an obvious one: The same logic does apply. I realized that withholding antiemetics is stupid; at least as stupid as not giving analgesia for complaints of pain. All of my reasons for administering analgesia work for administering antiemetics. The protocol allows it, there is minimal cost to me, the medications are relatively safe, and they are easy to deliver. I can give the meds via intramuscular injection – I don’t even need to start an IV! Why wouldn’t I get the easy win? Help a patient? Make them feel better?

If making someone feel better is a win, why wouldn’t a good paramedic give the medication that makes the patient feel better?

So now I am trying to offer antiemetic medications more. I still try to wave an alcohol prep under the patient’s nose and other less-invasive ways to end nausea first, but a little IM Zofran is an easy thing to do.

*Not true, of course, if contraindications like allergies, concomitant CNS depressant use, altered mental status, and such exist.