Advocating Pain Management

You’re on your way to a private residence at Third and Kenard, and you know the place. It’s a dead house; one of so many sad homes in your area that have been vacated due to hard times. The cheerless empty gaze of its unlit, uncurtained windows reminds you of the Jolly Roger’s eye sockets.

You’re responding for a fall. And fully mindful of your warning equipment, your routing and the traffic, you still can’t help thinking about the family who once lived at this address. They were more acquaintances than friends. But you knew them well enough to know their house was certainly never vacant.

On arrival you encounter a small woman in her late fifties, lying on her right side next to a toppled four-foot stepladder in the living room. Her head is resting on her right arm, which is fully extended above her head. Her right shoulder obviously hurts a lot. She cries out when you touch her, no matter how gently. The story is, she’s been cleaning the place for a realtor. She was reinstalling the diffuser on a ceiling lamp. Her old wooden ladder wasn’t situated properly, and when she leaned, its legs slipped on the hardwood floor. She probably fell from the third step, and tried to break the fall with her outstretched arm.

This lady is terrified even more by her predicament than her pain. Her husband died of cancer two years ago, and his medical expenses wiped them out. Now she ekes out a meager living, all by herself, as a house cleaner. She’s not old enough to qualify for Medicare, and she has no other health insurance.

Your first priority is to ease her pain (and her fear), and in your system you need MD orders for narcs. You explain the lady’s situation by phone, and despite her cries as you ask, your doc authorizes a whole two milligrams of morphine. Of course, it doesn’t touch her pain. But when you suggest a little more, it’s like he doesn’t even hear you.

Q. We never seem to be able to get narc approval from this doc, no matter what. He should be anything but a physician. We’ve confronted him about it in the past, and his typical response is that a little pain never killed anybody. He acts like he thinks that’s funny. We’d like to see if he’s right: inflict a little pain on him and see if he dies. Got any better suggestions?

A. Yours sounds intriguing, but it’s probably not in your scope of practice. Two things come to my mind right away. The first is, appeal to your medical director and let the two docs hammer it out. The second may be more effective, and you’ll probably find it less inspiring. I think it would be a good idea to talk to this guy again; personally, privately and one-on-one when he’s not busy. Appeal to him as a fellow caregiver. I wouldn’t be above begging him to reassess his approach to pain meds. But whichever solution you consider, take some documentation of specific calls with you. Keep things as specific as you can.

Q. Forget the medical director idea. Our medical director couldn’t care less. This is on us. As for talking to the offender again, what would make that any more effective this time than it’s been in the past?

A. If it’s on you, as you say, you need to advocate. Tell the doc you respect his education and experience, but you think pain management is important, especially during transport. Tell him you think he’s out of line compared to the vast majority of his colleagues. Do that passionately, persuasively and persistently, and never give up. I think the part about privacy is the most important element of this approach. If it’s just you and him, I think it’s more respectful, and he doesn’t have to feel outnumbered. Imagine yourself in his position. Eventually, if he’s human, he’ll have to start questioning himself.

Q. I don’t think you understand; we’ve confronted, appealed, cajoled, begged and bartered with this a------. He likes being in control of people who aren’t.

A. Well, sometimes it’s about as much as you can do to be responsible for the quality of your own medicine. Speaking of which, you may be able to try one other thing.

Q. You have my undivided attention.

A. You could go to medical school.

Thom Dick has been involved in EMS for 41 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of the EMS World editorial advisory board. E-mail boxcar_414@yahoo.com.