An appeal to do one thing well

21 May

I’m fairly sceptical on a lot of things that we do in medicine. Perhaps one of the most important things I’ve learned (partly through my Dad’s illness and death) is the importance of symptom control, and more particularly analgesia.

We see all kinds of stuff that we can do little to fix but here’s the big secret – we can treat pain, the morphine works!

Every single study into pain management in the ED says we’re not good at it.

I listened to this podcast (via EMCrit) recently and Dr Gentile (what a name…) does a great job outlining his pain protocol. He also has a slightly hypnotic voice and manages to keep you entertained.

I’m certainly far more willing to give decent analgesia (substitute “opiate” for “decent analgesia”…) in recent years than I was when I first started. I think I used to think that the use of an opiate mandated admission or some huge work-up.

Chronic pain and IVDUs can be a different problem but for acute pain I think Dr Gentile is right on the money. Especially on the dubious reasons we give for not giving decent analgesia…

Here’s my list of reasons (largely bullshit) for not wanting to give morphine:

– it’s a hassle, getting the keys to controlled drug cupboard, getting someone to sign out some morphine, the whole process is a lot more hassel than just writing for two paracetamol and hanging the chart back

– where i’ve worked most of the time, the docs have to give it (IV at least) and that means you have to actually spend time with the patient, which as we all know is one of the more problematic part of the job and one we’d like to avoid as much as possible

– keeping track of what’s left in the syringe. You make up your 10 in 10 and you’re feeling generous and you give the old lady with the broken hip the actual minimal dose of 0.1mg/kg but still that leaves you 4 mls lying around. And what are you supposed to do with it? You put a sticky on it and leave it on the desk and then it gets lost, or you pop it in your pocket and all of a sudden you arrive home with 4 mls of opiate in your pocket and you’re freaking out thinking you’re going to go to jail while you’re squirting it down the sink…

– in general I like to give my morphine to patients when they’re lying down but in most EDs you need to be recently missing a leg, or actively fitting to be able to get a bed

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