Pain Medication in the E.R.

[Vandy]

something I found very useful in pain management is lidocaine patches -- they come in patches ~ 5"X8", and you can cut them to fit various body parts. I've had pts w/ musculoskeletal pain who have found these very helpful, and it's totally topical. you can combine it with oral meds for stubborn MS pain.

 

These things are great, but insurances won't cover them unless pt has post-herpetic neuralgia. They are $$$.

[Vandy]

I use Nubain somewhat regularly in the military side of practice and it seems to do well. The best aspect of this medication is that it is not controlled.

 

I have better results that Ultram use in the outpatient population than you must, PhD.

 

Toradol. Works for kidney stones. Works for post op pain control as a one time dose while closing.

 

I had a stupid NP student shadow me the other evening and she wanted to give an elderly patient 90 mg of Toradol IM!!!! I told her that even 30 mg of Toradol would be considered alot for an elderly person and she said, "But he's really large!" She had no idea that this could potentially shut down his kidneys or cause a GI bleed. AMAZING! Maybe a "geriatric NP" would know this - LOL!

[MrSinn]

I had a stupid NP student shadow me the other evening and she wanted to give an elderly patient 90 mg of Toradol IM!!!! I told her that even 30 mg of Toradol would be considered alot for an elderly person and she said, "But he's really large!" She had no idea that this could potentially shut down his kidneys or cause a GI bleed. AMAZING! Maybe a "geriatric NP" would know this - LOL!

 

Ouch....thats a little hard on the NP student to be calling her "stupid". Shoot everyone has these stories. Worked with a PA who would give 50mg boosters of rocephin to 5y/o just incase another who tried to send home a 2 week home newborn with a fever without a workup because the child looked good ( actually none of the RNs would carryout their orders)

Your right though, dosage of toradol should be basic for any RN especially one that is a NP student.

[Vandy]

Ouch....thats a little hard on the NP student to be calling her "stupid". Shoot everyone has these stories. Worked with a PA who would give 50mg boosters of rocephin to 5y/o just incase another who tried to send home a 2 week home newborn with a fever without a workup because the child looked good ( actually none of the RNs would carryout their orders)

Your right though, dosage of toradol should be basic for any RN especially one that is a NP student.

 

Okay, I shouldn't have called her stupid, but I'm amazed at what she doesn't know. She had never heard of the Sanford Guide nor the Beer's list for elderly pts. She also wanted to give a pt Cipro 500 mg BID X 10 days for an abrasion...SHE THOUGHT IT WAS CELLULITIS!!! She has 10 yrs of experience in cardiology and I'm sure she could run rings around me in that, but how the heck is she doing clinicals without the basics???

[caldje]

Okay, I shouldn't have called her stupid, but I'm amazed at what she doesn't know. She had never heard of the Sanford Guide nor the Beer's list for elderly pts. She also wanted to give a pt Cipro 500 mg BID X 10 days for an abrasion...SHE THOUGHT IT WAS CELLULITIS!!! She has 10 yrs of experience in cardiology and I'm sure she could run rings around me in that, but how the heck is she doing clinicals without the basics???

 

 

She IS a student ya know? The whole learning thing... kind of implies she doesn't already know.

 

chris

[EMEDPA]

She IS a student ya know? The whole learning thing... kind of implies she doesn't already know.

 

chris

 

yeah, but the whole concept of short np clinicals( 1/4 the time of a typical pa program and part time to boot) is that they already "know a lot from their rn clinicals and practice".....

hmmmmmmm

[MrSinn]

yeah, but the whole concept of short np clinicals( 1/4 the time of a typical pa program and part time to boot) is that they already "know a lot from their rn clinicals and practice".....

hmmmmmmm

 

Yea i dont understand how and why a NP program allows so little clinicals. My fellow NP students at the clinic i am at have the summer off from their 3 days a week 4 hour days. Dont get me wrong some NP programs such as USCF have really strong clinicals. As a RN you learn alot sure (alot of paper work), but giving meds and knowing why your are ordering meds are two different beasts. ( this has been my own experience)

 

Anyhow back to pain meds..do you all use inapsine in your pain cocktail?

[EMEDPA]

"do you all use inapsine in your pain cocktail?"

 

used it all the time until the fda blackbox warning. now you need an ekg and 30 min of tele monitoring to give it. turns a fast track pt into a tele pt. no thanks. I use a lot more ativan now instead.

[Vandy]

She IS a student ya know? The whole learning thing... kind of implies she doesn't already know.

 

chris

 

She should have become familiar with the Sanford guide in her advanced pharmacology class. I could tell the difference between an abrasion and cellulitis when I worked as a MA! This student has worked in cardiology for 10 years, so all of this other stuff is new to her. What's really scary is that we rarely see any kids at our UC clinics (there are several UC clinics for kids in town) and she's been doing all of her clinicals with us. She told me that she's doesn't have to do any clinicals in pedes, even though she is going to become a Family NP. How can she legally treat kids if she was never exposed to them in her clinicals? I can see the shorter clinical hours IF the NP is specializing in an area such as Pedes, Geriatrics, Psych etc, but 500 clinical hours in FAMILY PRACTICE? There is NO WAY I would ever send someone to a FNP and I mean NO WAY!

 

Back to migraines...caffeine seems to work for some pts - tall glass of Mountain Dew. I prescribe Topamax for prophylaxis if pt has had more than 3 migraines in a year. The women love it because they lose weight!

[EMEDPA]

"500 clinical hours in FAMILY PRACTICE? There is NO WAY I would ever send someone to a FNP and I mean NO WAY!"

 

for comparison I had a required 12 week rotation in fp of 480 hrs. that was 1 of 8 rotations. we also had a second 12 week selective that had to be fp or em. if I had done that I would have had 960 hrs of fp. instead I ended up with 27 weeks of em/trauma + 27 weeks of fp+psych+obgyn+IM

[BlocDoc]

"500 clinical hours in FAMILY PRACTICE? There is NO WAY I would ever send someone to a FNP and I mean NO WAY!"

 

for comparison I had a required 12 week rotation in fp of 480 hrs. that was 1 of 8 rotations. we also had a second 12 week selective that had to be fp or em. if I had done that I would have had 960 hrs of fp. instead I ended up with 27 weeks of em/trauma +fp+psych+obgyn+IM

 

For crying out loud E, how do you remember this stuff from so many years ago? I can't even remember what I had for dinner last night.

[brookspa]

i can tell a lot of er time in the above threads. love toradol im/iv for renal stones also does well for orthe injury early on. ultram is probably used too often by me for the DSB crowd, try to avoid not treating pain dont want pain , pain bad. too many tooth aches in the er but who has $250 $ to see a dentist, up front money no less and i know of very very few who will see you without cash. no matter the problem. cash required. im treating more and more of these lately.

[yddub80]

In Illinois we can look up anyones name online and get a list of ALL the controlled substances they were prescribed, the amounts, the dates, and the name of the doctor who wrote it.

Its very helpful!

[RetNavyPAC]

For migraineurs: tank 'em up with 1-2 L of NS, add 10mg Compazine, 50mg of Benadryl & 10mg Decadron if the migraine has lasted longer than 24hrs. In my experience this works, like a charm, 95% of the time.

[ventana]

Recent article in one of the Mags/Journals about the database for controlled substances

 

I am part of a study for one of the companies trying to develope and then sell this system - I see it as pointless - on a larger not single payer would solve it as there is only one payer.... But if this is never going to go through then a database for all controlled is an excellent idea. Even the pharma companies are getting behind it as the FDA has come down on them REALLY hard for the huge increases in controlled substance abuse, diversion and addition! Times they are a changin......

 

See

http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm163655.htm

[RetNavyPAC]

For recalcitrant migraines - not responding to 1st or 2nd line meds - I've had a couple of patients respond VERY quickly to low-dose droperidol 0.625 - 1.25mg.

[rcdavis]

ahh droperidol... a GREAT drug.

 

but the Black Box warning makes it pretty inconveinent to use in the ED.

 

(Is there anyone using it in their ED w/o record review and EKG?)

[EMEDPA]

ahh droperidol... a GREAT drug.

 

but the Black Box warning makes it pretty inconveinent to use in the ED.

 

(Is there anyone using it in their ED w/o record review and EKG?)

 

funny thing is our medics can use it in the field with just a lead 2 rhythm strip but we need an ekg and 30 min of continuous monitoring to do it in the e.d......

so have not used it in years....

[CAdamsPAC]

For recalcitrant migraines - not responding to 1st or 2nd line meds - I've had a couple of patients respond VERY quickly to low-dose droperidol 0.625 - 1.25mg.

 

 

My former ER used Droperidol for recalcitrant drunks disrupting the ED!:rolleyes:

[EMEDPA]

My former ER used Droperidol for recalcitrant drunks disrupting the ED!:rolleyes:

I used to write it multiple times/day:

1.n/v

2.migraines

3.behavioral pts

 

that's what, 20% of any e.d.?

[skyblu]

You have to fill out paperwork, get it notarized, and send it in to be granted access, but this is a GODSEND in dealing with seekers!

 

Imemented a year or two ago in Massachusetts, this is a system tracking all controlled substances prescribed for an individual in the past year. I use it daily at work:

 

https://gateway.hhs.state.ma.us/authn/login.do

 

Of course, people can give a fake name, fake ID, etc, so it's obviously not foolproof. But many seekers don't know it exists yet, so that helps.

 

It would be great to see this go national!

[Febrifuge]

Illinois (where I went to school) and Minnesota (home, and where I practice) have state registries too.

 

I have not yet decided if it really poses a threat to the truly motivated drug-seeker, but I have to admit I enjoy bringing out "Exhibit A" during the discussion part of the visit. I make it clear that WE KNOW, and hopefully somehow word might get around that our clinic is not the greatest destination for the seeker.

[EMEDPA]

in areas on state borders it is less helpful as er providers frequently don't have access to the registry for the other state unless they are also licensed and employed there. ours(wa) has multiple hoops to hop through for usage. you have to always log in from the same computer/ISP address for example. this is a pain if you are working with 6 other folks as you don't get the same computer every shift.

[Febrifuge]

Wow, that system clearly was not designed with actual users in mind. Amazing that the state where you can vote by mail gets the usability aspect so very wrong on that one.

[True Anomaly]

Actually, it sounds more like whatever group was "pro-narcotics" (usually a group who claims they are pro-"patients rights") when the lobbying for that particular bill was going down made sure that certain provisions were in place to make it more difficult to access the database.