Alternative routes for IV fluids

[SouthernDZ]

Originally Posted by SwedeGlocker

I my opinion based on my time in ER, OR, EMS and in a remote setting is that there is always a way to offer a patient pain controll. It can be everything from a comforting hand to Ketamine IV. If a patient have pain in most cases it will be harder to threat the patient. A screming and moving patient dosnt make it easier to do invasive procedures. If the patient is hemodynamic instable the perhaps a regional block och lowdose ketamine? I does take training and experience to threat pain and to find a solutin that fit every patient but it is possibly. And dont forget Acetaminophen as the base in pain controll.

Swede:

I tried to make my last post the final, but I feel I must explain to you.

I can understand what you are saying, especially after what you have seen transpire above. "Pain is the patient's problem" is a quote from Dr. Halsas from Baltimore Shock Trauma (hence the multiple references to MIEMSS above). It is not meant to be taken literally unless one is predisposed to do so. His meaning was to alleviate the anxieties (from a then young 18D who felt way out of his league) I was having because of the procedures I was expected to perform. Central lines, external jugular, IOs, DLPs, thoracostomies, etc. I worried about the pain I would be inflicting; however, I didn't take his comment literally then, you shouldn't now. There are many comments you hear in the medical profession and others, "to cut is to cure"; "cold steel & sunshine"; "kill them all and let Allah sort them out" - try to "dissect" the meaning. Not your fault; based on the above I would take me for a bumbling fool as well. I would never (and have never) needlessly inflict pain on another; I assumed that was a given.

I hope this lays all of this to rest, but somehow I doubt it.

[Eagle5US]

Originally Posted by SouthernDZ

I can understand what you are saying, especially after what you have seen transpire above. "Pain is the patient's problem" is a quote from Dr. Halsas from Baltimore Shock Trauma (hence the multiple references to MIEMSS above). It is not meant to be taken literally unless one is predisposed to do so. His meaning was to alleviate the anxieties (from a then young 18D who felt way out of his league) I was having because of the procedures I was expected to perform. ... however, I didn't take his comment literally then, you shouldn't now.

This was done, finished, I even retracted a final post after I read your previous final parting shot. Now this post about you not meaning to be taken for what you wrote


How can you write that you didn't expect people to take you literally when you have been argueing this as your very point?

Originally Posted by southerndz

For what it is worth, an 18D has to have the mindset that medicine isn't always pretty and pain "is the patient's problem" - this sounds cold and uncaring, it isn't. Proper medical care sometimes hurts; bury your emotions and do what is proper and necessary.

Once I posted that I disagreed with you-this was a portion of your retort:

Originally Posted by SouthernDZ

Which is certainly your perogative; however, I've been in emergency medicine since 1973 and I've never yet administered pain medication to a semi-conscious casualty yet and won't begin at this point....

continueing in the same post...

Originally Posted by SouthernDZ

Realizing that "pain is the patient's problem" is a coping mechanism that allows you to deal with the tragic circumstances of a life that has often been altered permanently. Especially when dealing with children.

After 23 years, 5 months and 19 days of team time, I never once allowed a casualty to carry-on in pain, when it could be prevented. It isn't always in my power to alleviate such; therefore it might be best to be dispassionate about what you have to do and soulsearch about "how you could have made it a little less painful" later

I wish you would have just stuck to what you believed was right, we could have agreed to disagree, and moved on.

I didn't have a "low opinion of you" before-I just didn't like this aspect and personal philosophy on how you practiced medicine. I tell you what though...I have a lower opinion of you now.
Not that it really matters, but your explanation doesn't jive with your previous posts...which makes you look less than truthful in trying to get out your point out through this discussion.

Eagle

[x SF med]

SDZ, Eagle-
As 18D's, and me as a reclass 18B, we have a different take on medical care than about 98% of other care providers. There is a passionate dispassion at times that comes across as callous to an observer, but the boiling emotions underneath are not visible to them. Empathy is one of the reasons we took, kept and excelled at our jobs as 18Ds, but we also, like all good SF soldiers can compartmentalize emotion from action - it's not that the empathy, emotion and sympathy are not there, it is pushed behind the immediate need to care for the patient(s) in front of us.

When you treat a Teammate in a training setting (Tib/fib fx on a DZ, with ambulances and a hospital close by) emotion and empathy don't have to be as deeply buried - next level care is iminent. In a Shit Hits The Fan op, same buddy more serious injury, you will be just as passionate, just as skilled, but seem colder - there is more to keep track of, and less time, resources and access to next level care - you think differently, but do not compromise level of care.

We seem to have all been saying the same thing - but we voiced it in ways that weren't ringing true to the others - I realized this after rereading the posts. We have to be very conscious of our wording and our perceived tone in writing, what we write as an innocuous statement may be construed as a jibe by others.

DOL guys - Primum non Nocere.

[swatsurgeon]

Gentlemen/ brothers in medical arms,
We are the most compassionate and caring bunch of cold hearted practicioners of the healing arts. You more than me know the emotional toll treating a combat or civilian casualty takes on you.......especially a friend or a kid.
Let's agree on one thing, we do things that hurt, period. We sometimes do and sometimes do not have the luxury of administering analgesics pre-procedure, other times just alittle and other times adaquate doses. We do this with one thing in mind: help the patient.

What is in play here is the 'Principle of Double Effect':
- the act must be good or morally neutral
- the agent (procedure) intends only the good effect, the bad effect may be tolerated but NOT intended
- the bad effect must not be a means to the good effect
- the good effect must outweigh the bad effect

We must be careful with words and explanations, to the public and sometimes to each other. The phrase: the pain is the patient's problem, is actually inaccurate. The pain is the patient's symptom and it is my problem to deal with the best I can.
Read the trailer on my post...it has real meaning and means alot to me. I am human, I hurt when they hurt, I do things that really hurt and do my best to allieviate that hurt when it is appropriate. I recently took an open angulated ankle fracture, the patient was already screaming and as soon as he hit the trauma bay, I reduced it before the nurse could give the meds I ordered: 150 mics of fentanyl and 2 mg versed, but after the reduction, his pain went from a 10:10 to a 5:10, then the meds kicked in and he was happier still. Did I violate a trust that he had in me to help him by causing a momentary increase in his already 10:10 pain? No, I don't believe I did, I made a "monumentous and dreadful" decision, all in the patient's interest. But, no the pain is not his problem, it remains mine and to that I will not back down from and either should any of you. You (we) are 'warrior' healers, never forget that, but the patient always should suffer less than you.

Respectfully,

ss

[x SF med]

SS-
Much more eloquent than my attempt, thanks.

[The Reaper]

Originally Posted by swatsurgeon

Gentlemen/ brothers in medical arms,
We are the most compassionate and caring bunch of cold hearted practicioners of the healing arts. You more than me know the emotional toll treating a combat or civilian casualty takes on you.......especially a friend or a kid.
Let's agree on one thing, we do things that hurt, period. We sometimes do and sometimes do not have the luxury of administering analgesics pre-procedure, other times just alittle and other times adaquate doses. We do this with one thing in mind: help the patient.

What is in play here is the 'Principle of Double Effect':
- the act must be good or morally neutral
- the agent (procedure) intends only the good effect, the bad effect may be tolerated but NOT intended
- the bad effect must not be a means to the good effect
- the good effect must outweigh the bad effect

We must be careful with words and explanations, to the public and sometimes to each other. The phrase: the pain is the patient's problem, is actually inaccurate. The pain is the patient's symptom and it is my problem to deal with the best I can.
Read the trailer on my post...it has real meaning and means alot to me. I am human, I hurt when they hurt, I do things that really hurt and do my best to allieviate that hurt when it is appropriate. I recently took an open angulated ankle fracture, the patient was already screaming and as soon as he hit the trauma bay, I reduced it before the nurse could give the meds I ordered: 150 mics of fentanyl and 2 mg versed, but after the reduction, his pain went from a 10:10 to a 5:10, then the meds kicked in and he was happier still. Did I violate a trust that he had in me to help him by causing a momentary increase in his already 10:10 pain? No, I don't believe I did, I made a "monumentous and dreadful" decision, all in the patient's interest. But, no the pain is not his problem, it remains mine and to that I will not back down from and either should any of you. You (we) are 'warrior' healers, never forget that, but the patient always should suffer less than you.

Respectfully,

ss

And that, Gents, I believe is referred to as medical ethics and a professional opinion.

Thanks, Doc.

TR

[swatsurgeon]

SouthernDZ,
Does the doc who you quoted have a rational grip on reality? It makes me worry about what morals and ethics he (she?) teaches. I know Dr. Scalea and doubt he would accept the premise of your other doc's stance on patients and their pain.
Trauma surgeons, like 18D's are not immune from the realities of tragedy, profound injury, suffering and do create barriers to protect our moral obligations to treat those in need, sometimes asking them to endure pain while we try to help. I for one will try to make people laugh in the most stressful of times, but I would never use as a defense mechanism that it is the responsibility of the patient to endure the terror of pain, regardless of the procedure they need....that is too cold and irresponsible of a care provider. In the hopes of providing relief: a needle decompression, a bone realignment, there is relief. In the field, some things are done that hurt, but as in my last post, the symptom is pain , the problem is how to alleviate it. Your example of a chest tube to relieve a tension PTX, why didn't you needle it, it is faster to do. If you had to place a chest tube, the small incision and trocar placement is so fast that the pain is minimized and the relief quick, then give meds ASAP.
Please ask your doc to think about his statement and explain it in a more educational way so that there is no misunderstanding. It really does bother me that he explains it the way he does...no compassion and this goes beyond a defense mechanism, it goes against what we stand for in trauma care.

TS, can you get Doc T to chime in on this one?

Southern DZ.....always question the status quo, never settle for what is obvious, seek greater knowledge and counsel. You have a heart...tell that doc to find his.

ss