Question: We were presented with a patient on scene who stated she had fallen 2 hours prior. The fall was due to a slip on the ice. There was no LOC, no head injuries or any other neuro deficits. The patients vitals weren't abnormal and was in a mild state of distress on scene. The only injuries noted were some wrist and knee pain, where there was no obvious deformity or injuries evident but stated both as 7/10 pain. She also mentioned her back was in moderate pain from the fall as well. My partner and I were unsure of whether to provide symptom relief for pain management. Yes there is trauma to 2 different extremities but it was the simultaneous back pain that threw a twist in, as the directive states that the patient must have "isolated hip or extremity trauma." We were minutes from the hospital and I did ask the patient if the pain was tolerable until we got to the hospital where they would provide more effective pain management, but for future reference it would be nice to no! t have to think twice if put in this particular situation again.

This continues to be a confusing medical directive as it is possible to have multiple interpretations of the wording. The intent of the directive was to be able to treat trauma patients who do not have serious underlying trunk or head trauma. The medical directive permits treatment of back strain but does not permit treatment of back pain from trauma because of the possible additional underlying organ injury. Isolated hip or extremity trauma is meant to be interpreted as trauma that excludes the head and/or trunk. Isolated is not meant to be interpreted as only one extremity. If more than one extremity is involved, it is permissible to administer analgesic.

In the case example you presented, your actions were correct. Although it involved 2 extremities, it also included back pain from trauma, therefore a contraindication existed to treating this person with analgesics.

The Regional Base Hospitals agree that the indications and contraindications for the analgesia medical directives are confusing. The Ontario Base Hospital Group MAC to the MOHLTC has been working on editing this medical directive to allow more patients in clear discomfort to receive analgesia by paramedics. Stay tuned, changes are anticipated.

Analgesia,Pain/Sedation/Nausea

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