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Great pain management can be simple and cheap. So why isn’t it more standard?

Suffering is optional. Unfortunately for some of our patients, it’s at our option and not theirs. As I look back and am confronted by some of the most difficult patients that I ever cared for, it was the suffering that was the problem. Maybe it’s because I’m old, or maybe it’s because I’ve just seen enough, but what I realize is that we have an active role, despite the disease entity or the personality involved, to ease our patients’ suffering. Everyone is going to die; no one has to die in misery. We can make any diagnosis we want, but if we don’t take care of the patient in the process and relieve their pain, we have failed in our role as physicians.

The myths are told over and over, and we start to convince ourselves that the suffering of the patients is “not our problem.” We get to the point where we become numb to suffering. We walk down halls listening to the crying coming from the rooms, the screams of pain. In the emergency department, it is incredibly easy to lose perspective on the fact that other human beings are in pain. We tell ourselves things such as, “the pain medication might mask the diagnosis.” Nothing could be further from the truth. There is no literature base to defend the idea that properly used analgesics take away our diagnostic abilities. Surgeons have claimed this for years.  They’ve been wrong for years. Or perhaps a nurse says, “You’re not feeding that person’s drug habit again. Are you?” We hear these statements, and we start to doubt our clinical skills in deciding whether someone is suffering or not.

As an aside, it is amazing to watch the difference in the emergency department between the skilled and the unskilled in managing the suffering patient. The skilled seemed to do it effortlessly, consistently and with a genuine sense that this is as much a part of their job as diagnosing meningitis, tuberculosis or appendicitis. The question is this: If we know that the majority of patients present to the emergency department with pain – a fact which has been documented in paper after paper – why isn’t every EP skilled in its management?

The reason this column is being written is that I’m trying to put together, through the myriad of articles sited in the literature, some reasonable way of packing into an hour lecture the mistakes we’re making in pain management. There is no lack of literature. There is no question that certain groups of patients, based on age, sex and ethnicity, get less intense pain management than others. It is incredible that this is not a more frequent grand rounds presentation in residencies and discussion point in our various groups. The management of pain should be concise, to the point and predictable. It should not be dependent on which doctor is staffing the department at any one moment in time. This priority needs to be moved to the front of the line.

Let me illustrate this with a medical-legal situation. Within the past week, I have looked at yet another lawsuit about a missed subarachnoid hemorrhage. Part of the physician’s defense is that the patient refused the lumbar puncture. I wonder if that physician (and I will know when the deposition phase is done) actually went and told the patient, “I can make this procedure pain free.” The newer medications are fantastic, short acting and they block memory formation. Often, patients don’t even know they’ve had a procedure. I believe that most patients who refuse procedures, such as an LP, do so for obvious reasons: they’re afraid of the pain. So, just take that fear away and the patient will be able to participate in what you’re doing.

One thing about pain medication is that we have a lot of it. Many pain medications are relatively inexpensive, have very low adverse effect profiles when used appropriately and are easily reversible. How can you beat this? 

I’m not just talking about the use of hypnotics and narcotics, either. The simple femoral block not only makes the elderly patient with the broken hip almost pain free, but much more manageable for the X-ray techs who are forced to move the patient’s leg to get the necessary images.

The use of simple techniques, which are well known, well documented and add almost nothing to the cost of health care, should be essentially mandatory in every department. The literature is replete with articles that show that the size of the needle does effect the amount of pain the patient receives. Why someone would be receiving anesthetic solutions through anything larger than a 27 or a 30-gauge needle is beyond me. The temperature of the liquid injected and the rate of injection make a difference as well. Distraction techniques can also make a difference. Buffering local anesthetics also has a positive impact. All of these basic elements should be taken into account.

The people who think about this more than the average are those physicians dealing with children. On a laceration, LET (lidocaine/epinephrine/tetracaine) placed in cotton balls and packed into the wound do help to relieve the discomfort when further injection is required. Keeping those children in relatively quiet rooms, letting them hold their mother’s hand and providing careful reassurance all go a long way in deciding whether that child is going to be cooperative or not. The sign that the emergency department has not advanced is when every room is equipped with a papoose board. Physicians should be skilled enough to take away that pain so that the child’s future contact with the health care system will also be more pleasant.

Having to do a talk on pain management is relatively simple. Everything is known. All of the science of the last 40 or 50 years in regards to pain management has been explained in excellent detail, and there is general agreement throughout the profession that this is the way it ought to be handled. But where is the leadership that is going to make sure that the science that we know is given to the patients who have come in looking for relief from pain? The desire to end suffering must live in the heart of the physician or it will be absent from the department.


Domine, dirige nos

 

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