I believe that every physician, nurse, PA, NP, tech and clerk who works in an ED should periodically have an organ removed. We have lots of organs that will only get us into trouble, so let’s remove them before that happens. Hey, we don’t need that appendix or gall bladder, and the ladies can get rid of that bothersome uterus once they hit the menopause.
What good can come of jettisoning these unneeded organs? Well, if you get rid of them prophylactically they’ll never ruin your vacation by acting up. But more importantly, going under the knife would provide the opportunity to be on the other side of the bed rail – the opportunity to be a patient – horizontal, dependent, scared, needy.
I have thought about this idea frequently. As we get older, we have more and more opportunities to be on the other side of the stethoscope and generally we learn by these experiences just how important the touch of a gentle, reassuring hand can be. We see how vitally important a myriad of small kindnesses go towards making a positive experience when the patient is worried and under stress.
If healthcare providers were more familiar with the pains and anxieties of being a patient, we would be more inclined to create what has been coined, “the ouchless ED.” This phrase has been adopted by some pediatric EDs, but I don’t see it promoted in our general EDs. Is it just children? Of course not. Aren’t adults afraid of needles? Aren’t adults freaked out by the sights, sounds and smells of the ED?
Here’s my list of places to start with the “Ouchless” ED. And yes, I know that some readers will be rolling their eyes at creating more incentives for all of those “unnecessary” visits that so many complain about.
The reason I’m starting with this topic is because there is a thread on the Emergency Department Benchmarking Alliance asking about protocols on how to have nurses do this procedure with some initial anesthesia. Our Emergency Medical Abstracts database has 11 articles on the topic of how to make an NG placement more palatable. The best way, by far, is to stop inserting unneeded NG tubes. One very old study rated NG tube insertion as the most noxious ED procedure by ED patients. In the meantime the literature has debunked NG lavage in GI bleeds and in gastric decontamination (except for rare cases) and a more recent paper has questioned their use in small bowel obstruction. So why else would it be used in the ED? Certainly, it should be a given that local anesthesia would always be used in an awake patient (and not just as a lubricant, but given in advance of passing the tube). If you yourself were the patient, it would likely be inconceivable that you would tolerate an NG tube without serious efforts to provide really good local anesthesia.
Removal of EKG leads should not be a waxing experience. So please, with permission, shave the hair off of men’s chest where EKG or monitor leads are to be placed so lead removal is less painful. And what about when starting an IV on a hairy forearm? And yes, this suggestion will really annoy the providers who already think most ED patients are wimps.
If you are interested in this topic there are a bunch of papers giving ways to limit the discomfort associated with IV starts – from topical anesthetics to cooling sprays to intradermal local anesthetics. Just making the effort will win you lots of points with the patients (every anesthesia department worth its salt uses techniques to limit IV start pain, why shouldn’t EDs?). And all of the excuses used in the ED to not routinely, as a matter of policy, use local anesthetics when starting an IV are bogus – takes too long, will cause more misses, starting an IV really doesn’t hurt. They’ve all been disproven. I can tell you that making it a departmental policy to use local when starting a decent size IV line will be met by howls from the nursing staff. Then ask each to submit to an 18 gauge IV started on the radial aspect of the wrist. They won’t admit it hurts, but watch their faces – it does. So, before starting IVs, try giving a little dose of local alkalinized lidocaine (see below on how to make it) with a 30 gauge needle. And, if you miss the IV, no sweat. It also won’t hurt when you try the second time.
How often do we hear the platitude “it’s just a little stick” as the 18 gauge IV is inserted like an umbrella up somebody’s forearm. Yes, a little stick for the sticker, but not the stickee. If nurses watched their patient’s faces when they started an IV they would get the sense that there is clearly needless pain and anxiety. And please, don’t blame the patient for having “bad veins.” “Bad veins” can often become “good veins” by learning to do ultrasonographic searches for veins when they are not readily apparent.
Don’t even think of injecting local anesthetic into any wounds using the 25 gauge needle that comes in the suture kit– especially for a digital block – if you want to earn significant style points. No, the standard needle for all of these procedures should be a 30 gauge (your ED manager may need to special order them)
And yes, warm the lidocaine to room temperature, ideally to body temperature. Yes, I know that some regulatory agency won’t let you carry that bottle of lidocaine in your pocket. It has to be stored under lock and key so some lidocaine addict doesn’t rip you off. But who’s getting the anesthetic anyway, the patient or the regulator? Get the pharmacist to add 1ml of bicarbonate (the kind we used to use in ACLS) to a 10ml bottle of lidocaine and have them label it and give it an expiration date. It has been demonstrated repeatedly that injecting warmed, alkalinized lidocaine significantly decreases the pain of injection.
And what about using some topical anesthetic on that laceration site before injecting local anesthetic, like a mixture of tetracaine / epinephrine / cocaine or lidocaine / epinephrine / cocaine. There is a ton of old literature that shows these agents work but all seem to have fallen out of favor because we don’t want to take the time needed to use these agents. They worked great on those chin lacerations in children, even to the point that sometimes they needed no other anesthesia. Boy did you make the parents happy. Adults will appreciate it too.
How many times have you seen shaving or cleansing done before local anesthesia? Seems we were afraid that if we injected local anesthesia before some ritual betadeine ablution that we would cause an infection. But it doesn’t, so anesthetize first, shave and clean second. And you can always use some bupivacaine later to substantially prolong the period of anesthesia and decrease the need for subsequent analgesics. And a word to the wise – if a patient has a particularly dirty wound and you want them to wash at the sink – stay with them. A recent lawsuit involved a patient washing alone, unsupervised at the sink – the head injury that occurred when he fainted resulted in permanent brain damage.
Are people still using the old fashioned technique where you inject into the right and left side of the proximal phalanx? Ouch! What about using a single injection technique (flexor sheath injection or dorsal or ventral single injection techniques as described in the literature). Check out Al Sacchetti’s YouTube video on how to do the flexor tendon sheath block – very cool.
Early fracture / dislocation analgesia
Another source of unnecessary pain: going to x-ray with an obviously deformed extremity without first providing decent analgesia. In my opinion, that automatically excludes anybody being given ketorolac, because this does not, in any way, equate to adequate analgesia for anything but a kidney stone, maybe. There are lots of studies demonstrating, at least in some EDs, protracted periods of time before analgesia is administered to patients with long bone fractures. And who is at particular risk of oligoanalgesia in the ED? According to the literature its minorities, children, women and the elderly. Seems that the only ones who may be getting decent analgesia are white male adults.
So here’s my belief. There is pain the patient comes in with and pain that we cause (generally due to thoughtlessness). ED staffs need to become really proficient at relieving and preventing both types of pain. Maybe being a patient and experiencing some of this unnecessary pain will make us more sensitive to it. As will being given a gown that doesn’t cover our tush and having a nurse call light that is not connected to the wall. And on and on.
I think every ED should be highly focused on pain relief. It is one of the few things that we should be able to do rapidly, consistently and effectively. All’s that is needed is the departmental desire to achieve this goal. Honestly, it is really simple. But it needs to be a departmental priority. Not just a priority of this doctor or this nurse. It should not be a prerogative not to participate. It can’t be optional.
What’s wrong with making people comfortable? Why aren’t all EDs “ouchless” and why don’t we market this as much as the lies about our short waiting times? And why can’t we follow the lead of Geriatric EDs? Why don’t all EDs do what these EDs do: wider beds, warmer lights, decreased departmental noise, actively encouraging family to be with the patient, increasing efforts to provide privacy, better food, TVs in every room and WiFi access, better access to rest rooms. Wouldn’t any patient, independent of age, want these things?
We need to be reminded that patients coming to the ED are, on average, paying very serious money for care, probably averaging at least $600 for those who are discharged. We have to change our mentality and welcome these patients and make it clear that we appreciate their business. This latter sentence will likely annoy a lot of the more burned out ED staff, but we are the only business that complains about having too much business, or worse, we act as if we are doing the patients a favor.
I don’t get it. As noted in a recent column, I have no idea why CEOs don’t fix the problems associated with overcrowding and understaffing. Is this an insurmountable problem? Certainly not. So the answer must be motivation. And the great motivator is money. CEOs’ bonuses need to be tied to ED metrics related to throughput – both admitted and discharged patients.
We need the hospital to create EDs of which we can all be proud. There is no harder place to work in a hospital that the ED – hands down. So administrators need to step up to the plate and make it happen so that those that work in the ED don’t see it as some sort of hell hole and that patients are consistently provided a level of service worthy of the premium that they will pay.
And finally, remember that there are 9,000 urgent care centers out there and the number is growing rapidly. They are going to thrive on the many patients who would rather go to a place that makes it clear that they are appreciated through a myriad of small kindnesses.
Richard Bukata, MD is Editor of Emergency Medical Abstracts (www.ccme.org)