A pri­or­ity for care providers

Pain com­plaints are the third most com­mon health­care prob­lem in the world

The Guardian (Charlottetown) - - OPINION - BY DES COLO­HAN Des­mond Colo­han is a re­tired emer­gency physi­cian and pain spe­cial­ist.

Re­cently I re­ceived a phone call from a dis­traught grand­fa­ther des­per­ate to help his daugh­ter, who was try­ing to nav­i­gate the health care sys­tem seek­ing pain re­lief for her teenage daugh­ter, who is suf­fer­ing with as yet un-di­ag­nosed se­vere chronic pain. I could hear the an­guish and frus­tra­tion in his voice and, sub­se­quently, that of his daugh­ter and grand­daugh­ter when I spoke with them as they hud­dled in an emer­gency depart­ment (ED), the sec­ond one they had vis­ited.

In ad­di­tion to serv­ing as an al­most ex­clu­sive por­tal to hos­pi­tal ad­mis­sion, EDs sup­port pri­mary care by per­form­ing com­plex di­ag­nos­tic workups and han­dling of­fice over­flow, as well as meet­ing af­ter-hours and week­end de­mand for care. Although the core role of EDs is to eval­u­ate and sta­bi­lize se­ri­ously ill and in­jured pa­tients, the vast ma­jor­ity of pa­tients who seek care in an ED walk in the front door and leave the same way.

Re­search in­di­cates that most am­bu­la­tory pa­tients do not use EDs for the sake of con­ve­nience. Rather, they seek care be­cause they per­ceive no vi­able al­ter­na­tive, or be­cause a health care provider sent them there. At least 75 per cent of ED pa­tients have a chief com­plaint of pain. It is the third most com­mon health­care prob­lem in the world.

In “Man­age­ment of Pain in the Emer­gency Depart­ment,” Dr. Stephen H. Thomas re­views the role of the Emer­gency Depart­ment in re­liev­ing pain. Let me sum­ma­rize his sage ad­vice.

Since pain is a fre­quent rea­son why peo­ple go to the Emer­gency Depart­ment, its treat­ment should be a pri­or­ity for care providers. His­tor­i­cally, the ED has demon­strated short­com­ings in both the eval­u­a­tion and ame­lio­ra­tion of pain.

Suc­cess­fully re­liev­ing pain is one of the most im­por­tant things that care providers can do. The im­por­tance of pain re­lief to in­di­vid­ual pa­tients and fam­ily, and the rel­a­tive ease with which pain can of­ten be ame­lio­rated, ren­der pain con­trol an achiev­able tar­get for op­ti­miza­tion of a pa­tient’s ED care.

Se­vere pain can cre­ate a bar­rier to per­form­ing an ad­e­quate his­tory and phys­i­cal exam. De­liv­er­ing pain re­lief can fa­cil­i­tate bet­ter pa­tient care. The risks of anal­ge­sia should al­ways be kept in mind, but a fair risk/ben­e­fit assess­ment should in­clude the po­ten­tial to make pa­tients more com­fort­able, not just the pos­si­ble risk.

Un­for­tu­nately, ED pro­ce­dures can of­ten cause ad­di­tional pain. Even some­thing as seem­ingly triv­ial as tak­ing blood can cause enough pain to be per­ceived by pa­tients, es­pe­cially chil­dren, as sig­nif­i­cant. A lit­tle ex­pla­na­tion be­fore the fact would go a long way to al­le­vi­at­ing anx­i­ety.

Whether or not pain is treated, and there are very few cases in which non-treat­ment is truly ap­pro­pri­ate, ED providers should ac­knowl­edge the pa­tient’s pain and dis­cuss a plan for treat­ment. When the plan is for no treat­ment, it is es­sen­tial that pa­tients un­der­stand why they are not re­ceiv­ing pain re­lief. A rea­son­able ex­pec­ta­tion would be that pain be ad­dressed within 20–25 min­utes of ini­tial eval­u­a­tion in the ED.

Slow­ing of a pain-re­lated tachy­car­dia, fast heart rate, may have sub­stan­tial pos­i­tive ef­fects on some­one hav­ing a heart at­tack.

Pa­tients are of­ten frus­trated when they go to an ED for pain re­lief and are given the same med­i­ca­tions they had been tak­ing at home. In some sit­u­a­tions, the right ini­tial ED anal­gesic will be a non-pre­scrip­tion drug, but, when th­ese med­i­ca­tions have al­ready failed at home, it doesn’t make much sense to try them again.

The right ini­tial ap­proach is quite of­ten a “broad spec­trum pain med­i­ca­tion” such as an anti-in­flam­ma­tory anal­gesic or opi­oid. How­ever, there may be sit­u­a­tions in which more tar­geted anal­ge­sia is best.

Den­tal pain com­monly raises the specter of “drug-seek­ing be­hav­ior.” A long-act­ing lo­cal anes­thetic block can achieve bet­ter pain re­lief than strong pain pills, and can get a pa­tient through the night. Putting in tem­po­rary fill­ings and re­gional nerve blocks can also be help­ful. Hip frac­ture pa­tients of­ten have pro­nounced risk of side ef­fects from opi­oids.

In my next ar­ti­cle, I will dis­cuss rea­son­able ex­pec­ta­tions for pain man­age­ment in the Emer­gency Depart­ment.

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