A priority for care providers
Pain complaints are the third most common healthcare problem in the world
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.