Pain management

[Christopher]

It would be virtually impossible to do without turning this into a :censored: swinging contest, but it would be interesting to find out the department run volume and district demographics of the various posters on this thread and to see if there's a correlation between that and their opinion on this scenario.

It's a good question, I looked at our 2013 numbers YTD:

1172 transported patients.
505 transported patients reported Pain > 0 at first recorded pain level.
97 received a "pain medication" (fentanyl, morphine, toradol, ibuprofen; 155 including adenosine/diltiazem/NTG/atropine/lidocaine/procainamide).

Patients receiving pain medication (n=97, 19.2%)
Average initial VAS: 8.9 (p=<0.0001)
Average final VAS: 5.5 (ns)
Average delta VAS: -3.4 (p=<0.0001)
Pct reporting no change or increased pain: 22.1% (p=<0.0001)

Patients not receiving pain medication
Average initial VAS: 6.6 (p=<0.0001)
Average final VAS: 5.8 (ns)
Average delta VAS: -0.8 (p=<0.0001)
Pct reporting no change or increased pain: 63.4% (p=<0.0001)

Pct Male patients receiving pain medications: 34.6% (p=<0.0001)
Pct Female patients receiving pain medications: 27.5% (p=<0.0001)

Pct White patients receiving pain medications: 19.1% (ns)
Pct Non-White patients receiving pain medications: 18.4% (ns)

Not finished comparing 2012 to 2013, but a YOY increase of 7.1% for patients receiving pain management. The addition of Fentanyl in 2010 tripled the number of patients receiving narcotic analgesia.

 

[epipusher]

Well said usalsfyre

 

[Christopher]

It's a good question, I looked at our 2013 numbers YTD:

1172 transported patients.
505 transported patients reported Pain > 0 at first recorded pain level.
97 received a "pain medication" (fentanyl, morphine, toradol, ibuprofen; 155 including adenosine/diltiazem/NTG/atropine/lidocaine/procainamide).

To update, 187 patients received some medication (other than O2, NSS, D50, and LR) AND had a Pain > 0 at first recorded pain level.

Average initial VAS: 8.1
Average final VAS: 5.3
Average delta VAS: -2.8
Pct reporting no change or increased pain: 33.7% (n=63)

Most common patient category with Pain > 0:
Overall: Sick Person (n=90)
No pain control: Sick Person (n=78)
Pain control: Traumatic Injury (n=20)
Any med: Chest Pain (n=54)

 

[FiremanMike]

I've run just about every system size, volume and demographic out there and it hasn't changed my thought process. This tends to go back to my prior statement that pain management in EMS often seems to be demographically driven rather than patient driven.

Well sais usalsfyre

So the below was the described scenario
---
Drive by, pt flags you down, 30-70 yrold states 10/10 sudden onset leg pain, throbbing, constant, non radiating non traumatic. Appears in no distress. Vitals stable, hx irrelevent. Wants to go to hospital, en route says he wants morphine. Same person flags you down everyday for different complain.
---

Vitals stable, does not appear to be in distress, patient flags you down which (to me) implies that he is ambulatory. Even without the knowledge of this person's previous call history, I would not be inclined to give pain medication either. I will take this person to the emergency department for further evaluation and treatment. I don't believe me this makes me judgmental or even prejudiced, but rather I am pulling on my own personal experience as well as the presenting signs and symptoms.

Furthermore, to draw a conclusion that providers who would not universally provide pain medication are judgmental is in and of itself a judgmental position. To blanketly state that you give everyone pain medication that present with a complaint of pain is the same as saying you give nitro to anyone with chest pain, ignoring all mitigating factors.

 

[FiremanMike]

It's a good question, I looked at our 2013 numbers YTD:

1172 transported patients.
505 transported patients reported Pain > 0 at first recorded pain level.
97 received a "pain medication" (fentanyl, morphine, toradol, ibuprofen; 155 including adenosine/diltiazem/NTG/atropine/lidocaine/procainamide).

Patients receiving pain medication (n=97, 19.2%)
Average initial VAS: 8.9 (p=<0.0001)
Average final VAS: 5.5 (ns)
Average delta VAS: -3.4 (p=<0.0001)
Pct reporting no change or increased pain: 22.1% (p=<0.0001)

Patients not receiving pain medication
Average initial VAS: 6.6 (p=<0.0001)
Average final VAS: 5.8 (ns)
Average delta VAS: -0.8 (p=<0.0001)
Pct reporting no change or increased pain: 63.4% (p=<0.0001)

Pct Male patients receiving pain medications: 34.6% (p=<0.0001)
Pct Female patients receiving pain medications: 27.5% (p=<0.0001)

Pct White patients receiving pain medications: 19.1% (ns)
Pct Non-White patients receiving pain medications: 18.4% (ns)

Not finished comparing 2012 to 2013, but a YOY increase of 7.1% for patients receiving pain management. The addition of Fentanyl in 2010 tripled the number of patients receiving narcotic analgesia.

Thanks for your stats! VAS is an acronym for pain scale I assume?

As for demographics, I was actually referring to urban versus rural versus suburban as well as your overall run volume. I personally find that race plays almost no factor in my clinical decision making, and certainly would be irrelevant in terms of pain management.

 

[Brandon O]

To blanketly state that you give everyone pain medication that present with a complaint of pain is the same as saying you give nitro to anyone with chest pain, ignoring all mitigating factors.

What mitigating factors do you have in mind for pain?

I expect we'd all agree that certain comorbid conditions or the patient's physiological status may contraindicate many analgesics. But many folks in this thread (and in the field) seem to be responding to a separate issue, which is that they either don't believe the patient is in pain (they're lying), don't believe it's bad enough (patients should only treatment for very severe pain), or generally don't believe pain management is important or EMS's responsibility (not my job).

In other words, it's more of a philosophical difference, which is why it warrants discussion. There's not much argument over the pharmacological points.

 

[FiremanMike]

What mitigating factors do you have in mind for pain?

I expect we'd all agree that certain comorbid conditions or the patient's physiological status may contraindicate many analgesics. But many folks in this thread (and in the field) seem to be responding to a separate issue, which is that they either don't believe the patient is in pain (they're lying), don't believe it's bad enough (patients should only treatment for very severe pain), or generally don't believe pain management is important or EMS's responsibility (not my job).

In other words, it's more of a philosophical difference, which is why it warrants discussion. There's not much argument over the pharmacological points.

To me, in this particular case, the mitigating factors are stable vital signs, (presumed) normal ambulation, and no signs of distress. I don't feel that these are philosophical issues, but rather these are objective signs that don't seem to be consistent with a patient who is experiencing 10/10 leg pain, which is supposed to be "the worst pain I can imagine". It is also a mitigating factor to consider that this patient is a known drug seeker who calls daily, but I consider this to be lower on the list because I do agree that even drug seekers can have an episode of legitimate pain.

 

[Christopher]

Thanks for your stats! VAS is an acronym for pain scale I assume?

Visual Analogue Scale, 0 to 10 (or 0 to 100 mm). This would be similar to the Wong Baker Faces number line you have kids point to.

As for demographics, I was actually referring to urban versus rural versus suburban as well as your overall run volume.

We're Suburban/Rural, population of ~20k in our fire district. We're one of 3 ALS units which serve the area (2 county based units). Our call volume will be ~2300 runs this year in total given our forecasts. 90th percentile Call Received to Arrival of ~11 minutes.

I personally find that race plays almost no factor in my clinical decision making, and certainly would be irrelevant in terms of pain management.

This would be counter to the literature. Females and minorities typically receive less pain control. Apparently my own service has a disparity between males and females (but none for race).

 

[DrankTheKoolaid]

Something I've noticed in my years as Paramedic instructor is students who already work in a 911 system as EMTs come in with a bias already. When I preach pain management to students I get the usual response from them "my partner this, my partner that" so unfortunately this becomes a generational issue also.

Last cycle I was giving a chest pain scenario where the patient had 3 - 10 C/P. about 3/4 of the students did not give MS after their NTG and when asked why almost all responded with "I can live with the patient being in 3/10 pain". It didn't really click for them until I bluntly pointed out this wasn't about them it's about their patient and can the PATIENT live with it. Thankfully a few light bulbs turned on. There is a reason even ED physicians are are held accountable to answer when A patient has not been given analgesia in the ED In a set time period. We are all human and have formed biases through out life and our own experiences, but they have no place in medicine when treating other human beings.

 

[truetiger]

Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?

 

[FiremanMike]

Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?

This is exactly what I was trying to get at, thanks!

 

[Brandon O]

To me, in this particular case, the mitigating factors are stable vital signs, (presumed) normal ambulation, and no signs of distress. I don't feel that these are philosophical issues, but rather these are objective signs that don't seem to be consistent with a patient who is experiencing 10/10 leg pain, which is supposed to be "the worst pain I can imagine". It is also a mitigating factor to consider that this patient is a known drug seeker who calls daily, but I consider this to be lower on the list because I do agree that even drug seekers can have an episode of legitimate pain.

So in this case, you're falling into either the "patient's lying" or "it's not that bad" (i.e. they're lying about how bad, or they're just a wuss) groups?

There's quite a bit of both literature and common sense suggesting that physical presentations of pain vary tremendously, and presumably we agree that we have at least some responsibility to manage pain. At the same time, there are obviously drug-seeking patients out there, and we may have a responsibility not to feed that (as I alluded above, it's not clear how much responsibility).

So it seems like the real question is where you fall on this spectrum. Granted that if you try too hard not to be fooled, you'll let many people suffer, and if you try too hard to manage pain, you'll support many drug seekers, where along that line do you want to land?

Unfortunately, due to practical obstacles (such as mandated authorization, documentation, QA, and resupply after narc administration), and a common culture/mindset that hates "getting fooled" and generally respects a sort of mountain man self-sufficiency, I think most of us inevitably end up pushed toward the med-sparing side of the spectrum. And since pain that's not of the most obvious sort (sudden and profound, or associated with overt trauma) doesn't jump out to tell us we were wrong, it's not hard to do.

 

[DrankTheKoolaid]

Not exactly the same thing now is it. But to answer your question if coaching didn't help then yes I would and begin to question the validity of my assessment. I treat patients and not machines. Pulse oximetry has a lot of variables that can affect it including lag. But then again I would also want to look at Etco2 waveform as I don't trust SPO2 as far as you can throw it.

 

[Brandon O]

Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?

As an asthma patient who has often experienced mild shortness of breath without overt wheezing, I hope you would. It is not much fun.

I know we all understand that symptoms are not things you can detect from the outside (that's their definition; otherwise we'd call them signs). So this seems to come back to the issue of whether you think they're actually experiencing bronchospasm (or pain, for the original topic). It's sensible to wonder whether the pathogenesis is something different if you're not noting physical findings you would otherwise expect. But if that dilemma isn't on the table (e.g. there's no question of CHF, anxiety, etc), and deep down, what you're really asking is "is he REALLY short of breath/in pain?"), then we should be able to acknowledge that we're merely debating whether the patient's lying to us. And as I said, that only matters if we decide we're responsible for some sort of gate-keeper duty. (For narcs, maybe. For albuterol, ehh...)

 

[truetiger]

No, he falls into the category that does a proper assessment. It is imperative to be able to match complaints/findings and see what holds water and what doesn't. This has more to do with just narcs. Some of us work in systems that your transport decision is made by a good assessment.

 

[Ewok Jerky]

Bias aside, I think this has more to do about complaints not being supported by exam/objective findings. Would you give any other drug that was not indicated by YOUR findings? I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?

The problem with your analogy is that pain does not have physical findings like other diseases such as asthma. Take for example Shingles. The pain is originating in the sensory nerve itself and patients can experience sever pain for days before any rash shows up.

also- Remember that narcs aren't the only way to treat pain. Could this be a cause of some the differing opinions we are experiencing here? I know a lot of services only stock narcs and benzos but I am thinking big picture here with pain management.

 

[truetiger]

So are you saying that the verbal pain scale is our only assessment tool when it comes to pain? And is the only determinant in pain management?

 

[Christopher]

also- Remember that narcs aren't the only way to treat pain. Could this be a cause of some the differing opinions we are experiencing here? I know a lot of services only stock narcs and benzos but I am thinking big picture here with pain management.

Our pain control protocols are pretty broad in terms of the tool we may use, ranging from ASA/tylenol/ibuprofen to toradol to narcotics to antihistamines to benzos.

 

[chaz90]

I'll give an example, you have an asthma patient that reports shortness of breath. S/He's 100% on room air, has clear lung sounds, is moving good air, and is not breathing with any difficulty. She reports shortness of breath. Are we going to give her a breathing tx?

I sure would, or at least think about it. After ruling out other potential causes for the SOB and the patient telling me this feels like asthma and her inhaler typically fixes it, I'd give some albuterol a try.

This seems to correlate fairly well with a common nebulous pain control scenario. How about a frequent patient who complains of 10/10 abdominal pain? Says it feels like pancreatitis and that Dilaudid typically helps him when administered at the ED. We don't see textbook outer signs of "severe" pain, but he winces visibly when moved and quickly comes back to complaining about the pain if briefly distracted. Similar to our SOB patient above, none of our assessments reveal anything remarkable, but I would likely choose to medicate this patient anyway.

We do this all the time with another common patient. Think of our chest pain calls. How many of them do we go exclusively off of patient reported symptoms without any directly objective signs? 60 YOM, frequently calls complaining of chest pain. 5/10 dull chest pressure for the past two hours, non reproducible, and radiates to the arm and neck. Other evaluations at the ED for what seem to be identical complaints have never revealed any cardiac event. 12 Lead EKG and vital signs are all stable. How do we treat this patient? Why, based on subjective symptoms alone, this patient would be treated for suspected ACS by any competent EMS provider.

How different is this really from treating pain based solely on subjective symptoms? No where in my job description does it say that I was hired to be a stingy gatekeeper hoarding access to narcotic analgesia. I maintain accurate records and treat only when indicated, but I don't think we should get caught up in thinking of pre-hospital opioid use any differently than other medications we carry.

In my mind, desire to do our part to prevent drug abuse and addiction needs to come second to our primary responsibility to patient care. I've treated patients with admitted opioid addictions for pain before, and I'll do it again. I'm certain I've been tricked before, and quite frankly, I'm not overly bothered by it. I don't control access to all legal and illegal drugs, and all I can do with many of my medications is treat people based on what they tell me.

 

[Ewok Jerky]

So are you saying that the verbal pain scale is our only assessment tool when it comes to pain? And is the only determinant in pain management?

Pretty much yes. Objective findings are useful in Dxing the etiology of the pain. Plenty of things that cause pain can be managed non-pharmacologically. But when someone is sitting in front of me and tells me they are in pain, I can neither rule in or out the fact they are in fact experiencing pain. All I have is their word.