Oh What a Relief It Is!

1. Oh What a Relief It Is! Pain Management in EMS Laurie A. Romig, MD, FACEP Medical Director Pinellas County (FL ) EMS

2. ‘‘We must all die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself.’’ -Albert Schweitzer

3. Objectives • Provide a better understanding of how badly we and the rest of the medical profession handle pain • Identify some of the barriers to better pain management for all patients • Describe some common pharmacological pain interventions • Describe some nonpharmacological pain interventions

4. Survey says: • Do you believe that prehospital pain management is a: • High priority and important goal • Nice to do if you have the time, but not a priority • Not at all important • Not our job or our problem (nobody ever died of pain)

5. Survey says: • How many of you have: • Protocols for pain meds before or without medical control contact • Protocols for pain meds only after medical control contact • IV opiates • Intranasal opiates • Other non-opiate analgesics such as ketorolac (Toradol) • BLS measures only

6. Survey says: • How well do you think your service does with pain management? • We do great. Nobody suffers unnecessarily • Pretty good, but we could do better • Not very well • What pain management?

7. Prevalence of Pain • Studies show that pain of some type is a presenting complaint for up to 70% of all ED patients • The percentage for EMS is probably similar. • One study showed that 20% of EMS patients complain of at least moderate to severe pain • Other studies show that all medical practitioners, including EMS are poor pain evaluators and managers

8. JCAHO now recognizes pain evaluation as the “fifth vital sign” and judges hospitals on their pain management policies • In many cases, pain relief is the primary expectation of our patients

9. In many cases, it is the ONLY thing that we can offer the patient other than transport to the hospital • Pain management is often neglected or, at best, delayed in Emergency Departments

10. 1073 patients with suspected extremity fractures only 1.8% were administered analgesics 17% received ice packs 25% received air splints Akron Fire Department Published 2004 EMS Literature

11. 124 patients with ED diagnosis of hip or lower extremity fractures 18.3% were administered field analgesics 91% received analgesia in the ED (ED patients - 2 Hour Delay) William Beaumont Hospital, Royal Oak, Michigan Published 2002 EMS Literature

12. 128 elderly patients with field diagnosis femoral neck fractures 51% received field pain management Only 2 patients received splints in the field Westmead Hospital, Sydney, Australia Published 2003 EMS Literature

13. Few EMS textbooks devote significant attention to pain management EMS education on pain management lacking Many EMS systems do not have pain management protocols Why is oligoanalgesia so prevalent?

14. EMS personnel want to avoid conflict with ED physicians ED physicians want to avoid conflict with surgical consultants Why is oligoanalgesia so prevalent?

15. Care providers can accurately assess a patient’s pain by observation Pain affects all people in the same way Everyone responds to analgesics in the same way Analgesia can create difficulty in assessing abdominal pain and other clinical conditions Myths About Pain Management

16. Myths About Pain Management • Patients become unable to give informed consent • Use of narcotics in acute pain leads to increase in addiction • Analgesic use in the field is unsafe

17. Myth: Care providers can accurately assess pain by observation • Self-reporting is actually shown to be the most accurate reflection of pain intensity, NOT the care provider’s opinion • Care providers are influenced in their subjective evaluations by other patient factors and by their prior personal and professional experience with pain

18. Myth: Pain affects all people in the same way • Pain perception is affected by: • Age (KIDS DO HURT AND THEY DO REMEMBER IT!) • Gender • Race • Culture • Emotions • Cognitive state • Previous experience

19. Pain Assessment • Objective measures of pain ratings improve pain management • Help to balance imprecise clinician pain assessment • Assist in tracking success of pain management • Are available for both adult and pediatric ages, even down to neonates!

20. Pain Assessment • Numeric Rating Scale • 0-10 • 0 = No pain • 10 = The worst pain you can imagine • Requires verbal and cognitive ability

21. Pain Assessment • Visual Analog Scale • 10 cm line with left end being “no pain” and right end being “worst pain imaginable” • Have patient mark their pain level on the line • Pain level measured in millimeters • Requires vision, cognition and relatively large amount of space to perform

22. Pain Assessment • Verbal Rating Scale • None, mild, moderate, severe, unbearable • Requires cognitive ability

23. Pain Assessment • Wong-Baker FACES Scale • Works well for pediatrics • Also works well for some adult patients unable to perform other scales Also comes in a 0 to 10 format

24. Myth: Everyone responds to analgesics the same way • Many factors can affect how a given drug and dose will affect different people • Body weight • Lean vs. total • Hemodynamic status • Drug tolerance • Metabolic rate • Concurrent drug use

25. A number of studies have shown that early administration of analgesics Allows patients to relax Removes voluntary guarding Permits better assessment of localized tenderness Myth: Analgesics can create difficulty in physical examination and diagnosis

26. Administration of morphine to pediatric patients with abdominal pain did not affect the clinician’s ability to recognize children with surgical conditions Published 2002 Myth: Analgesics can create difficulty in physical examination and diagnosis

27. In a survey of emergency medicine physicians ED physicians believe judicious use of pain medication does not compromise physical exam BUT the majority withheld analgesics until after evaluation by the general surgeon Published 2000 Myth: Analgesics can create difficulty in physical examination and diagnosis

28. Multiple studies show that patients retain their ability to give informed consent despite the effects of analgesics Myth: Patients become incapable of giving informed consent

29. Myth: Use of narcotics in acute pain leads to an increase in addiction • NO research supports this • Assumption is often based on the fact that many people appear to become “drug-seekers” after an acute injury • In fact, these “drug-seekers” are often only the victims of inadequate pain management (oligoanalgesia) and a medical culture that does not recognize it’s own limited understanding of pain issues

30. A note about “drug-seekers” • Check with your medical director about his or her philosophy • In general, EMS should NOT be attempting to determine if a patient is a drug-seeker • Especially without an on-going familiarity with the patient • Doing so may cause you to unfairly under-treat patients

31. One study evaluated 84 cases using small doses (2-4 mg) of morphine Only one case of MS induced respiratory depression was found Published 1992 Myth: Analgesics are Unsafe

32. Myth: Analgesics are Unsafe Another study reviewed 131 air-transported patients who received fentanyl. There were no untoward events Published 1998

33. Myth: Analgesics are Unsafe 2129 patients administered fentanyl in the field 12 patients (0.6%) had a VS abnormality due to fentanyl administration Only 1 patient required a recovery intervention Published 2005

34. Remember that any analgesic (and most EMS drugs) CAN be unsafe in the field if used outside of reasonable protocols and standard of care boundaries and without appropriate quality management.

35. Let’s take a break!

36. Safe Use of Analgesics • Understand the concepts of time of onset of action and peak effect (pharmacodynamics) and the values for each drug you use • Giving additional doses of medication prior to a previous dose taking effect puts you at risk for creating a problem for the patient

37. Safe Use of Analgesics • Slow and steady is better than hard and fast • Titrate small doses at appropriate intervals

38. Safe Use of Analgesics • Beware the effects of combining drugs • Particularly when added to not taking pharmacodynamics into account, adding one CNS depressant or hemodynamic depressant drug to another can create unpredictable changes

39. Safe Use of Analgesics • Don’t forget to ask about medication allergies, current medications and when they were last taken • Remember to look for Fentanyl patches!! • Adding IV opiates on top of recently taken oral sedatives, analgesics or muscle relaxants may cause unpredictable additive effects as well

40. Safe Use of Analgesics • Know your pain management goal • Does your pain management protocol have a goal? • ”Make the ride more bearable”? • “Decrease pain by 50%”? • “Decrease pain to “x” or less”? • “Make patient painfree”? • Your goal may actually be different for different types of patients

41. Safe Use of Analgesics • Reassess the patient (including pain scale) frequently • Document carefully (including pain scale) • Take the patient’s hemodynamic state into account if your medication may affect it

42. Safe Use of Analgesics • Always give complete report to ED staff regarding drugs given, time given, and results or adverse reactions • It can be difficult to sort out whether changes in level of consciousness or development of respiratory or circulatory compromise are due to the drug or to underlying illness or injury without good info on timing and sequence

43. Who should receive analgesics? • As always, go by your own protocol • Your local protocol may depend upon your medical director’s attitudes and experience with pain management and/or your medical community’s

44. Who should receive analgesics? • Your protocol may (and should) address • Abdominal pain patients • Pediatric/infant patients • Headache patients • Trauma patients (particularly multiple blunt trauma) • Hemodynamically unstable patients • The elderly • Short transport time patients

45. Who should receive analgesics? • Your protocol MAY contain minimum pain level requirements or specifications for acute versus chronic pain • ED docs may complain about what they perceive of as “minor” patients receiving IV analgesics • They may also complain about chronic or subacute pain patients receiving IV analgesics

46. Who should receive analgesics? • Remember that nonpharmacological pain management methods are usually safe and can be surprisingly effective • Ice or heat • Elevation • Splinting/positioning • Emotional support • Distraction (guided imagery, biofeedback, breathing exercises)

47. Common Prehospital Analgesics

48. How do I choose? • Desirable characteristics for EMS analgesic • Quick acting (short onset and peak effect) • Short duration • Minimize side effects • Hypotension, respiratory suppression, emesis, etc. • Easy to administer • Multiple administration routes available • Reversible • Inexpensive

49. How do I choose? • Take patient allergies into consideration • Take patient condition into consideration • Use the least hemodynamically active agent if patient is unstable • Sometimes it’s a crap shoot! • Individual patients may react better to some drugs than to others, but usually it’s still just a matter of giving ENOUGH drug

50. My Favorite… Fentanyl