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Pain Management - Is It An Important Focus Of Medical Care?

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As a current Paramedic working on transitioning to the dark side I read the following article and thought does nursing or any other medical profession really not understand the importance of pain management or is it really just an EMS problem? Having been a patient as well as an EMT and now a Paramedic I have experienced a number of different attitudes towards patients pain both prehospital and in hospital. So I guess really I am interested on what to expect as I advance in my education and move indoors in regards to pain management.

I also hope the article might also give you as a Nurse an ideal of why the patients you see brought in by ambulance may not all be treated the same way for the same injury or illness.

http://www.associatedcontent.com/article/5930346/is_an_ambulance_an_ambulance_the_differences.html?cat=5

wondern, ASN

Has 20 years experience.

I would certainly hope for the pain med and paramedic for my loved ones in pain. I guess I should add here from an obvious traumatic injury. I really can't imagine my family being in an ambulance for any other reason. How inefficient and senseless would that be if they had to wait until they are seen in the ER. They may be in shock from the pain by then. :sstrs:

Edited by wondern

BluegrassRN

Has 14 years experience.

It's very important; I'd say in the inpatient setting it is more important than in the prehospital or ED setting. I mean, I completely understand that in those settings the priority is the cause of the pain. If you mask the pain to much, you aren't always doing the patient a favor as you are taking away a clue to help with a diagnosis. Likewise, you don't have any or much history on these people--allergies, previous reactions, current meds. Finally, from floating down to the ED occasionally, I'm amazed at the people who play you (or try to) to get pain meds.

In an inpatient setting, we have a little more time to figure out what's going on, what previous history the patient has, what works best for the patient, what is stress and what is actually pain, and we get a feel on those who are playing us. We have more time to develop a professional relationship with that patient. At that point, yes, pain management is a very important focus. We aren't worried about the patient dying from some unknown cause like you are sometimes in the prehospital setting...we can focus on treating the cause of the pain AND the pain itself.

Zookeeper3

Specializes in ICU, ER, EP,. Has 17 years experience.

From my limited ER knowledge... the problem with pain management in an ambulance to treat pain rests in the availibility to have either a paramedic or a crew that has the time to call in the situation to the ER doc, lacking a paramedic to treat the source of pain.

While this may be a viable option in a BLS ambulance with a clear cut injury with a lengthy arrival time... many ER doc's are very hesitant to prescribe narcs on the phone without visually assessing the patients injury. In fairness their fear is that when the patient hits the ER door, the injury cannot be properly assessed.

The point of this article is to point out the need of the paramedic to be able to treat pain. While this is laudable, abdominal pain is never treated with narcs prior to an MD assessment... as well as many potential diagnosis.

So I agree, we need to be more proactive with pain management to comfort the patient. But no comfort to the patient is given with a compromised ED doc assessment upon arrival that will guide their decisions to assessment testing.

Pain management is a high priority but not above an MD determination of care. And yes, patients in the ambulance and ED do suffer until being seen by the doc. The alternative of missed diagnoses IMHO does not outweigh the pain.

Many won't agree with me, and anyone watching a patient in pain will disagree, but I've coded and lost many abdominal injury's masked by pain meds in route and the ER that were plain as day... way too late.:uhoh3:

Wish i had the compromise, but survival and good outcomes in the end weighs heavily on me... more so than than presentation of pain, no matter how difficult it is.

count me in the minority.

Zookeeper3

Specializes in ICU, ER, EP,. Has 17 years experience.

I"ll give one more before I leave this to others to debate. My daughter in an MVA, a GCS of 4 at the scene... had obvious right sided crush injury which was obviously very painful... rolled car at least three times each time hitting her side... 45 minute car removal due to the crush.. Probable entire right side broken and crushed, no LOC by the time paramedics arrived.

Life flight was called due to seriousness of injuries and she needed intubation (probable head injury).... now we all can argue based upon crushing injury she needed pain meds as it was clearly obvious there was severe pain involved.

Life flight records... Nimbex for intubation..... intubation followed by several more boluses and no pain meds until arrival at a trauma center to scan the brain injury and all the many fractures. First 24 hours in the ICU... nope no pain meds no sedation on a vent to monitor neuro status to determine if a ventricular drain needed to be placed.

Do ya think I was going to scream treat the pain? Heck no, don't mask any neruo signs and as tough as it was with a kid with 5 hip fractures, two spine fractures and a latent ankle one... they knew what they were doing.

So my case sounds rare, but for those of us that work ER and Trauma ICU, pain is an excellent sign and we revel in it and use it to monitor status.

Don't get me wrong, my co-workers, my lovely ICU nurses were crazy about it as was I. But remember that pain is an excellent neuro assessment skill that when masked... eliminates your astute assessment skills. One change in her assessment meant neuro surgery. Pain assessment does have a purpose in a select patient population that is not limited to my personal experience.

Patients and family simply need to be educated that in the first triage and possibly further assessment, pain is pure indicator of treatment and therefor must be left untreated however we may personally disagree.

When you can watch you baby on a vent, pain untreated for a better purpose of diagnosing and catching the smallest change in status, and understand the need for it... you'll accept pain as an acceptable outcome. People just need education through the tough time and more times than not, they'll understand the rationale... the others.... just need to be angry at the situation.

She never remembered the multiple fracture pain,the trauma in the car, or any of the short term recovery, simply the head injury pain which is long lasting and takes a heard of a neuro team AFTER to fix.

Edited by Zookeeper3
re read

usalsfyre

Specializes in CCT. Has 8 years experience.

It is completely inappropriate to claim pain is useful to "catch changes in status". You should have been monitoring the patient in other ways. Not to mention pain usually is not a diagnostic indicator (especially in the prehospital realm) for ANY neuro complaint. If you daughter had to suffer for that long I'm incredibly sorry for her sake, but to claim it had any use other than ignorance of appropriate pain management is ridiculous and excusing the inexcusable. Pain tells you jack, other than that a particular area needs examination.

EMS is a poor manager of pain because of misunderstanding of the negative effects of pain.

nurse2033, MSN, RN

Specializes in ER, ICU.

I'm not sure I quite got your question but I've been an EMT, paramedic, and now a nurse. Pain should always be addressed even if you might not be able to give meds for some reason. Anything greater than a 3-4/10 should be addressed. If the patient doesn't want treatment then just document why meds weren't given. The old school seemed to put the impetus on the provider to decide if meds should be given, the new school is to let the patient decide. This does create a lot of conflict for providers when they believe the patient is seeking. This is a whole area of discussion too large for this little text box.

BluegrassRN

Has 14 years experience.

Usalsfyre, you want to expand upon that a little? What in your ER or trauma experience leads to believe that pain is not an indicator of any sort of change in status, or that it is not a concern that the effects of pain medications will mask other symptoms? What studies or protocols has your facility used to treat pain in the prehospital and trauma areas while still diagnosing and treating an unstable patient?

I'm not trying to be snarky; I don't work these areas, and I honestly want to know. I was taught in school, and have seen in practice since, that with certain pain or trauma, you do not want to give pain meds until the patient has been evaluated adequately. How does your facility handle something like a head injury? What sort of pain medications do you give to a patient with an obvious head injury who is also c/o pain, either prehospital or in the ED? Is there no concern that giving the pain medications prior to evaluation will potentially cause further deterioration of the pt's neuro function, impeding the ability to appropriately diagnose and treat?

Like I said, I'm not in these areas, so I'm relying on some education and floating experiences that could be fairly outdated. I'm looking forward to hearing your response and learning something new.

Edited by BluegrassRN

OttawaRPN

Specializes in acute care med/surg, LTC, orthopedics. Has 5 years experience.

It is completely inappropriate to claim pain is useful to "catch changes in status". You should have been monitoring the patient in other ways. Not to mention pain usually is not a diagnostic indicator (especially in the prehospital realm) for ANY neuro complaint. If you daughter had to suffer for that long I'm incredibly sorry for her sake, but to claim it had any use other than ignorance of appropriate pain management is ridiculous and excusing the inexcusable. Pain tells you jack, other than that a particular area needs examination.

EMS is a poor manager of pain because of misunderstanding of the negative effects of pain.

Yikes, I have no idea who you are or if even a health professional but there are many different kinds of pain which need to be identified before effective pain management can be initiated. Somatic pain, visceral pain, nerve pain, sympathetic pain, all with unique characteristics activating different pain receptors and responding to different pharmaceutical options. Most definitely a diagnostic indicator, especially in decreased LOC. I'm also guessing you've never heard of referred (or reflective) pain otherwise you wouldn't have made that last comment.

usalsfyre

Specializes in CCT. Has 8 years experience.

Yikes, I have no idea who you are or if even a health professional but there are many different kinds of pain which need to be identified before effective pain management can be initiated. Somatic pain, visceral pain, nerve pain, sympathetic pain, all with unique characteristics activating different pain receptors and responding to different pharmaceutical options. Most definitely a diagnostic indicator, especially in decreased LOC. I'm also guessing you've never heard of referred (or reflective) pain otherwise you wouldn't have made that last comment.

Somatic, visceral, nerve, sympathetic, ect all respond to opiates in the ACUTE phase of injury, which is what we are discussing here. I seriously doubt you will see spinal blocks, ect prior to surgery with the possible exception digit blocks. When was the last time you saw pain used in diagnosis to the exclusion of lab results, diagnostic imaging, ect. In addition if properly titrated pain can still be elicited on PE but the patient will at least be comfortable (if not pain free) while at rest. Referred and reflective pain should raise your suspicion of index for certain injuries/illnesses but shouldn't be the only diagnostic finding. I seriously hope we're not doing splenectomies on everyone who has left shoulder pain.

We handle head injuries with short acting opiates. If the surgeon wishes the patient to emerge, they will wear off. However, all of these patients will get a head CT to reveal surgical injuries anyway, and in the case of diffuse axonal injury the opiates will eventually wear off but there will be massive deficits anyway.

Not to mention how is a patient being bolused with a neuromuscular blocker (Nimbex in the example above) going to be evaluated neurologically anyway? Not to mention the effects of pain and anxiety on ICP....

The "pain is diagnostic" excuse is to not treat pain at all is barbaric. Better to titrate to a level of patient comfort where PE can still be performed.

I am a healthcare professional, but not a nurse. I'll be happy to compare background/specialty areas with you via PM, but it's not germane to this discussion.

Yikes, I have no idea who you are or if even a health professional but there are many different kinds of pain which need to be identified before effective pain management can be initiated. Somatic pain, visceral pain, nerve pain, sympathetic pain, all with unique characteristics activating different pain receptors and responding to different pharmaceutical options. Most definitely a diagnostic indicator, especially in decreased LOC. I'm also guessing you've never heard of referred (or reflective) pain otherwise you wouldn't have made that last comment.

this is 100% true.

many, many docs will withhold pain meds, until a definitive dx is made.

otherwise, it can and will, mask very critical symptomology.

leslie

usalsfyre

Specializes in CCT. Has 8 years experience.

this is 100% true.

many, many docs will withhold pain meds, until a definitive dx is made.

otherwise, it can and will, mask very critical symptomology.

leslie

Not trying to be rude, but can you name one example of a critical symptom that is masked by appropriate pain management that can NOT be discovered by other means which are routinely also done for the complaint as it presents? Or are we just buying into old-school surgeons "trained hands" BS?

ZippyGBR, BSN, RN

Specializes in Spinal Cord injuries, Emergency+EMS.

I'd be interested to note what 'critical symptomology' is masked by appropriate pain relief ( vs snowing the patient to next february)

From my right-pondian perspective it seems that pain management is a neglected field in the US

All our A+E ambulance crews have access to analgesia - middle tier, volunteer and techs to entonox and (in some places) paracetamol

paramedics and ECPs routinely carry IV tramadol and/or Morphine and increasing numbers of services are carrying oramorph as well , plus they've got entonox and paracetamol ( and possibly a NSAID depending on drug protocols)

all these meds are given on the practitioner's own determination and inthe case of Paramedics it is legally enshrined as part of the legislation that governs Paramedics in the UK.

adequate analgesia is a integral part of patient care.

linearthinker, DNP, RN

Specializes in FNP. Has 25 years experience.

I do t want a paramedic making any determination about my neuro status. I just want them to drive me to the ED.

Not trying to be rude, but can you name one example of a critical symptom that is masked by appropriate pain management that can NOT be discovered by other means which are routinely also done for the complaint as it presents? Or are we just buying into old-school surgeons "trained hands" BS?

well, other than r/o appendicitis and other gi issues, i am thinking of a hospice pt i had, who has since died.

he was on painkillers for lower back pain, which his pcp generously prescribed.

pt's speech became more slurred and garbled.

this was attributed to heavy doses of painkillers.

turns out this guy had brain tumor.

by time it was officially dx'd, it was too late for treatment.

he died at 37.

leslie

adequate analgesia is a integral part of patient care.

as a hospice nurse, i couldn't agree with you more.

but there are exceptions, when immediate analgesia is not advisable.

that's all i was saying.

leslie

CrufflerJJ, RN

Specializes in ICU. Has 5 years experience.

I do t want a paramedic making any determination about my neuro status. I just want them to drive me to the ED.

I don't want a CCRN making any determination about my neuro status. I just want them to hold my hand until I'm evaluated by a physician.

There....doesn't that sound helpful??:cool:

I was active in volunteer EMS for 19 years (2 years EMT, 17 years paramedic) before going into nursing. I find it unfortunate that some folks still feel that Paramedics/EMTs are just "ambulance drivers." Yes, their level of training and scope of practice differ from those of a RN. That being said, I would much rather be assessed/stabilized/packaged/transported by a trained EMS person than being merely "driven" to the ED.

Over the years, evidence based practice has played an increasing role in field EMS. This has resulted in a return to the older "load & go" approach to handling serious trauma versus the "stay & play" treatment modality. Even in "load & go", however, assessment and treatment of the pt (to the limits of scope of practice) play a role.

Back to the OP's original post....treatment of pain in the field is important. Depending on region of the country & standing orders under which EMS providers operate, a pt may be given nitrous oxide, morphine, fentanyl, nalbuphine, or any number of other agents. Over the years, I saw my standing orders become more liberal. This was done in order to enable field personnel to provide pain control as early as possible.

Once upon a time, we could only give morphine after calling medical control ("call for orders"), and only in non-abdominal pain pts. This changed after a while to us being able to give the first dose (5mg) of morphine under standing orders even to abd pain pts, then give subsequent doses only after calling the ED doc. Eventually, this changed to us being able to give up to (2) 5mg doses of morphine at a set time interval without calling for orders. This is very handy when treating nasty pain like a compound femur fx. I could give the first dose even before splinting the pt, and a second dose (if needed) during transport.

Ohio permits EMT-Intermediate level personnel (not just paramedics) to give meds including morphine, nalbuphine, ketorolac, meperidine, or other analgesics for pain relief.

Pain control (or if not "control", at least taking the edge off it) is a good thing.

usalsfyre

Specializes in CCT. Has 8 years experience.

well, other than r/o appendicitis and other gi issues, i am thinking of a hospice pt i had, who has since died.

he was on painkillers for lower back pain, which his pcp generously prescribed.

pt's speech became more slurred and garbled.

this was attributed to heavy doses of painkillers.

turns out this guy had brain tumor.

by time it was officially dx'd, it was too late for treatment.

he died at 37.

leslie

Every appy I've ever seen appropriately medicated for pain (see the snowed in comment above for an example of inapproprite) still went primate feces when you messed with there RLQ. All of them also got an abdominal CT prior to surgery.

As to the second guy, there's a name for not investigating a new onset of change in mental status. It's called malpractice.

To me, as soon as an assesment is done attempt to control pain. Your patient deserves it.