Pain Management, Part 2

Zachary posted a comment in my last post regarding pain management;

"Do you see any problems with an increase in drug seeking?"

The short answer (from my perspective, anyway) is: no.  But this does lead to another facet of why we treat pain the way that we do.

Why do we scrutinize our patients to see if they're "worthy" of our precious narcotics?

Fear.

When I was learning the profession of EMS as a new EMT, then again as a paramedic student, I saw plenty of examples of patients who reported they were in significant pain, but didn't receive adequate analgesia because the treating paramedic didn't feel they were "really in THAT much pain".  Similarly, I saw patients with a history of opioid abuse; some actually told us their addiction, while other times the crew made an assumption based on their medications, allergies, or history of ED visits.  These patients too rarely, if ever, received pain meds.  When I (curious mind that I am) asked these medics "why?", I heard various answers:

"They didn't look like their pain rating was 10 out of 10."

"Their vital signs were normal; if they're really in severe pain they'll be tachycardic or hypertensive."

"There's no way in hell I'm going to support their addiction; they'll just keep calling us and calling us.  If we give them narcotics, they'll just relapse."

These are all excuses based on fear, bad information, or burnout.


They didn't look like they were hurting that bad.

Ever get fooled by a patient presentation?  Happened once to me....actually, it happened lots of times to me.  When we view our patients through our own prisms of belief or subjectivity, we stop being objective and exploring all the possibilities.  And we make mistakes.  Consider the initial pushback that came when 12-lead ECGs starting finding their way onto ambulances.  Many seasoned, experienced medics said "I don't need some fancy machine to tell me when my patient's having a heart attack!  I KNOW what a heart attack looks like."

And they got suprised when normotensive patients without crushing chest pain had a 12-lead ECG that showed a STEMI.  Oops.

A large portion of our assessment relies on subjective information relayed by the patient; the best example of this is pain.  Some patients might communicate their pain level in a nonverbal way pretty well; but what about the mom who's trying hard to not cry from the pain and freak out her kids?  Or the guy trying to be tough in front of his buddies?  We can't objectively measure pain; we have to trust what the patient is telling us.  Trying to objectively measure the subjective is tricky at best, and unethical at worst.  I miss "Scrubs"; this clip summarizes the idea pretty well.

http://www.youtube.com/watch?v=-VR4onx2riQ

"Their vital signs were normal."

For most of us, this is pretty true; pain is accompanied by anxiety, which causes a sympathetic response and a catecholamine rush.  Hence the tachycardia and hypertension.  However, if patients have a condition that causes chronic pain, their body often adapts.  Rather than having an almost constant rush of catecholamines, their body simply stops releasing them every single time the brain registers pain.  It's called "sympathetic modulation".  Again, you can't objectively measure pain.

"They're drug-seeking."

So what?  People with opioid dependence hurt, too.  As a matter of fact, people who abuse opioids can have an exaggerated response to a painful stimulus; that is, something that would merely annoy you or I can be excruciating to a heroin or oxycontin addict.  I can identify with not wanting to prolong or complicate an illness with your treatment; I think many paramedics who withhold opioids from patients with opioid dependence are trying to do the best for the patient in the long run.  But there are two fundamental problems with this approach;

1)  Acute pain management doesn't seem to make dependence worse.  In fact, undertreating acute pain can make long-term management MORE difficult.  Here's a nice article that summarizes some common misconceptions and myths about giving opioids to patients with opioid dependence;  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816/

2)  As EMS providers, we're not long-term care providers.  That's not our role.  Nor are we addiction specialists.  That's not our role either.  When an ER doc identifies a medical condition in one of their patients that needs to be managed outside of their domain, they do one of two things; they refer the patient to their primary care doc for long-term management, or they refer them to a specialty service that has the training and clinical experience to give the best care to the patient.  In the meantime, the ED doc does what he/she can to treat the symptoms and make the patient feel better.  Why should we do any different?  Drug seekers don't call 911 and complain of abdominal or back pain for the fun of it; their body is demanding that drug.  Their body needs that drug to function.  Who are we to tell our patients "no"?

I do think we get hamstrung by the meds we carry; EMS is the only medical specialty I know that only has one option to control pain.  There's a lot to be said for ibuprofen and Tylenol (that's just about all I used after my hernia surgery).  Why aren't we using those as alternatives to use the right med for the right problem?

This has been a little long-winded...sorry.  But a little hisotrical perspective is in order.  Medicine all started because one guy (probably a guy, anyway) saw that people felt bad, and started looking for ways to make them feel better.  We've grown much, MUCH more sophisticated in how we do that, but the "why" should still be the same; someone doesn't feel good, and we want to make them feel better.  It goes right along with one of my favorite quotes from Hippocrates:  "Cure sometimes, treat often, comfort always."