Background and Clinical Pearls
Aside from the unpleasant or even torturous experience of pain, pain stimulates a fight-or-flight response that is an additional physiological stressor on the acutely ill or injured patient. Effects range from elevated vital signs to impaired healing of injuries. Yet as many as 43% of EMS patients have inadequate pain relief, according to the Agency for Healthcare Research and Quality. Reasons include fear of adverse effects, masking of underlying conditions, and provider indifference. While data on analgesia-related adverse events is lacking, the availability of pulse oximetry, capnography, naloxone, and continuous 1:1 monitoring should make the prehospital environment a uniquely safe place for aggressive pain management.
The masking of symptoms and obscuring a diagnosis by relieving pain is a myth that has been thoroughly debunked. A physical exam is not impaired, but modern diagnostics such as CT are routinely used. Provider bias has been a well-studied problem throughout emergency medicine, with race, sex, age, and provider's perception of the legitimacy of complaints all associated with undertreatment. Patients labeled as "drug seekers" often have legitimate medical problems, and addiction or drug-seeking behavior is managed through a coordinated case management approach. In other words, you aren't going to create or solve addiction in the back of an ambulance. However, not all patients need opioids. Nonpharmacologic interventions, nitrous oxide and ketamine are possible alternatives. Pain assessment is subjective as vital signs are unreliable.
Performance Improvement and Best Practices
Assessing pain with different scales may be beneficial depending on the patient's age and presentation. Different scales include 1-10 numeric, Wong-Bakers, CPOTT, and Bloomsbury Sedation Scale.
The assessment of pain relies on subjective and objective information. As prehospital providers, it is essential to document all assessment findings related to the patient’s pain, including interventions and responses.
Subjective findings of a patient’s pain may include their description and rating of the pain. Everyone experiences pain differently, so all complaints should be treated as valid. Objective findings may consist of physical assessment findings and physiological changes. Document the patient's pain complaint as you would any other vital sign; for example, every 5 minutes for patients considered unstable and every 15 minutes for stable patients.
There are various treatments for pain ranging from BLS interventions to ALS medication administration. Choose the most appropriate means and document all responses and changes in the patient’s complaint. Simple interventions such as warming pads have been found to reduce pain from injuries, various abdominal conditions, and kidney stones.
Often overlooked by the ALS provider are BLS interventions that are synergistic with medication administration. Splinting and positioning are essential interventions that can profoundly affect the overall pain management.
When performing pain management with medication, remember that more medication can always be given, but a large dose cannot be taken back if adverse effects occur. Consider diluting drugs to make them easier to push over a more extended period. Consider a pain management drip for prolonged patient contact times depending on local protocol.
There are special patient populations for whom extra care should be exercised due to their ability or inability to metabolize medications. Pediatrics, geriatrics, renal insufficiency, and hepatic insufficiency patients should all be medicated according to local protocol, with consideration given to their specific presentations and conditions.
Other Relevant Data and Educational Resources
EMS providers often treat patients presenting with painful conditions and symptoms. This JEMS article is entitled, A guide to Prehospital Pain Management helps providers understand the physiologic mechanism that causes pain, the physiologic response to pain, and the methods to control it. This understanding makes providers well equipped to care for these patients.
Different approaches to the management of pain in the prehospital setting are discussed in this article entitled, 10 Things EMS Providers Need to Know About Acute Pain Management provided by EMS technology solution provider Pulsara.
Rural EMS Counts Pain Measures
Pain- Pain Management Intervention Performed for Pain >4
Description: The report calculates the percentage of patients with a pain score of five or greater from any cause (trauma, cardiac, other) who received some form of pain intervention and the percentage of patients with pain relief.
For the purposes of reporting the percentage of patients receiving pain intervention, the following interventions are considered: Toradol, Ibuprofen, Tylenol, Fentanyl, Morphine, Nubain, Versed, Versed Drip, Midazolam, Valium, Darvocet, Demerol, Dilaudid, Hydrocodone, Percodan, Stadol, Nitroglycerin, Nitronox, Nitroprusside, Nitrostat, Nitro Infusion, Nitro Paste, Nitro Spray. The following interventions when applied in the presence of a self-reported pain score of greater than 4 are assumed to be used in part to reduce discomfort; splinting, traction splint, cooling, bandaging, burn care and irrigation. That report requires documentation of at least two pain scores.
Specific filters to identify for this report include: 1. Highest Pain Value Gathered ≥ 5. [This value is documented in the vital signs section.] Pain- Pain Intervention Resulted in Pain Reduction for Pain >4 Description: This report calculates the percentage of EMS transports originating from a 911 request for patients whose pain score was lowered during the EMS encounter. Specific filters to identify for this report include: 1. Highest Pain Value Gathered ≥ 5. [This value is documented in the vital signs section.]