When pain relief is not enough in the Emergency Department. St.Emlyn’s

Treating pain in the Emergency Department is a skill, and a really important one.  Although we’d like to think otherwise, saving lives actually accounts for only a very small part of what we do as emergency physicians.  The other, much larger, part of our role is to make our patients’ lives better.  There are many ways that we aim to do that.  One of the simplest and most immediately rewarding ways is the treatment of acute pain.

Most of our patients are actually in pain.  More than 1 in 3 of our patients has ‘severe’ pain (rated >7/10).  And anyone who’s ever been in pain knows how terrible that can be.  So we need to do something to make it better.

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[DDET What can we do to relieve pain?]

Give painkillers.  Obviously.  We prescribe analgesia according to how severe we (as doctors) and patients (as the one’s who have the pain) think it is.  There’s been lots of focus on how quickly we get pain relief to our patients in recent times, and we don’t always do so well.  Some people have even started calling pain ‘the fifth vital sign’ to raise awareness of this problem and to get us to do better.  That’s great! [/DDET]

[DDET So what are we missing?]

Imagine you’re a patient.  I know it’s hard but just for one moment picture yourself walking in to a crowded ED waiting room without at least hoping that you may be seen as a vIP.   You know that you’re going to have to wait on an uncomfortable trolley or a cold metal chair while you wait several hours to be seen by a doctor you’ve never met and put your entire wellbeing in their hands.  What’s more, imagine that you had no medical knowledge.  But you’ve got a pain in your chest.  It’s not a bad pain – probably 2/10 – but you’ve seen the clips on YouTube.  You’re pretty scared, right?  Any moment now you might go into cardiac arrest.  In fact, did your heart just skip a beat?  What if you never get to see your kids grow up?!  In that context, the pain may not be so intense but I imagine that you’d be suffering quite a bit.

On the other hand, imagine you’ve just bashed your funny bone while having a laugh with some mates.  That hurts pretty bad, right?  Your ring and little fingers feel like they’re on fire.  This is a serious pain – maybe even a 6/10.  But you know what’s happened.  It’s only your funny bone – it’ll be better in 30 seconds and it’s nothing to worry about.  In that situation, I’d guess that you’d be suffering very little. [/DDET]

[DDET What’s my point?  ]

Pain and suffering are very different things.  You can be in mild pain and suffer greatly or you can have severe pain and suffer relatively little.  Arguably, what makes our lives go worst is suffering – not actually pain. [/DDET]

[DDET Why is this important?] This is important because suffering is a much bigger problem than pain.  Pain is just one way in which we can suffer.  But there are lots of other ways that we can be suffering, both physically and mentally. [/DDET]

[DDET What have we done about it?] The St. Emlyn’s crew did some research on this, which is hot off the press.  We ran a prospective cohort study of 125 patients (all comers) who presented to the ED.  We ran a questionnaire immediately after triage to ask if and how patients were suffering, and we repeated a questionnaire before they left the ED.  Using the responses we ran a thematic analysis.  Here’s the abstract.  The full text is at the EMJ

Link to PubMed citation

Link to PubMed citation

[/DDET]

[DDET What were the key findings?] Our findings did actually confirm that pain and suffering are different things.  Interestingly, there were patients who had severe pain (>7/10) who said that they weren’t suffering!  We did, however, find that patients were suffering in many different ways, including with physical symptoms, e.g. pain, nausea, vomiting, dizziness; and emotional symptoms, e.g. anxiety.

Our thematic analysis revealed a number of important themes.  In order to ease their suffering, patients were most often hoping for some quite simple interventions: reassurance, diagnosis, explanation, basic care, and to either go home, receive treatment or see a specialist. Ultimately, our analysis revealed that our approach to easing the suffering of our patients should (in the opinions of the patients we included) focus on:

    • Emotional distress (addressing this)
    • Physical symptoms (addressing these)
    • Information (providing this, particularly reassurance, diagnosis and explanation)
    • Care (basic care, including food drink and friendliness)
    • Closure (finding out what’s wrong and, where possible, going home)

[/DDET]

[DDET What does this mean for our practice?] There hasn’t been too much work in this area so far.  The St. Emlyn’s team has previously written a review article exploring the relevant issues but our latest paper is perhaps unique in being original research.  It tells us that simply providing timely analgesia for our patients is just not cutting the mustard.  We’ve got to do better if we truly want to make the wellbeing of our patients our priority.  To do that, we need to remember all the elements of EPICC – and do them well.

The next step will be to explore some of these issues further, and to see what happens when we start to use such a framework in practice. Any comments or suggestions would, as ever, be extremely welcome.  You may help us to take the next steps in what we think is a very important area.

Rick [/DDET]

Posted by Rick Body

Professor Richard Body MB ChB, FRCEM, PhD is Professor of emergency medicine in Manchester. He is honorary Consultant in Emergency Medicine at Manchester Foundation trust. He is also the director of the Manchester Diagnostics and Technology Accelerator (DiTA) and Research Director of the Emergency Medicine and Intensive Care Research Group (EMERGING). His research interests include diagnostics, cardiac disease and the philosophy of emergency medicine. He is an acclaimed international speaker on cardiac diagnostics . He can be found on twitter as @richardbody

  1. Great post, Rick.

    The terribly wise Bernard Foex and I were talking about pain only last week; his perceptive insight as an ICM doc – “there’s more to pain than nociception.”

    Considering pain contributes so significantly to the reasons patients attend the ED, I think we could definitely improve the way we approach it. There is often a perception (certainly among junior staff) that ED attendances are for investigation of the cause of pain, rather than also helping with its management; consider patients who presenting because of neck pain post RTC. Sometimes they need investigations which take an hour or two and are ultimately normal but at the conclusion of the diagnostic process the pain is still the same (or worse if we’ve immobilised them throughout that time)!

    I think patients probably find this tough (“I spent three hours in the ED and when I left I was exactly the same – all they did was an x-ray”) and I think that showing that simple, regular analgesia is an important part of management (alongside diagnosis, reassurance, explanation and especially an outline of the expected course of the illness or injury) can really help patients. It seems to make sense to me (also why I explain to sprained ankle patients that analgesia won’t make their ankle better but will help them to get going, which will make things better).

    Looking forward to hearing more about this.

    Nat

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  2. Great piece Rick. I have often thought that the staff going round offering pillows, tea, sandwiches and a kind word are more effective than co-codamol. I wonder how much of our ‘standard’ ED environment and actions actually increase suffering? The relief when you take out the cannula and remove the full cardiac monitoring is always pretty evident.

    Agree wholeheartedly that pain should not be used in isolation. It is measurable though and I guess it is also used as a proxy for departmental efficiency in College audits etc. Is there a validated way to measure global suffering to move us away from this? Maybe the SSS (St Emlyns Suffering Scale).

    There has been some interesting discussion about the origin, and validity, of the claim that pain should be the 5th Vital Sign in the Wall Street Journal. Leon Gussow from The Poison Review highlighted the issues in some of his posts http://tinyurl.com/o738g4e
    or for more links follow read this PDF (links to wall street journal article)
    http://tinyurl.com/pzquy62

    Cheers

    Tom
    @tmit2

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  3. […] might be subconscious but you can bet patients pick up on it. Rick and his research team did some fantastic primary research on patients reasons for attending the ED and found that they had four main priorities which can […]

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  4. […] to think about. Suffering is very subjective. How do we measure it? (You might want to check out a blog post I wrote on one of my recent papers) Should we make our own judgement about how much the patient […]

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