One of her children demonstrated for emergency physician Kelly D. Young, MD, the highly variable nature of pain. “One has a really hard time with shots,” she said, “and takes a lot of preparation. The others just kind of skip in and get the shots.”
Her experience as a mother convinced her there was more to pain than meets the eye, and led to research on how pain is treated in the emergency department, particularly in children. “Each person is different, and each person interprets pain in his or her own way,” said Dr. Young, an assistant professor of emergency medicine at the David Geffen School of Medicine at the University of California, Los Angeles.
“There are different factors involved, and one may be the child's previous experiences,” she said, noting that the key to alleviating children's fears may lie in better ED treatment.
But changing the way pain is treated requires an ED culture change, Dr. Young said. It may mean different ways of listening to patients as they describe their pain, and it may take more time. It may even mean changing the doctor-patient exchange. But most emergency physicians say the result is worth the effort.
As the number of people seeking care in emergency departments continues to climb, it is increasingly clear that pain is what most often motivates them. In its most recent evaluation of emergency department statistics, the Centers for Disease Control and Prevention in Atlanta found that contusions, acute upper respiratory infections, abdominal pain, and chest pain were the most frequently reported primary diagnoses.
Recent interest in pain research is easy to understand, said James R. Miner, MD, the assistant research director in emergency medicine at Hennepin County Medical Center in Minneapolis. “Ten years ago, there was so little research done in the area,” he said.
Such nonchalance wasn't unusual: Pain was easy to overlook. “No one dies of pain,” Dr. Miner said. “When someone is critically ill, it is hard to make it a priority. Pain got put on the back burner during the early years of emergency medicine. It is now time to refine what we do.”
The problem, said Dr. Young, is that the emergency department is so fast-paced. “We want to get things over with fast, and parents do, too,” she said. “They want to get out of there.”
But she found that the children's experiences can affect how they deal with pain in the future, and using techniques to reduce their fear and pain can have long-term positive consequences. “I think it's important to use these techniques. What we gain in time in the short term, we lose in the long term by the children's subsequent reaction to pain and whether they seek care in the future as adults,” Dr. Young said.
In a review of pain in pediatric procedures (Ann Emerg Med 2005;45:160), Dr. Young pointed out that recent emphasis on pain control by institutions such as the Joint Commission for the Accreditation of Healthcare Organizations has boosted use of pain control in emergency departments, particularly for children. “Understanding and studying the pediatric pain experience has increased exponentially during the past two decades,” she wrote. “Besides the negative experience of pain itself, growing evidence supports the occurrence of long-term negative effects from inadequately treated pediatric pain, especially in infants.”
Dr. Young said short-term adverse effects occur in children, including hypoxemia, altered metabolic stress responses, and even death. “Despite the exponential growth in knowledge of pediatric pain determinants, assessment, and treatment, standard clinical practice continues to inadequately address prevention and treatment of procedural pain in children,” she wrote.
Addressing the issue means being aware of the stress, fear, and pain caused in children by even minor procedures such as fingersticks and venipuncture. “Yet interventions to reduce pain and distress are infrequently used,” she said.
Research in animals as well as infants in the newborn intensive care unit showed that repeated painful procedures, for which pain is inadequately managed, can have a detrimental long-term effect on children. “The developing brain's neuronal architecture may be permanently altered by repeated noxious stimuli such as painful procedures,” she wrote.
Babies who have undergone repeated painful procedures in the NICU react to subsequent pain with fewer outward signs of a pain response but with higher responses from the cardiovascular system. While the parents of NICU graduates rated their pain sensitivities as low at 18 months, the children were found to be more pain sensitive in their teens. A host of studies demonstrate that early pain experiences appear to sensitize children to pain later in life. “A survey of young adults correlated high childhood pain and fear of medical problems with high adult fear, pain, and avoidance of health care,” Dr. Young wrote.
Dr. Miner agreed. “There is enough basic science evidence that leaving children in pain causes more pain in the future,” he said. “It doesn't make sense that a kid would suffer through something and be fine. Pain can cause vegetative symptoms and delayed wound healing.”
“We are not adequately treating pain,” added Dr. Young. “Now that we have identified the problem, we need research to fix the problem. There is a lot of it going on in the emergency department. It requires system changes. What can we do to improve pain management without changing the flow and keeping the emergency department moving?”
The answer is a change in the culture of the emergency department. “It's a change in expectation on all parts,” Dr. Young said, starting with those of doctors and nurses. “Doctors will expect the nurses to use the numbing medication before the doctor comes in. The nurses expect standing orders for pain control methods. It cannot be changed by one physician. We all have to get together to get a system change.”
The adjustment has to include parents, who need to be educated about their children's needs for pain control, she said. Even if the parent is in a hurry, he needs to understand the long-term consequences of his child's pain.
In her study, Dr. Young pointed out that some factors can be changed and others cannot. Younger children, for example, have greater pain responses, as do girls. Difficult children are more likely to have a higher pain response than those who are adaptable. Anxious children are more likely to have a greater pain response than those who are stolid. Greater pain responses also are seen when the emergency department procedure is painful, invasive, or takes a lot of time. When children are not told about the procedure or prepared for it, their pain response is higher, as it is when the children have a decreased sense of control or are in a chaotic, noisy environment.
A parent's presence can be positive or negative, depending on the adult's anxiety level and how he interacts with the child. “Adult behaviors associated with increased child distress include reassurance, criticism, apology, and giving control to the child,” Dr. Young wrote. “When you have a child who is fearful, it is important not to force on the child our own values. We have to recognize that each person is different and individualize our approach.”
“Pain got put on the back burner during the early years of emergency medicine. It is now time to refine what we do.”
Dr. James Miner
The first step is to assess the child's pain, she said. “Because pain is subjective, self-report is considered the criterion standard.” She said tools such as visual analogue scales can be used. “People try to assess pain more quickly and accurately,” she said. “It's important not to get hung up on a number.”
One person's 4 on the pain scale might be another person's 8, she said, adding that physicians can ask patients if they need something to reduce the pain or can tolerate it.
“One thing that helps and is shown to help is distraction. We try to get the parent to take part in distraction as well,” Dr. Young said. “Get them a book to read with the child or a game they play together to help them both to distract each other.”
New products also allow doctors to avoid stitches, and topical anesthetics can reduce pain and take effect in 20 to 30 minutes.
“More and more is coming out about pain research at all levels, whether in terms of pharmacologic treatments or others. We are learning about the right drugs and the right combinations,” she said. “There's also research coming out to identify the patients for whom we need to go the extra mile and take time versus those with whom we can take the usual approach.”
Dr. Miner said he and his colleagues are looking at alternative dosing strategies in children, particularly at medications that contain acetaminophen and those that do not. “You don't want to have to stick an IV in a person with a sprain,” he said.
Dr. Miner agreed that research will go a long way in answering questions about pain. “The funny thing about pain is that we will never be able to measure pain, and we won't know when it's gone,” he said. “It's always a social interaction between physicians and patients. Scales cannot measure that.”
Dr. Miner and his colleagues attempted to determine what it is about the relationship between patient and physician that affects how patients perceive their pain treatment. In their study (Acad Emerg Med 2006;13:191), patients undergoing treatment for pain in the emergency department were asked to measure their pain on a visual analogue scale. Researchers recorded demographic information and the treatments for pain that each patient received. The patients then completed a second visual analogue scale before leaving the ED.
“each person is different, and each person interprets pain in his or her own way.”
Dr. Kelly Young
They were asked to answer three questions about their interaction with the physician. Once the patients were gone, the physician was asked to complete a query describing the interaction with each patient and a visual analogue scale that described how likely he thought it was that the patient was exaggerating his symptoms in order to get pain medicine.
Researchers analyzed data from 1,663 patients. Of these, 72 percent received pain medicine in the emergency department. The researchers found no association between the patient's receiving pain medication and the physician's perception of whether the patient had exaggerated his symptoms, the physician-patient interaction, or the patient's ethnicity. There was an association, however, between whether the physician thought the patient had exaggerated his symptoms and the change in the patient's pain before and after treatment. Patients were less likely to achieve pain relief if the interaction was rated as bad or very bad, even if they had received medication. Physicians said Native American patients exaggerated their pain more than members of other ethnic groups.
“The more we look into it, there is a communication barrier that will limit the effectiveness of therapy,” said Dr. Miner. “It has a lot more to do with relieving pain than what drug you are using or how much.”
“I was surprised by the results of the study,” he said. “We went into it not knowing what we would find. In Minneapolis, we have a neighborhood with a lot of Native Americans who tend to be poor. If the study were conducted elsewhere, you might have different findings.
“We couldn't find a consistency between how much pain people complained of and what was wrong with them,” Dr. Miner said. “They had every kind of pain score, and it didn't correlate with vital signs, injury, or treatment. The problem is the way we measure pain is so dependent on how people feel about their physicians when they are asked to give a score. When both patient and physician say they are getting along well, pain gets better, whether the patients are medicated or not. The fact is that if someone is satisfied and trusts the doctor, they get better pain relief than if there is some friction.”
Dr. Miner noted that even a single person can respond to pain in different ways depending on the circumstances. “If you are running around looking for your car keys, and you stub your toe, it hurts more than if you do it in a social situation. A lot more goes into pain than tissue damage. As we get into pain and find it has a lot to do with communication, we will be able to refine how we treat pain,” he said. “We don't have good ways to tell objectively how to treat someone.”
He said physicians' fear of drug-seeking behavior probably outpaces actual drug-seekers. Although the behavior exists, Dr. Miner said how patients respond to pain breaks down along ethnic lines. A homeless man with no education might be suspected of drug-seeking more than someone with a cultural background and education similar to the doctor's, and doctors need to be aware of that bias, he said.
Dr. Miner agreed that changing the culture in the emergency department is key to improving pain treatment. “In our department, we are changing it by talking about it more frequently. Each year, when the faculty meets, we give them the number of how many people are treated for pain. Since we have started doing that, the numbers have gone up, but the rate of complications has not.”
“A lot of emergency physicians feel burdened treating pain,” Dr. Miner said. “We spend a lot of time with people, but are not sure they are in pain. How to get them comfortable contributes a lot to the stress of our practice. We are taking care of people with painful conditions that are otherwise benign.”
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