While I highly value prompt, effective, safe management of pain, I fear that we as a specialty are too willing to abandon the rigorous evidence-based, outcome-oriented approach that we apply to other aspects of our practice. (“Recognizing Pain in the ED is a Painful Process Itself,” EMN 2007;29:36.) Here are some quotes that concern me.
“Drs. Descosterod and Hugli emphasized that the pain scale … was the fifth vital sign.” This is a misguided concept. Pain is neither vital (with a range outside of which life is not possible) nor a sign (it is a symptom, with all of the inherent vagaries of our perceptions). This “vital” designation could lead to potentially dangerous practices.
The article also noted: “The researchers noted that door-to-analgesia time was as important as the door-to-needle time in the case of acute MI.” Where is the evidence for that outrageous conclusion? They are also quoted as saying “pain also could be included as a high priority on the triage scale, allowing those patients to be admitted immediately.” As EDs are increasingly crowded and resources are relatively more limited, triage becomes of paramount importance. Our triage policies must, more than ever, be based on solid evidence and not unduly influenced by the sometimes seemingly capricious requirements of the Joint Commission or the results of easy-to-acquire but scientifically weak patient satisfaction surveys.
Kelly Young, MD, is quoted as saying “If children have a bad experience with these easy procedures [venipuncture], then as subsequent procedures get worse, you turn them into adults with chronic pain syndromes or as patients who don't seek care until the last minute.” Is there evidence for that conclusion?
We all agree pain is essentially always bad. And it is one of the few things that we can eliminate with treatment. But we must remember that it is not a fatal, “vital” condition. Our treatment of conditions that are not fatal and probably cause no permanent disability must be very, very safe. That means safe for the patient who receives the treatment and for those whose treatment is delayed by preferential treatment of the patient in pain.
Here is what I suggest. We should all strive to acquire better knowledge and skills to treat pain safely just as we strive to treat nausea, vomiting, hallucinations, agitation, and other unpleasant but non-life-threatening conditions safely. We should continue to strive even more to educate ourselves and design our triage and treatment systems to address potentially life-threatening conditions, including respiratory distress, shock, hemorrhage, and acute cardiac syndromes.
I'm afraid that the non-evidence-based acceptance that “the more pain treatment, the better” puts our patients in jeopardy. I am sad that our already-stretched nursing and ancillary staff is required to repeatedly explain and record 0–10 pain scores on every patient. I would rather they spent time rechecking truly vital signs.
Stephen J. Playe, MD
Palm Coast, FL