“The patient is waiting for you to write something that will make him feel better. This is your job.” In a hurried scrawl that may look like a series of scratches the patient is unlikely to fathom, that is just what you do. You write. What have you given this patient? Not just help. Not just medication. You have given “a mixture of hope and wishful thinking, science and sorcery,” and most of the time, it will work.
This spot-on description is proffered by emergency physician Pamela Grim, MD, in her unabashed book about life in emergency medicine, Just Here Trying to Save a Few Lives. (New York: Grand Central Publishing; 2002.) Her opening lines in the chapter on prescription-writing turn that routine act into a potentially magical feat, as it is for many patients. After all, pain relief is the most common reason for a visit to the emergency department.
“I do think if a patient says he is in pain and needs analgesics, [we should] take that at face value,” said Adam Singer, MD, a professor and the vice chairman for research in emergency medicine at Stony Brook (NY) University Medical Center. He has been studying oligoanalgesia in the ED with others at Stony Brook, but providing pain relief is an act as simple as it is complicated because assessing the level of discomfort among patients in the ED can be, as any emergency physician knows all too well, a real pain.
As study after study has shown, symptoms don't necessarily correlate to disease severity, Dr. Singer said. And personality factors play a big but perplexing role. Relief-seeking behavior is universal, but drug abuse is pervasive, too, and determining whether addiction underlies an ED visit can constitute a difficult piece of detective work.
Those pain standards from the Joint Commission require that hospitals, particularly EDs, provide appropriate pain therapy. But defining appropriate pain treatment remains elusive, and fears of the Drug Enforcement Administration loom, as psychopharmacologist June Dahl, PhD, noted. (J Pain Symptom Manage 2002;24:136.)
“A few widely publicized incidents have given physicians and pharmacists the sense that the DEA is constantly monitoring their practices, ready to send armed agents to confiscate patient records if they prescribe or dispense outside some ill-defined limits,” Dr. Dahl stated in her examination of the issue, “Working with Regulators to Improve the Standard of Care in Pain Management: The U.S. Experience.”
So what's the most DEA-proof way to assess pain during those deadline-a-minute shifts in the ED? Research from emergency physicians suggests it is a combination of the physician and the pain scale.
Dr. Singer and his colleagues hypothesized that many patients who show up at the ED in pain don't really want analgesia, and most of those who do get it. And that is precisely what they found in a study that enrolled 400 patients. Nearly half of all patients who went to the ED in pain didn't want analgesia. These patients proved somewhat predictable, based on pain scores, which were lower. Still, their scores were frequently in the moderate-to-severe range. (Acad Emerg Med 2008;15:S131.)
Dr. Singer and his co-authors concluded that even patients in fairly severe pain should be asked whether they want medication, a finding seconded by a study at Massachusetts General Hospital in Boston. There, about 100 patients were queried about whether they preferred a numeric-rating scale to assess pain or a personal interaction in which they were queried about their pain. Most wanted the scales and the personal contact, and pain intensity was associated with increasing likelihood of preferring both. (Acad Emerg Med 2008;15:S129.)
The fact that patients want to speak to emergency staff about their pain symptoms comes as no surprise. Research into pain has shown that sufferers' anxiety actually is reduced in the presence of the same white-coated medical professionals who make blood pressure spike in other kinds of patients. Patient emotions can be a significant contributing factor to perceived pain levels. (Health Psych 2008;27:645.) The emergency physician can have a mitigating effect on it, simply by engaging in the art of conversation.
A second piece of the pain-prescribing puzzle appears to be surfacing, and it is one that seems to contrast with the human touch. Patients seem to do as well or better when they have an impartial way of relating pain, namely by using a pain scale, and more recently, by doing that at a computer. Computer support has been found to significantly improve pain management when used in conjunction with nursing care. (Ann Emerg Med 2007;50:462.)
“I am not very surprised,” said Stuart Schweitzer, PhD, an associate professor of health services at the UCLA School of Public Health in Los Angeles. “Interaction with health care providers isn't always that satisfactory, at least, not all the time,” he said. By using both approaches, it is the proverbial bird-with-two-stones technique.
“The nice thing about a computer is that it seems interactive, but it is not judgmental,” he added, noting that the GPS voice in his car, unlike some passengers he has had, can give him directions in a gentle, nurturing tone rather than by reprimand.
“Computers level the playing field,” agreed Peter Dunbar, MD, a professor of anesthesiology at the University of Washington in Seattle. Some patients, even older ones who are adept at computers, like the idea of a touchscreen or keyboard to describe symptoms. “There is a certain anonymity to this,” he observed.
Though computers catch data, there is no evidence yet that they diminish worry, and worry can exacerbate pain.
Fifteen years ago, two British psychologists, Graham C.L. Davey and Frank Tallis, showed fairly definitively in seminal studies that worry has an effect on health, and that this relationship extends to pain (Worrying: Perspectives on Theory Assessment and Treatment. New York: John Wiley & Sons, Inc.; 1994.)
Since then, American and English researchers have found that human interaction, particularly with a sympathetic authority, can cause a rapid decline in the worry factor, effectively dimming pain perception, at least in a substantial number of cases. Patients who are told about the probable cause of their pain, for example, such as what to expect from the medication, and who are given empathic advice in the process seem to benefit in self-described ways, such as declines in symptoms and episodes.
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