Pain and the Emergency Department Part 2

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What education is provided to ED staff about the management of acute and chronic pain and what advice would you give a chronic pain patient or their primary care provider to help prepare for a good response during an ED visit? 

Learn about critical pain issues from experts.

Read part 2 of ”Pain and the Emergency Department” to better understand how professionals have dealt with chronic pain patients in the ED.

Knox Todd, MD:

Knox Todd, MD, is the Director of the Pain and Emergency Medicine Institute, Department of Emergency Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, and the author of many publications on pain management.

The specialty of Emergency Medicine is relatively new; it is only about 25 years old. There is increasing recognition of the need to provide all emergency medicine physicians with more education about pain management. Emergency Departments in urban areas tend to have more specifically trained, board-certified emergency physicians. In other places, especially more rural areas, physicians who work in an emergency room are not board certified in Emergency Medicine, may work there part time, or may be part of a contracted service.

In terms of analgesic use, the good news is that the National Center on Health Statistics between 1997 and 2001, reported an 18% increase in the use of analgesics in U.S. Emergency Departments. That is a huge increase in only four years, and I believe it is largely due to education of Emergency Department staff about the problem of under treated pain.

To improve the care they will receive, it certainly helps if there is direct communication between the patient’s primary care provider and the Emergency Department, in advance of the patient’s visit, or during the visit. It is a good idea for chronic pain patients to bring with them succinct documentation of their diagnosis and current treatment plan, and to state clearly what their problem is, i.e., “I am a chronic pain patient with an effective management plan but due to X event I have had an acute exacerbation of my pain”. When patients tell the Emergency Department staff that they are seeking potent opioids, it may raise a “red flag”. A better way to give this information is to describe what has been used in the past, what has been found to be helpful, and what was found to not be helpful.

What education is provided to ED staff about the management of acute and chronic pain and what advice would you give a chronic pain patient or their primary care provider to help prepare for a good response during an ED visit? 

Learn about critical pain issues from experts.

Read part 2 of ”Pain and the Emergency Department” to better understand how professionals have dealt with chronic pain patients in the ED.

Jim Broatch, MSW:

Jim Broatch, MSW, is the Executive Director of the Reflex Sympathetic Dystrophy Association in Milford, CT (www.rsds.org)

The scientific advisory committee of the Reflex Sympathetic Dystrophy Syndrome Association has developed a document called “Hospital Protocol RSD/CRPS Patient: Handle With Care!” in response to the need to educate hospital personnel about the needs of patients being admitted with this syndrome. [note: see previous roundtable interview with Mr. Broatch] We are thinking of developing a similar document for Emergency Departments.

At the Reflex Sympathetic Dystrophy Syndrome Association we try to educate patients about how to help medical providers understand their specific needs. We encourage our patients to always carry a letter with them explaining their diagnosis, care plan, and medications, and instructions that can be used by emergency personnel like EMT’s and paramedics. Unfortunately, improper techniques in a medical emergency can result in a patient having a major pain flare.

RSD patients who have a sudden pain flare and cannot reach their pain doctor may go to an emergency department for care. Depending on how they have tried to treat the pain, what medications they have used, and how anxious they are, they may be perceived as a person who abuses pain medications. We understand that there are people misrepresent the facts, and that an emergency room doctor may need a “leap of faith” to respond appropriately.

I suggest that patients who feel that have not received good treatment go later to the hospital administrator or ombudsman and tell their story. I am a member of the National Organization for Rare Disorders (NORD) where we recognize that emergency room doctors and primary care doctors have to deal with complex patients with problems that may be new to them. Everyone involved in health care knows that more education is needed, but at the same time we are confronting the issue of rising patient needs at the same time as there are diminishing resources.

Rochelle Odell:

Rochelle Odell is a former health care provider (EMT and ICU Nurse Technician) now disabled with CRPS and chronic pain. She is the founder of the organization “CRPS/RSD Education in Emergency Departments (CEED)”. She initially contacted PainEDU in June, 2006 about her experiences with emergency department care and her story led us to develop this series of interviews. If you are interested in contacting her, please write to her at ofrdrsq@aol.com. 

In my experiences doctors in emergency departments know little if anything about CRPS, run needless tests, some of which can be painful. Unfortunately, it is a rare ED physician who will call the patient’s Primary Care doctor or better yet, the Pain Management physician, to find out the best way to care for us. I have developed a questionnaire to gather CRPS patients experiences, and I have collected some real “horror stories”. I hope to get the CRPS/RSD Education in Emergency Departments (CEED) organization off the ground. I chose this acronym because I want it to represent this idea: “planting the “CEED” of knowledge in all Emergency Departments about the never ending burn pain of CRPS/RSD.” I am very pleased by the many responses I have received. An example of a common theme was in a note from a former ED nurse who said that now that she is on the “other side” due to RSD, she is treated like a drug seeker at the hospital where she used to work.

One pain management physician who was treating me brought his team of Residents and Interns to my room during one of my hospital stays. He told them flatly, that unless they went into Pain Management, this woman knows more about her disease than you could ever hope to and to give her what she wants. She knows what she can tolerate.

After a bad experience in an emergency department, I ask to speak with the department administrator in order to provide feedback, and I urge that the staff get more training. I have been surprised by the number of situations in which the physician in the emergency department is a contract worker at the hospital and I question what they know about the hospital’s standards of care. I provide the administrator with a copy of the JCAHO Pain Guidelines along with the guidelines that the Reflex Sympathetic Dystrophy Association has developed.

I have learned I can get better care in an emergency department if I am accompanied by a friend or a spouse. I always carry a summary of my medical history with me, including my current medications, and contact information for my PCP and my Pain Management physician.

What education is provided to ED staff about the management of acute and chronic pain and what advice would you give a chronic pain patient or their primary care provider to help prepare for a good response during an ED visit? 

Learn about critical pain issues from experts.

Read part 2 of ”Pain and the Emergency Department” to better understand how professionals have dealt with chronic pain patients in the ED.

Alan Witkower, Ed.D.:

Alan Witkower, Ed.D.,is a Psychologist and the Assistant Director, Outpatient Pain Service, Associate Psychologist,, Department of Psychiatry, Massachusetts General Hospital, and Instructor in Psychology, Harvard Medical School

An essential part of work with patients with chronic pain involves teaching them techniques for coping with and managing their pain experience, including pain perception and pain behaviors. Having a strategy in place for managing an escalation of pain is part of this treatment. Some patients only have medications for flare-ups and have not been taught other means of pain relief. Patients who have these other fall-back measures will do better in an emergency.

I also think it is important for patients to be educated by their physicians when increased pain or a change in their pain represents an emergent issue, as opposed to when a pain flare-up can wait for a follow-up appointment or phone call to the physician. For example, increased pain associated with certain new neurological symptoms at the same time may warrant immediate attention.

I recommend to my patients to keep a packet together with their medication bottles, their list of medications, their pain contract, and the contact information for their doctors, to bring with them whenever they need an emergency medical visit. I also recommend that they tell the Emergency Department doctor what they think happened that caused the escalation in their pain and what they have attempted to do to manage the increased pain. The patient needs to provide the ED physician with sufficient information and at the same time not to be directing their care.

I think that what patients want as a “good outcome”, is to feel that they have had an appropriate physical examination, have been heard, believed and treated with respect, and in appropriate instances have been prescribed sufficient medication to provide relief until they can contact and be seen by their pain physician or primary care physician. I know that some hospitals have a protocol for their emergency department to “err on the side of treating and believing the patient’s report of pain”, and that makes sense to me and my patients.