Taking EMS Into Tomorrow: Part 6

"We haven't got time for the pain."-Carly Simon

Pain management is one of the oldest aspects of medicine. Hippocrates wrote about the pain-soothing effects of willow bark and leaves in 400 B.C. Opium was cultivated for pain management long before that. Using the active ingredients in these traditional remedies, aspirin and morphine were isolated in the 1800s, providing the foundation of the modern pharmaceutical industry.

     While some progress has been made in EMS pain management over the last few years, we believe the time has come to set a bold national goal: Deliver all EMS patients to hospitals pain-free. Some may say this goal is neither possible nor reasonable. Is Medtronic's vision of "a world in which no person dies suddenly as a result of a cardio-respiratory event" reasonable? Reasonable people will not make great improvements in EMS. Great improvements will be made by compassionate and patient-centered people committed to doing what others say can't be done.

Pain's Vital Purpose
     Physical pain is not a primary disease; it is a symptom of a disease or injury. It serves a vital purpose in our survival. It's our body's way of telling us to yank that used IV needle somebody left on the bench seat out of our butt. Pain is our inspiration for calling 9-1-1 in the middle of the night when our coronary arteries clog from one too many extra-cheese pizzas. It's what keeps us from doing more damage by climbing back on our mountain bike with a broken femur. Once pain has sounded the alarm and prompted a person to take action, it has served its primary purpose. Its secondary purpose is to remind us not to do things that aggravate the problem. Anyone who has taken a hot shower with a sunburn or tried to carry a 270-pound patient down the stairs before their torn back muscle was fully healed has experience with this benefit.

     Pain researcher Thomas J. Romano, MD, PhD, says, "When pain is no longer of value in warning the patient that there is a problem, it can become the problem." According to the American Medical Association, pain of all types is undertreated in our society. The pediatric and geriatric populations are especially at risk for undertreatment. The Joint Commission on Accreditation of Healthcare Organizations' new standards require organizations to screen all patients for pain, ensure competency of their staff in pain management and collect data to monitor the appropriateness and effectiveness of their pain management. They emphasize that appropriate management of patients with pain must be a top priority in healthcare.

     In EMS there are many strong opinions on the subject of pain management. One medical director who doesn't want to change his system's pain-management protocols is fond of saying, "No one ever died from pain." It is unlikely that this physician has ever experienced severe pain. Some EMS systems are worried about drug seekers and addicts manipulating them to get high. Physicians may worry that field pain management will obscure their ability to properly diagnose a patient once that patient arrives in the emergency department. They also worry that once someone has been given a narcotic for pain, they will not be mentally competent enough to consent to surgery should they need it.

     Our position is that pain can and should be aggressively managed in the prehospital setting. When you look at the reasons people call 9-1-1 for medical problems, pain is part of the picture more than half the time. If you ask EMS customers what they want from their EMS service, they'll tell you "Get here fast, make me feel better, make my pain go away and take me to the hospital." Pain is one of the primary reasons people call us, yet in most EMS systems pain management is approached the way third-graders approach cleaning their rooms. They know they have to do a little bit, but it's not a high priority, and there are other things they'd rather do.