Download WESLEY EMERGENCY DEPARTMENT THE QUEAS

Performance Improvement
Mark Mosley, MD, MPH
CME sponsored by Wesley Medical Center
ESPA, Wesley Medical Center
550 North Hillside
Wichita, KS 67214
Phone for copies: (316) 962-2313
WESLEY EMERGENCY DEPARTMENT
THE QUEAS-E UPDATE
(Quality, Uniformity, Education, Attitude, and Service - in Emergencies)
SPECIAL EDITION – PAIN MANAGEMENT REVIEW
Issue 88
“A professional approach toward pain”
Here is a review of pain management as it
relates to the ER. We should begin with a few
reminders:
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Pain is the most common condition seen in
the ER.
ERs are lousy at offering pain medications
promptly or in adequate doses.1,2
Severe pain is more clinically meaningful
than elevated blood pressure, sinus tachycardia, or even fever at triage (pain is often the cause of elevated blood pressure
and high heart rates).
Acute severe pain is often (but not always)
easy for anyone to recognize objectively
(so there is no excuse for second guessing
a patient with an objective measure).
Pain and fear are often synergistic
(treating one may help the other).
Pain and fear can often be soothed nonpharmacologically as well as pharmacologically.
Most medical professionals have almost no
formal training dedicated to acute pain
management.
The number one patient satisfier in the ER
is prompt control of pain.
The majority of conditions, even in an
emergency setting, are self-limiting and
need only pain and fear control.
September 2010
If an ER did nothing except excellent comfort
and reasonable information that the patient
agrees with – we would satisfy the majority of
patients using much less time and resources
with rare harm and excellent outcomes!
If this sounds preposterous, consider what we
say to each other every day “Most people who
come to the ER don’t need to be here.”
Consider all of the studies that prove that ER
staff do pain management poorly often because we don’t believe a patient should get real
pain medication unless they have a real
problem (critically emergent).
What if we spun this information in a positive
direction? What if we all believed that most
patients need to come to the ER to get
accurate information to relieve fear and they
need to come to the ER to get pain control because our current legal and medical environment does not allow this to happen by phone or
happen immediately at an office. Instead of
blaming patients who come to the ER (or who
are sent by others), what if we welcomed them
to the best place to have pain and fear
relieved emergently by medical experts who
are trained and excel in acute pain management and communication.
Instead of trying to chase patients away from
the ER (which by the way is not working) what
if we promoted it as the best current answer
for patients who need immediate answers and
relief?
PAIN SCORES:
“The positives and the problems”
The most positive things about pain scores
are:
ΠEveryone gets one putting pain control as a
front door top priority.
ΠThe adult patient defines it (usually) which
recognizes the subjective nature of pain
and prompts an individualized response.
There are several problems with pain scores:
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Staff refuse to believe a 10/10 if the
patient doesn’t look like a “10”.
Because of the subjective nature of pain, a
“7” is only a relative parameter for that
particular patient and is a poor comparison
to another person’s “7”. So knowing what
to do with a “7” cannot be standardized.
The scale measurement has 10 equal
increments when in reality moving from a
“10” to a “7” may be much more significant
than moving from a “7” to a “1”.
The scale assumes a “normal” of “0” when
many people may have a “normal” pain of
“5”.
The height of the pain score does not
predict who does or does not want pain
medications.3 (What does one do with a
“6” who “refuses pain medication”?)
“Pain” is still viewed culturally as a
negative.
(eg We write “patient still
complains of pain”. We are pleased by the
patient who says “I don’t want any more”.)
Advocating for more pain treatment goes
against the culture.
“Pain scores” imply “pain meds” and may
miss non-pharmacological strategies to
provide comfort from pain or fear.
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My wish is that we replace the “pain score”
which has negative connotation of what the
patient has, to a “comfort level” which has a
positive connotation towards what the
provider can do. A “comfort level” would also
imply that other measures should be done in
addition to “pain meds”.
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The question would be “What number
would you put on your level of comfort
right now with ‘10’ being your normal level
of comfort and ‘0’ being extreme discomfort?” (We would substitute “chest
discomfort” with “chest pain”.)
The next question would always be “What
are you hoping we could do to make you
more comfortable?” (We might be surprised by “I don’t want any pain medications, I just want to know…”)
Making patients “more comfortable” is much
more acceptable and perhaps much easier than
making patients “pain-free”.
COMMUNICATION:
“Patient control begins the relief”
After asking the patient’s input for “What
can we do to make you feel more comfortable?” The companion question is “By
what route would you like this – by mouth,
a shot in the muscle or an IV?” One should
not assume the route based upon a number
or your own assumptions about how much
pain they look like they are in. One can then
negotiate an opiod versus a non-opiod and if
they have a ride home.
Allow the patient the courtesy of a shared
decision-making process. By giving the
patient control over the route, you actually
decrease fear and pain. The medical professional should generally choose the drug;
but the patient should be given control of the
route.
SERVICE:
“Non-pharmacological comfort measures”
The reticular activating system (RAS) is
that part of the brain that “ramps up”
one’s level of awareness – kind of a
neurological volume button. By turning
down the RAS, fear, nausea and pain, as
well as blood pressure and heart rate deescalate.
NON-OPIOD ANALGESIA: “All about NSAIDs”
While NSAIDs are the most popular non-opiod
distributed and recommended coming out of an
ER, there is a lot of misinformation about
NSAIDs:
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Ways of non-pharmacologically turning
down the RAS include:
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never allowing a patient to remain
on a backboard in the ER
repositioning the patient on the
bed with pillows
always turning down the lights (if
it’s ok with the patient)
speaking in a calm soothing voice
with eye contact
offering a warm blanket
a gentle touch of someone’s hand
with a word of reassurance “We
are here to help you – you’ve got a
great group of nurses and doctors
here”
giving the patient (or loved one) a
call button (form of control)
closing the doors (enough to create
a sound block)
TV (cartoons for children) can be a
huge distraction and source of
comfort for some
quick
to
acknowledge
and
empathize with the patient’s
discomfort
The front line of “pain management” can
be done on every patient without a
medication and even without a doctor’s
order.
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Most arthritis, tendonitis, sprains and
strains do not respond to antiinflammatories any better than non antiinflammatories (eg OA of knee, ankle
sprains, etc).4,5,6,7
NSAIDs may be advantageous for preemptively reducing hollow viscous pain
which is prostaglandin mediated (eg kidney
stone, dysmennorhea and maybe gall
bladder would be the primary ER conditions)
though this has never been proven.8
One category of NSAID is not superior to
another category (although some individuals may respond to one category better
than another).9
Parenteral ketorolac (Toradol) is NOT
superior to oral ibuprofen.10,11,12,13
For adults, 400mg ibuprofen is as effective
as 800mg for pain relief.14
There is no benefit and no place for a COX-2
inhibitor (Celebrex) in the ER (or any other
place in medicine).15
Newer parenteral NSAIDs (Calador) will
unlikely be any more effective.
NSAIDs are the most harmful drugs used in
the US16 (because they are used so widely)
and are known to worsen CHF, inhibit the
effects of some anti-hypertensives, delay
bone healing, and even occasionally enhance heart attack risk in addition to
causing GI bleeds and renal dysfunction.
No NSAIDs for fractures (proven harmful for
post-op back surgery and unstudied in nonoperative long bone fractures).17
We should never write in our dismissals
“ibuprofen for pain” without limiting the
period of time (eg “for no more than 5
days”).
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NON-OPIODS: “Tramadol
is usually deception”
Tramadol (or any other combination with
Tramadol) has not been shown to be any
more effective than ibuprofen.18,19,20
The side effect profile is high with headache, dizziness and nausea being common.
The cost of trade name Tramadol (like
Ultracet) is much more expensive than
most opiods.
Tramadol’s only place in the ER may be a
recovered addict who wants something
else besides acetaminophen or NSAIDs
but does not want an opiod (and still does
not guarantee that there is not abuse
potential).
Tramadol is usually a form of pharmacological deception by a provider who
does not want to prescribe an opiod but is
too afraid to honestly confront the
patient.
“Tramadol allergy” is usually deception by
the patient to get an opiod.
ORAL OPIODS: “Think oxycodone 5.0”
Darvocet is no better than acetaminophen
with many more side effects.21
Codeine is less effective, has more side
effects, and is more expensive than hydrocodone, oxycodone or hydromorphone.22
A large percentage of caucasian (20-30%)
and Arabs and a lower percentage of
Asians and Africans have a genetic opiod
metabolic defect and metabolize codeine
(and morphine) unreliably.23
While no good head to head studies exist
comparing hydrocodone to oxycodone; oxycodone and hydromorphone in theory may
metabolize more consistently.
Oxycodone 5.0 is essentially the same
price as hydrocodone 5.0 (about $15-20
for 30 tablets). Hydromorphone 4mg tablets are equally inexpensive.
5.0 can be broken in half or added
together to make 7.5 or 10. Writing for
1/2 – 2 tablets every 4 hours allows more
flexibility for hydrocodone or oxycodone.
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Oxycodone with acetaminophen is a good
choice for acute pain. Hydromorphone
provides a good additional rescue (because
it contains no acetaminophen).
Stool softeners should be recommended
routinely for patients prescribed hydrocodone, oxycodone or hydromorphone.
IM MYTHS
It is not necessarily true that IM
medications work faster than oral medications. Oral meds connect in about 15-30
minutes and peak at about 1-2 hours. IM
meds are unreliable and unpredictable.
It is not true that IM medications last
longer than IV meds.
It is true that IM medications are faster
for the nurse than IV, but this does not
mean it is more effective than either IV
(or po) for the patient.
IM meds may be the best choice for the
patient if they are a very difficult IV stick
and the patient requests the IM route.
IV OPIODS: “Fentanyl and hydromorphone”
ΠMorphine has largely been replaced by
fentanyl and hydromorphone because they
may have less pruritis, and less nausea and
are not apparently affected by genetic
opiod metabolic effects (GOMD).
ΠAdult patients > 70 years old should use
25-50% of an opiod dose.24
ΠFentanyl 100 micrograms IV (50 micrograms for > 70 yr old) is an excellent
choice in the ER for emergent severe pain
due to its immediate onset of action (1
min) and its short duration (about 30 min).
ΠHydromorphone (Dilaudid) 1mg IV (0.5mg
IV for > 70 yr old) is an excellent combination with Fentanyl because it kicks in
well about the time Fentanyl begins to dissipate and lasts for 4-6 hours.
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IV OPIOD MYTHS
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“Biliary spasm” is a popular pimp
question to the medical student
on the surgery rotation but has
no good human clinical studies to
prove one opiod is better than
another.25
Anti-emetics are not required or
suggested routinely with opiods.
They do not improve pain control
and may increase respiratory
depression.
The pruritis associated with
opiods (particularly morphine) is
often treated with antihistamines in spite of no literature
supporting their benefit (eg
interestingly Ondansetron was
beneficial in one study).26
Patients given opiods are not
automatically ineligible or incompetent to sign surgical
permits or informed consents.
(A mini-mental status exam not
whether someone has received a
drug determines competence in
the ER.)27
Breastfeeding
mothers
who
receive an opiod do not have to
waste their breast milk for a
feeding or two (though the study
was very small that said the
opiod does not affect the baby
clinically).28
Obese patients do not need more
opiod (in fact if they snore, they
may be at risk for obstructive
sleep apnea [OSA] and actually
need less).
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AVOID TITRATION IN THE ER
Titration of IV opiods in the ER goes
against the recommendations of The Joint
Commission.
For the patient still in pain with a titration
order (eg morphine 2-10mg), the ordering
physician will not know if the patient has
been given only 2mg with a hesitant nurse
or 10mg and requires more.
ERs perform better that have pre-printed
order sets with set amounts.
>70
or OSA
…
…
Fentanyl 100 micrograms IV
Hydromorphone 1mg IV
…
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Fentanyl 50 micrograms IV
Hydromorphone 0.5mg IV
…
Repeat hydromorphone 1mg IV in
15 minutes if pain not well controlled (0.5mg hydromorphone if
> 70 or OSA)
*This 1+1 hydromorphone protocol
resulted in 95% effectiveness with no
clinically worrisome respiratory depression.29
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ANTIEMETICS IN THE ER
IV Phenergan is now black-boxed and
should probably be avoided.
IV Compazine and Reglan can both cause
akesthesia (which may be difficult to
recognize but goes away promptly with
Benedryl).
IV Ondansetron 4mg appears to be as
efficacious as 8mg in the patient not receiving chemotherapy.
No one antiemetic is more efficacious than
another (including Decadron 4mg IV or
Haldol) but Ondansetron is now generic
and has less side effects.30
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ADJUNCTIVE ANALGESICS:
“Muscle relaxers unsupported”
For patients with muscle spasms (not
chronic spasticity from CP, etc) there is no
good data which justifies the cost or side
effects of “muscle relaxers” (eg Flexeril,
Skelaxin, Robaxin, Valium, Soma, Norflex,
etc).31,32,33
Muscle relaxers are often used as a
substitute to avoid opiods but they have no
analgesic properties, just sedation.
ADJUNCTIVE ANALGESICS: “Neurontin
off-label and suspect”34,35,36
Gabapentin does not have FDA approval
for any pain condition except postherpetic neuralgia and diabetic peripheral
neuropathy.
Gabapentin is poorly bioavailable (27-60%)
and must be pushbed to rather high doses
for even marginal effect.
The makers of Neurontin have admitted to
criminal activity in marketing and deceiving
physicians to use Neurontin for conditions
that had no data.
One of the primary pain experts in the
country who advocated and promoted
Neurontin admits to falsifying his data or
having it ghost-written.
Lyrica (pregabalin) is simply a precursor
drug of gabapentin except it is outrageously expensive.
Fibromyalgia is not neuropathic pain and
Neurontin and Lyrica should not be
advocated.
All “neuropathy” is not the same as
diabetic neuropathy.
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PROCEDURAL PAIN RELIEF PEARLS
2x2 gauze soaked in 2% viscous lidocaine
and placed in the area of the dental block
for 10 minutes before injection.
Hurricaine spray (bupivicaine 20%) on the
tonsil before 30 gauge infiltration of
analgesia.
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Warm viscous lidocaine before all foley
caths in men or women (urojet), adult and
children.37,38
Warm viscous lidocaine jelly down nare
before NG (better yet avoid NGs
altogether).39
LET with occlusion on wounds or small
abrasions.
Silvadene cream on large surface abrasions
(lidocaine jelly burns too much).
Refrigerants (eg Pain Ease) topical spray
immediately before introducing 30 gauge
infiltration of abscess.
Use bupivicaine or lidocaine all the way
down on LPs and not just for skin wheal.
30 gauge, warm analgesia, slow infiltration
and can even buffer 1:10 with sodium
bicarb. (30 gauges are not in kits)
Use bupivicaine plus epi almost everywhere
including fingers and toes40 – lasts much
longer.
J-tip is needleless air driven analgesia
used for IV starts (popping can scare some
children).
Intranasal fentanyl (1.5 micrograms/kg) ½
dose atomized in each nare is an excellent
quick analgesia to get films without an
IV.41
Don’t let patients see all your needles and
bottles. Draw everything up out of site.
Hip traction doesn’t help.42
ADULT PSA: “Ketofol is a favorite”
Propofol is an excellent choice for
procedural sedation. Unfortunately it has
no analgesic properties and its use in the
ER creates a fair amount of apnea and
hypotension.
Ketamine is a dissociative anesthetic which
increases blood pressure and does not
depress breathing. Its contraindications
in adults due to hallucinations and head
trauma are overplayed and likely untrue.
A low dose of propofol (0.4mg/kg) combined with a low dose of ketamine
(0.3mg/kg) IV provides an excellent combination with high success, high safety,
and quick turnaround.43
CRITICAL PAIN RELIEF
Everyone intubated who has an adequate blood
pressure needs anxiolysis and analgesia. In a
study of 117 adults undergoing RSI who remained in the ED longer than 30 minutes after
intubation, less than half received any
analgesia and another fourth received trivial
doses. Only 3% received good doses of both
anxiolysis and analgesia.44
PEDIATRICS: “Painful memories”
If you took a psychiatrically normal adult and
wrapped them up in a straight jacket and then
had people lay on them while the doctor did a
procedure, your medical license and your
institution would be at legal risk. In adults,
this is called battery and torture. In children,
we call them papoose boards! Why do we allow
ourselves to do to children what we could not
morally imagine doing to adults?
How many of you, while forgetting the scalp
laceration you had five years ago, can
remember with vivid detail the laceration you
had to have sewn up as a young child? How
many muscle bound 6’5”, 25 year old men have
you seen who when confronted with a tetanus
shot act like a four year old? Why do you
think that is?
Childhood memory of pain is different. Pain
and fear are inseparable especially in children.
We should create an atmosphere of calm,
comfort, and safety just as much as we create
a bodily area of analgesia. We should do more
procedural sedation and analgesia (PSA) with
kids, not less. Throw away the papoose board!
(Read the article.)45
Some believe I am overly zealous to use
sedation and analgesia for rarely minor
procedures like LPs, and small facial lacs, and
small tweaks on the distal radius (that others
swear “do just as well” with a hematoma block).
But there is one huge factor that is misunderstood. We are not talking about the
physical result of the procedure according to
the doctor.
We are considering the psychological trauma
according to the child and his family. We fail
to recognize that pain and fear in a child’s
mind are often synonymous.
So telling a
weeping mother and her sweaty exhausted two
year old that “he really didn’t feel any pain, he
was just scared” – is a stupid statement.
Furthermore, we now have very interesting
proof that the pain and psychological
experience of a child is remembered physiologically and may have long-term or even
lifetime implications! We know that newborn
males circumcised with adequate analgesia
respond differently (better) at their 2 month
immunizations than circumcised counterparts
without analgesia.
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TOXICOLOGY:
“Illicit Methadone overdose –
hard to diagnose and treat”
Methadone is wrongly thought of as a
“safer” opiod because it is used as
part of treatment programs to wean
people off other narcotics or drugs.
If it is “safer”, it is because it is
carefully monitored.
Unfortunately, illicit Methadone use
on the street is gaining popularity.
And unlike many other narcotics and
drugs, a quick urine drug screen may
not identify Methadone. If a person
does not admit to Methadone or is too
out of it to tell someone, the treating
physician will likely treat the illicit
Methadone overdose just like the
unknown narcotic overdose (pinpoint
pupils, bradycardia, hypotension, hypothermia, somulent, etc).
(cont’d on next page)
(cont’d from previous page)
The recommended approach toward
unknown opiod overdose is low dose
narcan (0.4mg) as to not put the
patient into withdrawal.
But this
dose will likely not be enough to get a
response for Methadone which may
need up to 4-10mg! The routine EMS or
ER doc will simply assume it is not an
opiod because it appears to be a nonresponder with standard low dose
narcan.
I’m not sure of a way out of this one
other than begging the patient to be
honest if they’ve taken Methadone in
what you believe to be an opiod
overdose – because illicit Methadone
overdose is very lethal.
URINE DRUG SCREENS
ARE BAD “LIE DETECTORS”46
Some providers use a “urine drug screen” to
test honesty in a patient to determine
whether to write a script for opiods. Trusting
urine drug screens is very unreliable (except
for maybe cocaine and marijuana).
The urine test is also ok for morphine or
codeine within the past 2-3 days (up to a week
with heavier use).
However, for semisynthetic opiods (hydrocodone, oxycodone)
there are varying results.
And synthetic
opiods (Fentanyl, Methadone, hydromorphone,
propoxyphene) have minimal cross-reactivity
and may not be detected, especially at lower
doses.
There are plenty of both false positives and
false negatives to make urine drug screens a
bad “lie detector test”.
PSYCHOLOGY/PHARMACOLOGY:
“Addiction without substance”47
Pain is the most common condition in all of
medicine – and definitely the most common in
the ER. And yet few physicians have any significant formal training in acute pain management. And yet what diagnosis do we make with
frequency in our ERs but “drug-seeking” and
“addictive behavior”. But upon what training
and education do we make such decisions?
Where is the “substance” to our accusations?
Let’s start with what addiction is not. It is
not using a narcotic in escalating doses, this is
physical tolerance. It is not withdrawing from
a narcotic if you don’t get it, this is physical
dependence. It is not necessarily a drug that
you can’t do without psychologically – this is
psychological dependence and is present in
just about every diabetic. It is not necessarily a drug you get via illegal activity – in many
countries you might be able to get a necessary
medication only thru a black market. Addiction is also not necessarily defined by a drug
that you use despite it causing physical harm –
otherwise every person with dyspepsia from
NSAIDS would be an addict. It is not even so
easy as someone who lies to get pain
medication – this is frequently done at some
level because the medical profession is so bad
at giving appropriate doses for acute pain (this
is
called
pseudo-addiction
where
one
manipulates to get the right therapy).
There are also persons who have severe
mental illness who misuse and abuse medications not to achieve some desired effect but
rather due to their inabilities to maintain
responsible behavior whether it be medicine
related or not.
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(cont’d from previous page)
There is good evidence to suggest that
physical tolerance and physical dependence
upon opiods does not translate into addictive
behaviors. The idea that you will addict a normal individual by placing them on opiods for
acute pain is completely unfounded. Even the
myth that patients become euphoric who get
opiods is extremely uncommon.
In fact,
dysphoria is much much more common with the
administration of opiods.
So if we can admit that most of us have many
mis-definitions and misconceptions about
“addiction”, now let’s attempt a better
definition. I think the best definition I’ve
ever been taught is “A repetitive pattern of
using anything for the purpose it is not
intended.” Whether alcohol, food, sex, work,
exercise or pain medication, the definition
works.
So for ER acute pain management this
becomes relatively easy. If you have objective parameters of injury or pain (even in a
chronic pain patient): laceration, bruise, swelling, tachycardia, elevated blood pressure,
vomiting, diaphoresis, etc – you do not need to
fear using generous opiods for acute pain
relief and home opiods if necessary. Since you
will not addict these people, you do not need
fear. You can quit writing people for Ultram
and Flexeril.
There are scenarios where the pain is purely
subjective with no objective measures (eg
headache, tooth pain, back pain, etc) – and
these do require even more education, training
and discretion – but these are often the
minority of acute pain patients.
So let’s get better educated about “addiction”
and become very aggressive with acute pain
management.
OPERATIONS MANAGEMENT: “A novel
approach to chronic pain patients”
For decades, it has been the culture of
emergency medicine to have a secret box, or
bulletin board or back-room list or simply a
word-of-mouth among nurses, docs and staff
about “drug seekers”.
And among patients who frequent the ER for
chronic pain meds (eg headache, tooth pain,
and back pain), they frequently know which
doctors are “stern” (honest confronters?
mean?) and which are “softer” (compassionate? enabler and afraid to confront?).
Patients often come to the ER with their first
question being “Who’s on tonight?”
This type of culture is based mostly on
secrecy and deception. We at Wesley ER want
to take steps to begin to change this. We
would like to chip away at the term “drugseeker” and ideally reduce it to a rare word in
our vocabulary.
We begin by identifying “special patients” that
come to our ER frequently or for very unique
needs. This would include unusual genetic
diseases, hemophilia, sickle cell, migraine, etc
as well as people with acute or chronic pain
needs (which seem to center around back pain
and tooth pain). For those “special patients”
we create a fairly uniform care plan that may
vary considerably from what we might do
routinely as a medical professional.
This “Special Patient Care Plan” (SPCP) splits
patients into one of three categories:
I.
Patients who have objective evidence of
illegal activity (eg altering a script) or
bad behavior (hitting a nurse, leaving
with an IV in, etc). These patients will
receive only what is required by law: a
medical screening exam.
(cont’d on next page)
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(cont’d from previous page)
II.
Patients who have subjective accusations
of “drug seeking behavior”. These patients may or may not be offered
“bridge” medications. They will be given
a pamphlet for clinics and dental centers
for the underserved as well as a pamphlet with regard to drug treatment
centers. They will be asked to sign a 30
day “bridge” contract for chronic pain
which gives them 30 days to find a
primary care doctor.
III. Patients with unusual medical conditions
not centered around chronic pain issues
with a patient specific plan of management.
If our staff buys into this approach, it will be
a major step forward in separating objective
information from subjective assumption. It
will also promote a uniform plan regardless of
physician or nurse on duty. It may also provide us data to track and an approach with
which we join hands with other local ERs.
COST: “Price surprises”
Generic Lortab
5.0
7.5
10
#
20/30
20/30
20/30
$
12/12
12/20
12/20
Percocet
5.0
10
30
30
14
50
Dilaudid
4mg
20
14
Fentanyl patch
50 micrograms
4
100
Flexeril
10mg
20
10
Norflex
20
40
Oxycontin
40mg
30
221.41
Oramorph
30mgXR
30
40
* These are rough numbers and will vary
substantially from pharmacy to pharmacy
and even from year to year. It is interesting that it is roughly the same cost
between 20 and 30 Lortab 5.0.
Page 10
1.
2.
AN ENDING THOUGHT:
“Be a doctor, not a lawyer”
Imagine you finished your
career and you are standing
before an audience made up
of all the people you have
ever treated for pain. Would
you rather be known for
being more accurate by
catching more people that
lied to you but you misjudged
a fair number of people that
suffered.
Or would you
rather be known for being
overly
compassionate
by
offering more people adequate pain control and hearing from a fair number of
people that they fooled you?
To me medicine is about
advocacy and trust as compared to law which is adversarial and tries to find truth
by distrust. Be a doctor, not
a lawyer. If you are going to
make any mistakes, let it be
that you were too trusting
and compassionate.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Page 11
Wilson JE et al. “Oligoanalgesia in the emergency department” Am J Emerg Med 1989; 7:
620-23
Ducharme J et al. “A prospective blinded study
on emergency pain assessment and therapy” J
Emerg Med 1995; 13: 571-75
Blumstein HA et al. “Visual analog pain scores
do not define desire for analgesia in patients
with acute pain” Acad Emerg Med 2003; 10:
211-14 (N=104)
Khan KM et al.
“Overuse tendonosis, not
tendonitis” Phys Sports Med 2000; 28(5): 3848
Hertel J. “The role on Nonsteroidal antiinflammatory drugs in the treatment of soft
tissue injury” J Athletic Train 1997; 32: 35058
Almekinders LC. “Anti-inflammatory treatment
of muscle injury in sports” Sports Med 1999;
27(6): 393-408
Sports Med 1990; 9(6): 137-42
Catapano M et al. “Emergency department
management of pain” J Emer Med 1997; 15(2):
245-46
Brooks PM et al.
“Nonsteroid antiinflammatory drugs – differences and similarities” N Engl J Med 1991; 324: 1716-25 (review)
Turturro MA et al. “Intramuscular ketorolac
versus oral ibuprofen in acute musculoskeletal
pain” Ann Emerg Med 1995; 26: 117-20 (N=82)
Wright JM et al. “Use and efficacy in the
emergency department: single doses of oral
ibuprofen versus intramuscular ketorolac” Ann
Pharmacother 1994; 28: 309-12 (N=125)
Tramer MR et al. “Comparing analgesic efficacy
of non-steroidal anti-inflammatory drugs given
by different routes in acute and chronic pain”
Acta Anaesth Scand 1998; 42: 71-79 (review)
Neighbor ML et al. “Intramuscular ketorolac vs
oral ibuprofen in ER patients with acute pain”
Acad Emerg Med 1998 (Feb); 5(2): 118
Clin Pharmacol Ther 1986; 40:
1-7 and
www.medscape.com / view article/574279/June
30, 2008
The Big Fix Katharine Greider; (2003): 102-3
Wolfe et al. “Medical progress: Gastrointestinal toxicity of NSAIDs” N Engl J Med
1999; 340: 1888
Glassman SD et al. “The effect of postoperative NSAID drug administration on spinal
fusion” Spine 1998; 23: 834-38
18. Moore PA et al. “Tramadol compared with…
codeine and placebo” J Clin Pharm 1998 (June);
38(6): 554
19. Turturro MA et al. “Tramadol vs hydrocodone
in acute musculoskeletal pain” Ann Emerg Med
1998 (Aug); 32(2): 139
20. Stubhaug A et al. “Lack of analgesic effect of
oral Tramadol after orthopedic surgery” Pain
July 1995; 62(1): 111
21. Li Wan et al.
“Systemic overview of coproxamol…” Br Med J 1997 (Dec); 315(7122):
1565
22. Zhang WY et al.
“Analgesic efficacy of
paracetamol and its combination with codeine…”
J Clin Pharm Ther 1996 (Aug); 21(4): 261
23. Tennant F. “Making Practical Sense of Cytochrome P450” Practical Pain Management May
2010: 12-18
24. American Pain Society recommendations (2003)
25. Spiegel et al. “Meperidine or morphine in acute
pancreatitis” American Family Physician 2001;
64(2): 219
26. Charuluxan et al. “Nalbuphine versus Ondansetron for prevention of intrathecal morphine
induced pruritis…” Anesthesia and Analgesia
2003; 96(6): 1789-93
27. Vessey W et al. “Informed consent in patients
with acute abdominal pain” 1998; 85: 1278-80
28. Beilin Y et al. (no title listed) Anesth
2005;
103(6): 1211-17 (N=6)
29. Chang AK.
“Safety and efficacy of rapid
titration using 1mg doses of intravenous hydromorphone in ERs with acute severe pain (1 + 1
protocol)” Ann Emerg Med 2009; 54(2): 221-25
(N=223), Ann Emerg Med 48(2): 164-72
30. Wilhelm SM et al. “Prevention of postoperative
nausea and vomiting” Ann of Pharmacotherapy
41(1): 68-78
31. DeLee JC et al. “Skeletal muscle spasm and a
review of muscle relaxants” Curr Ther Res
1980; 27: 64-74 (review)
32. Pain Assessment and Pharmacological Management (2011) by Pasero and McCaffery. 693
33. Van Tulder et al. (2003) “Muscle relaxants for
non-specific low back pain” Cochrane Database
of systemic reviews (online) CD004252
34. Landerfield CS et al. “The Neurontin legacy –
marketing
through
misinformation
and
manipulation” N Engl J Med 2009 (Jan 8):
360(2): 103-6
35. Our Daily Meds Melody Peterson (2008);
Chapter seven:
“Neurontin for everything”
212-52
Page 12
36. Wall Street Journal blog by Sarah Rubenstein
“Hospital Chief of Acute Pain fabricated
medical studies on Lyrica” March 12, 2009
37. Emergency Med Australasia 19(4); 315: August
2007
38. J Urol 2003; 170: 564-7
39. Witting M. “You wanna do what? Modern indications for nasogastric intubation” J Emerg
Med 33(1); 2007: 61-64
40. Ann Emerg Med 50(4); 472: October 2007
41. Borland ML et al. “Comparative review of the
clinical use of intranasal Fentanyl vs morphine
in a pediatric emergency department” Emerg
Med Australasia 2008 (Dec); 20(6): 515
42. Int Orthop 2002; 26(6): 361
43. William EV et al. “A prospective evaluation of
ketofol in the emergency department” Ann
Emerg Med January 2007; 49(1): 23-30
44. Bonomo J et al.
“Inadequate provision of
postintubation anxiolysis and analgesia in the
ED” Am J Emerg Med 2008 (May); 26(4): 469
45. Baeyer C et al. “Children’s memory for pain”
Journal of Pain 2004 (June); 6: 241-9
46. Schiller MJ et al. “Utility of routine drug
screen in a psychiatric emergency department”
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47. Passik S et al. “Opiod therapy in patients with
a history of substance abuse” CNS Drugs 2004;
18(1): 13-25
Opinions expressed are not necessarily those
of Wesley or ESPA. Mention of products or services
does not constitute endorsement. This publication is
intended as a general guide and is intended to
supplement, rather than substitute, professional
judgment. It covers a highly technical and complex
subject and should not be used for making specific
medical decisions. The materials contained herein are
not intended to establish policy, procedure, or
standard of care.
QUEAS-E
CME
September 2010
Name_______________________________________
*Wesley Medical Center is accredited by the Kansas
Medical Society to sponsor continuing education for
physicians.
Date Completed_______________________________
1.
Toradol IM is superior to ibuprofen.
Wesley designates this educational activity for a maximum
0.5 AMA PRA Category 1 Credit(s)™. Physicians should
claim credit commensurate with the extent of their
participation in the activities.
T or F
2. The following decrease input into the reticular activating system (RAS):
a. dimming the lights
b. closing the door
c. a warm blanket
d. eye contact and a gentle touch
e. all of the above
3. For patients over 70 years old in severe pain you should use:
a. toradol only
b. morphine 8mg IV
c. Fentanyl 50 micrograms and 0.5mg hydromorphone IV
d. Fentanyl 100 micrograms and 1mg hydromorphone IV
e. Dilaudid 2mg IV and Phenergan 25mg IM
4. 20%-30% of the caucasian population metabolize morphine unreliably.
T or F
5. Flexeril and valium are as effective as oxycodone for muscle spasm.
T or F
6. It is unethical to paralyze a patient without sedation and analgesia.
T or F
7. Urine drug tests are accurate at picking up Lortab.
T or F
8. All foleys in children and adults should be placed with viscous lidocaine in the ER.
T or F
Circle the one correct answer.
To complete this educational activity, please check your test for accuracy. The correct answers can be found on the evaluation.
Dr. Mosley has disclosed that he does not have any financial relationship with any product or equipment that he writes about.
(Evaluation following)
Page 13
Continuing Medical Education
QUEAS-E Update Evaluation
Please circle a response to the following:
1.
Having read this CME activity, the participant should be better able to: demonstrate an increased
awareness of current practices, new therapies and new technologies appropriate for patients in the
Emergency Department?
Agree
2.
4.
4
3
2
1
Disagree
The educational content in this CME article will be:
Very useful
3.
5
5
4
3
2
1
Not at all useful
A great deal
5
4
3
2
1
In this article I learned:
Little
As a result of this CME article do you anticipate making a change in your practice?
Yes [
]
5.
Additional comments:
6.
What topics would you suggest for future articles?
(Answers to post test:
1. F
2. e
3. c
4. F
No [
5. F
]
6.T
7. F
8. T)
For CME credit, please mail this sheet to: Wesley CME Dept., 550 N. Hillside, Wichita, KS 67214
Please note: This publication is designed for physicians and documentation of CME
will be provided to physicians on an annual basis. For a transcript of credit for a specific
timeframe, please contact the Wesley CME Department @ 316-962-3304
or [email protected]
Credit Statement
KMS Accreditation Statement
Wesley Medical Center is accredited by the Kansas Medical Society to sponsor continuing education for physicians.
Wesley designates this educational activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)TM. Physicians
should claim credit commensurate with the extent of their participation in the activities.
L:/Jeri/WEmergency/Issue#88newsletterSept2010forwebsite.doc
Page 14