I have written much about pain management and find it one of the most gratifying aspects of being a care-giver. I feel a little bad that in my last post I made fun of some of my patient’s pain scales – something I will address further in my next post, but I wanted today to reclaim the high road and talk about a book –Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research – I highly recommend to all.

The book is largely about chronic pain, but it does mention acute pain and the need to treat it promptly. Unfortunately there is no mention of the EMS role in the book, but there are still many lessons for us in it.

I am going to quote and comment on the opening paragraph of the book, which I think is beautifully written and drives home much of what I have come to learn and feel about the importance of pain management.

“Protection from and relief of pain and suffering are a fundamental feature of the human contract we make as parents, partners, children, family, friends, and community members, as well as a cardinal underpinning of the art and science of healing.”

The very first role of ancient healers was to treat pain. In the mix of our learning of various diseases and the skills to combat them, we often neglect the very patient in front of us. William Osler, the father of modern medicine said, “Care more for the individual patient than for the special features of the disease.”

“Pain is part of the human condition; at some point, for short or long periods of time, we all experience pain and suffer its consequences.”

I have been giving my pain management talks for a long time and, at times, have been nearly hooted out of the room by old guard medics who followed the “I have to hurt looking at you for me to give you pain meds” philosophy and others who see a drug-seeker behind every person in pain. Over time many of these paramedics have come back to me and apologized, and said they had no idea of what pain was until they tore their shoulder or had a kidney stone themselves, and now they treat patients much more liberally and compassionately, understanding what it is like to be in real pain.

“While pain can serve as a warning to protect us from further harm, it also can contribute to severe and even relentless suffering, surpassing its underlying cause to become a disease in its own domains and dimensions.”

Untreated acute pain can rewire a patient’s body making them more susceptible to pain in the future. For people who think pain is a simple message from the injured part to the brain that goes away when the injury heals should think about amputees who still feel pain in their missing limbs to understand the complexity of our neurons and physiology. We need to think of pain as a disease that attacks the body right from the outset and pain management as a time sensitive intervention that in cases of acute pain, can affect the outcome of patient’s lives. As Dr. R McKenzie writes “The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.”

“We all may share common accountings of pain, but in reality, our experiences with pain are deeply personal, filtered through the lens of our unique biology, the society and community in which we were born and live, the personalities and styles of coping we have developed, and the manner in which our life journey has been enjoined with health and disease.”

Who are we to sit in judgment of others, not having walked in their shoes? Should the judgment of Drug Seeker! and Faker! be gaveled down in the court of the back of the ambulance? I am uncomfortable with that. I would rather err on the side of the patient and let the rest be sorted out in the hospital. How many times can we be wrong about a drug seeker to justify withholding drugs from someone truly in pain? And we must remember often people seek drugs because of their pain. They aren’t all just bored and looking to get a quick high.

“The personal experience of pain is often difficult to describe, and the words we choose to describe pain rarely capture its personal impact, whether it is sudden and limited or persists over time.”

Pain scales I realize are imperfect and better techniques of assessing pain need to be developed. But more about pain scales and their pros and cons in the next post.

“Severe or chronic pain can overtake our lives, having an impact on us as individuals as well as on our family, friends, and community.”

People as young children didn’t dream of growing up to become dependent on pain medicince. The suicide rate for people with chronic pain is much higher than the national norm. 100 million Americans suffer from chronic pain. Many of us will suffer chronic pain at some point in our lives. Let’s hope our care-givers are compassionate with us.

“Through the ages, pain and suffering have been the substrates for great works of fiction, but the reality of the experience, especially when persistent, has little redeeming or romantic quality.”

For most of history people believed that the mind and the body were separate — that people could just soldier on without damage. But we have learned now that mind and body are interlinked by physiology. Pain can destroy both body and mind.

“The personal story of pain can be transformative or can blunt the human values of joy, happiness, and even human connectedness.”

No one should have to sit before another and have to beg to be treated as a fellow human. In EMS we are caregivers. We are the door to compassion – to human connectedness. Open 24/7.

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Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research is a publication of the National Institute of Medicine that came out in 2011 and is available for free PDF download at this site:

Relieving Pain in America

Here is the description of the report:

Chronic pain costs the nation up to $635 billion each year in medical treatment and lost productivity. The 2010 Patient Protection and Affordable Care Act required the Department of Health and Human Services (HHS) to enlist the IOM in examining pain as a public health problem. In this report, the IOM offers a blueprint for action in transforming prevention, care, education, and research, with the goal of providing relief for people with pain in America. To reach the vast multitude of people with various types of pain, the nation must adopt a population-level prevention and management strategy. The IOM recommends that HHS develop a comprehensive plan with specific goals, actions, and timeframes. Better data are needed to help shape efforts, especially on the groups of people currently underdiagnosed and undertreated, and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. Because pain varies from patient to patient, healthcare providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted. In addition, because there are major gaps in knowledge about pain across health care and society alike, the IOM recommends that federal agencies and other stakeholders redesign education programs to bridge these gaps. Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.

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I recently ran across a fairly new blog that has made my regular read list. Mill Hill Ave Command is written by Brooks Walsh, an EMS medical control Doc in Bridgeport, Connecticut who comes from an EMS background (former EMT and paramedic). His posts center around recent research or interesting calls his medics have brought in. The posts are intelligent, easy to read and may change the way you practice or at least how you think about calls you are on. Recent posts tackle the issues of spinal immobilization, pain management, STEMI, cardiac arrest resuscitation and NTG in CHF and ACS. Walsh is also the coauthor of a recent study published in Prehospital Emergency Care about paramedic attitudes toward pain management that is quite eye-opening.

Paramedic attitudes regarding prehospital analgesia.

One of the best things about EMS I have seen over the years is the influx of motivated young EMS doctors who came from the streets themselves, who respect the work we do and are actively working to improve our systems and the care we provide. Brooks Walsh is one of these docs. You won’t be disappointed when you check his blog out.

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I am all for pain management, and in just about all cases I give my patients the full benefit of the doubt. Still, sometimes I am confounded by the answers I get to the pain scale question. “That’s be a 10.” “Oh, I’d say definately an 10.” “Five thousand. On the scale, mine is a five thousand.”

The other day my preceptee asked a patient his pain scale, and the man calmly said, “That’d be a 10.”

Now I don’t even remember what the patient’s presentation was it was such an unremarkable call.

“I don’t think you understand,” my preceptee said. “Zero is no pain, 10 is like an alligator biting your leg off pain.”

I about drove off the road I was laughing so hard.

Unphased, the man said, “Yeah, mine’s a ten.”

Later in the day, another woman said her pain was an 11.

It made me recall the famous scene from the movie, This is Spinal Tap, where the guitarist describes his amplifiers that go to 11.

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A handsome boy plays guitar in his garage band, thick black hair down to his shoulders. Man is he in to the music. The drummer in the background is also smiling, the kid on the bass is into it too. The photo colors are faded. I’m thinking 1970. In front of the 3X5 photo in the drug store frame sitting on the book shelf like an offering is one guitar pick. The guitar itself—-a Stratocaster–is hung on the wall like a museum piece. Next to it is a glass framed psychedelic 60’s era poster. Bright wavy yellows, purples and greens. Iron Butterfly at the Fillmore. I can hear those kids now playing at their high school dance. In-da-gadda-da-vida, baby. All the chicks digging it.

I look at the books neatly lined in the cases. Herman Hesse, Carlos Castenada, Hemingway, the Anarchists’ Cookbook, Jack Kerouac, all books I own myself. On another shelf there are others. How to Win in the Sport of Business, Effective Marketing Strategies, The Power of Habit. There is a purple bong that looks like it hasn’t been used in decades either, set up on the top shelf. Memories.

The living room is freshly vacuumed. The Electrolux sits by the door, its electric chord neatly wrapped in place. The superindendent who let us into the apartment stands there waiting patiently.

A middle-aged man in a bathing suit with his arm around three smiling children(maybe seven, twelve, and fourteen), poses on a beach, the Caribbean sea behind them. On the wall in the small open kitchenette the police officer is looking at a framed poster that says “My Kid Made This.” There is a 1st grade drawing of a man and woman and a house and a dog and a great big sun.

On the coffee table in front of the couch is a lap top computer, still open, its screen gone black, a pair of eyes glasses, neatly folded next to it. A glass of what looks like scotch with only one last drink left in it. A neatly typed sheet of paper is also laid there titled “Instructions.”

Down the hall there is a bottle of aerosol on the ground by the half open bedroom door. There is another bottle on the ground by the bed and one on the bed stand. The bed is neatly made. The man lays supine on the bedspread, his arms holding a black garbage bag wrapped around his head.

My young partner runs the strip. Six seconds of asystole. Then he looks at his watch and calls the time.

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I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student’s own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service’s medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again.

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