Education: Pain Management

I have been procrastinating on approaching this topic. I will start off by reviewing a study that assesses pain management before and after continued education. The results are pretty interesting. I know this a subject of particular interest to Rogue Medic, so don't be surprised if he chimes in with some added opinionated criticism information.

The Abstract:

INTRODUCTION: Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. OBJECTIVES: To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. METHODS: All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. RESULTS: The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%;) paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%;) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%;)improvement in pain reassessment following intervention. CONCLUSION: As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.
Well at least they provided pain therapy. Pain is the most common reason people seek healthcare, and prehospital care providers are generally lacking in pain management skills. It is reassuring to see studies like this.

If you read the abstract you will note that there was no significant change in the use of pain medication; 4.3% according to the full study. Documentation improved as well as nonpharmacologic therapy. This was after just 3 hours of training. With appropriate QI/QA follow up, this may improve much more.

It seems the authors of the study were slightly biased. They emphasize the positive results much more than mentioning the slight improvement in medication administration.

I believe the problems we have with pharmacological pain management has to do with a few factors:

- Laziness. Controlled substances usually require more work, during and after the call.
- Fear of administering medications. Some medics just don't like giving drugs.
- A judgmental attitude. Not everyone is a "drug seeker", and we need to use a better assessment.
- Disregarding the complaints. "I'm in pain" generally means "I'm in pain". Some medics have a tendency to completely ignore issues of comfort, searching for a TRUE medical emergency.
- These patients are commonly triaged as BLS.

There are probably many more reasons, but I think these are probably the most prominent. I will touch on this subject in further posts, I just wanted to get the ball rolling.

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