One recent evening in Denver, a man known to EMS to have a history of drug abuse was brought by ambulance to Denver General Hospital after being hit by a car. A bone in his arm was poking through his skin, but paramedics didn’t give him pain medication. “We’re familiar with him. He likes his drugs,” Christopher Colwell, M.D., an emergency physician and medical director for the Denver Fire Department and Denver Health Paramedic Division, recalls medics telling him.
Colwell was appalled. The man was obviously in severe pain, yet he was being denied relief because of his drug dependency status. “It was astounding. Here was someone with a bone sticking out of his arm, whose pain should have been treated,” he says. “Yet medics were not able to step out of that and treat the patient based on his current situation rather than his history.”
Pain is one of the primary reasons people call 911, Colwell adds. “It’s something we see on every shift every day,” he says.
Mike Taigman, general manager of American Medical Response (AMR) in Ventura County, Calif., puts it this way: “So often when people call 911, their complaint is I can’t breathe; I hurt bad; or I’m going to puke. Of course, not always—sometimes they’re unconscious. But pain and suffering is so frequently the reason they picked up the phone.”
Yet there’s a growing concern in EMS that paramedics and EMTs aren’t doing enough to assess, treat and relieve pain—whether it’s through the use of opioids and other pain relievers, or other techniques to ease the anxiety and distress that can make pain seem even worse. “I would be running calls with my crews, and we’d show up and there would be somebody with a broken hip and I would listen to paramedics really eloquently say, ‘We’re going to get you onto this scoop stretcher or board. It’s going to hurt a little bit, but we’ll get you into the ambulance and then we’ll give you something for the pain,’” Taigman says. “Why do we spend so much time telling patients that what we’re going to do to them is going to hurt, and sending the message that they need to suck it up a little bit? Why don’t we manage the pain first?”
The reasons for not treating pain adequately run the gamut and can vary from responder to responder, medical director to medical director, and patient to patient. But in recent years, as hospitals and the rest of the health care system have put a greater emphasis on pain management, so, too, have some thought leaders in EMS. With efforts under way in Denver, at AMR and elsewhere to understand the barriers to pain management in the field and to find ways to improve, many believe EMS is undergoing a cultural shift in the way it looks at pain management. “If you don’t give pain medication to somebody who needs it, it prolongs unnecessary suffering,” says Taigman, who is on the leadership team of a quality improvement initiative that includes pain management at AMR. “We are here to take care of people, and part of taking care of them is to reduce their suffering … it’s cruel and inhumane not to address somebody’s suffering if we have the means to.”
Relieving pain becomes a priority
For a condition as uncomfortable and as universal as pain, it took until the mid-’90s for pain management to become a priority in hospitals. “At the time, we were really coming to full recognition of how poorly we were doing in managing patients’ pain,” says Bob Twillman, Ph.D., director of policy and advocacy for the American Academy of Pain Management in Sonora, Calif.
Research papers showed that patients with poorly treated pain were more likely to end up with chronic pain conditions, post-traumatic stress, depression, and other physical and psychological problems, while other research showed that proper pain management could help with wound healing and get people home from the hospital sooner, Twillman says. At the same time, new pharmaceuticals came on the market, providing alternative pain-relief options. “Prior to the mid-’90s, we had oxycodone (Percocet) and hydrocodone (Vicodin, Lortab) and only one long-acting opioid—morphine,” Twillman says. “But then fentanyl patches and Oxycontin became available. We had a lot more options for treating people not just with acute pain, but with longstanding pain related to cancer or other pain conditions.”
In 1994, the Federation of State Medical Boards, the national organization that oversees physician licensing, issued a policy statement calling for improved pain management. Then, in 2001, recognizing the “historical undertreatment of pain” for hospitalized patients, the Joint Commission on Accreditation of Healthcare Organizations (now known as the Joint Commission), which accredits U.S. hospitals, surgery centers and long-term care facilities, implemented pain-management standards that required organizations to assess pain on an ongoing basis, to manage pain and to educate patients and their families about pain management.
“Unrelieved pain is a major, yet avoidable, public health problem. Despite 20 years of work by educators, clinicians and professional organizations and the publication of clinical practice guidelines, there have been, at best, modest improvements in pain management practices,” wrote researchers from the University of Wisconsin–Madison’s Pain Management Improvement Group in a study published in 2000 in Pain Management Nursing discussing the implications of new pain-management standards. (Experts from the University of Wisconsin–Madison Medical School helped write the standards.)
Yet the emphasis on treating pain, coupled with the new drugs, came with a dark side: soaring rates of overdoses and addiction. Drug overdose death rates in the U.S. have more than tripled since 1990, according to the CDC. Many of those deaths are caused by prescription painkiller misuse.
As a psychologist at the University of Kansas Medical Center in the mid-’90s, Twillman headed up his hospital’s first multidisciplinary pain-management team, which included physical therapy and psychosocial support. But too often, those non-pharmaceutical strategies were left out of pain management. “As we began to manage pain more and more, unfortunately, managing pain increasingly became equated with opioids,” he says. “In reality, managing pain is about a whole lot more than that. It’s about other kinds of medications, physical therapy, psychotherapy.
“Psychological factors play a big role in pain, but all of those things didn’t get addressed,” Twillman adds. “People saw these requirements and said, ‘The easiest and fastest thing for me to do is to write a prescription.’ And that’s what’s gotten us into the problem we’re in now.”
Responders reluctant to give drugs
Even as hospitals worked to better manage pain, awareness of the importance of pain management in the prehospital setting lagged. EMS has no pain-management standards as part of accreditation. (The Commission on Accreditation of Ambulance Services, or CAAS, doesn’t include a pain-management standard as part of its clinical assessment.) Nor is pain management a major part of EMS education, Taigman says. Sure, pain medications are touched on. But there are no long discussions about the role of the prehospital care provider in treating pain. “There’s a long module on reading EKGs, a super long module on trauma assessment and management, but there’s no module on pain management,” he says.
As a result, responder attitudes—and patient care—is all over the board. In a 2012 study in Prehospital Emergency Care, Yale University researchers interviewed 15 experienced paramedics from five rural and urban EMS agencies in three New England states and found a widespread reluctance to administer opioids. Reasons given included:
• Worries that the drugs would mask symptoms and make a diagnosis more difficult for physicians
• A hesitancy to use what they viewed as overly high doses of pain medications
• A reluctance to administer opioids without clear signs that a patient needed them, such as limb deformity, hypertension, tachycardia, anxiety or sweating
• Uncertainty if they should control the pain or just “take the edge off”
Many of those concerns are either overblown or have been outright debunked, Colwell says. Decades ago, physicians were taught that they should hold off giving pain medications because they needed to pinpoint the source of the pain to make a diagnosis. No longer, he adds—treating pain can actually make it easier for physicians to determine what’s wrong because patients aren’t writhing around during the exam. Likewise, vital signs are a poor measure of pain, as pain doesn’t always result in changes in blood pressure or heart rate that would provide a clear sign to paramedics, he adds.
As for worrying about giving too high a dose of painkiller, a one-time dose of opioids in an ambulance carries very low risk of causing an overdose, Colwell says. Overdose and dependency worries should be much more of a concern for primary care doctors, who may prescribe their patients the drugs for months and years at a time, he adds.
“In some ways, the medical community as a whole is partly responsible for this. We have instilled a fear in not only the public at large but also the medical profession of the downsides of pain medications and sedation,” Colwell says. “We have created too much concern that we have overdone it and put fear into providers’ minds when in fact, when used appropriately by well-educated individuals, these can be very safe drugs.”
Judgment calls
The Yale study identified yet another barrier to pain management in the field: a “preoccupation” among responders that patients could be addicts seeking drugs.
EMS certainly does encounter people who are prescription painkiller dependent. But it’s often not possible for paramedics to know with certainty if a patient is an addict, and even if the patient is, whether the addict is also experiencing legitimate pain.
As a young medic, Taigman learned how easy it is to guess wrong. Years ago, he ran a call involving a man who had been pulled over by police for weaving. “He was drunk as a skunk, loudly and flamboyantly complaining, ‘Oh, my chest hurts,’” Taigman recalls. “The cop believed he was faking it but called us anyway. As soon as he was out of eyesight of the cop, he quit complaining of pain and started being sexually flirtatious with my paramedic student. His EKG showed no signs of anything. His respiratory rate was normal, his pulse rate was normal and his EKG was normal.”
A few moments later, while Taigman was filling out paperwork, the man went into cardiac arrest and died. “I would have bet any amount of money he was faking his situation,” Taigman says. “And I would have been wrong. He was having a huge, fatal myocardial infarction. It’s why I tell my crews, ‘If you want to judge somebody as purely being a drug seeker, I will back you up. But it’s really hard to prove you’re right.’”
In any case, the back of an ambulance isn’t the place to start a drug treatment program, Taigman says. “The treatment for addiction is long term and complicated, involving psychosocial and physical issues,” he says. “It’s beyond the scope of what an EMS system can do during the time they’re with the patient.”
But that doesn’t mean responders can do nothing. “To point somebody to that treatment is absolutely something we can do,” Taigman adds.
There are also cases, such as when a patient is clearly impaired, that withholding opioids may be the best course of action, Colwell says. Still, he says, “When in doubt, treat. I would much rather be fooled into giving narcotics to a patient who ultimately didn’t need it than to withhold narcotics from someone who did.”
Changing attitudes
So what’s the best way to determine how much pain someone really is in? Ask patients, perhaps using a pain scale to help assess the level of pain at the initial assessment and then after treatment. “Vital signs aren’t accurate. People can experience plenty of pain without vital signs showing it,” Taigman says. “There is no gauge, no probe. The only reliable way to assess pain in someone else is to ask them how much they hurt and to believe what they tell you.”
As EMS becomes more enlightened about pain management, some EMS organizations are taking steps to improve their performance. As part of AMR’s quality improvement initiative, Caring For Maria, Taigman is spearheading an effort in Ventura County to reduce pain and suffering. “The reason I talk about suffering management and not just pain management is because from the patient’s perspective, it might not be a specific pain. It might be, I’m feeling really bad. I’m throwing up, sweating, ready to pass out. If we give an opiate and something to manage the nausea, that might relieve their suffering,” he says.
When he first broached the issue with responders last year, Taigman confronted a wide range of attitudes. “I have some folks who really believe the prevention of pain is important and they do it aggressively,” he says. “And I have a whole group of other paramedics who think pain isn’t that bad.”
This belief doesn’t occur only among providers, Colwell says; some medical directors and ED physicians can still harbor a bias against painkillers. “Don’t yell at paramedics because they gave 8 mg of pain medication rather than 6,” he says. “If they are hearing from medical directors and from their emergency department physicians, ‘I don’t want you using pain medications,’ that’s what’s going to happen.”
At AMR Ventura County, to determine how well responders manage pain, they ask patients about their pain initially, and then after treatment, all of which is entered into the patient care record. By educating providers about the importance of pain management and tracking their performance, Taigman is already seeing improvement. A few months ago, about 24 percent of patients with pain in a random sample of 100 consecutive charts reported a reduction in pain and suffering thanks to EMS. As of March, that was up to 61 percent.
Another change: Instead of giving patients a 2 to 4 mg dose of morphine, followed by a second dose as needed, they recently experimented with a pilot program in which the morphine dose was determined using the patient’s weight. That strategy alleviated pain more effectively, and Taigman and his team are looking into implementing it permanently in Ventura County and elsewhere.
Another agency working to improve pain management is Nature Coast EMS in Citrus County, Fla. Calling pain assessment “the 5th vital sign,” Jane Bedford, R.N., education director, last year had every EMT and medic attend a four-hour training session on assessing pain in elderly patients who may have dementia or other hearing or communication issues. “If you ask them, ‘How are you doing?’ most of the time they say, ‘I’m fine,’” Bedford says. “So you have to assess other things, such as if they are grimacing. Or talk to their caregivers. Sometimes the first indication of pain in an elderly person is their caregiver will say, ‘They aren’t acting normal.’”
Beyond opioids
While opioids are potent painkillers, no one is suggesting that’s the only way to treat pain. In elderly patients, providing a pillow to rest on and helping them to shift their position may help. “Sometimes, comfort measures, or connecting with your patients, can go a long way,” Bedford says.
Proper splinting, ice and elevation can help for broken bones. So can reassuring patients, making eye contact and explaining what you’re doing, all of which can help alleviate the fear and anxiety that make pain perceptions worse. “Being able to calm down somebody’s distress with just your bedside manner is a legitimate part of pain and suffering management,” Taigman says.
To educate her staff on bedside manner, Bedford invited a woman who had been thrown from a horse and suffered a badly broken arm to speak to her responders about how much it helped when a medic held her hand. “As responders, the tendency is to think about the clinical,” she says. “Sometimes saying, ‘We’re going to take care of you’ and holding someone’s hand is just as important.”
As EMS becomes more enlightened, many believe that assessing and treating pain will be as routine as checking blood pressure and pulse. “We are trying to develop a culture of pain medication use,” Colwell says. “I’m not suggesting we give everyone narcotics. But more often than not, if situations are in the gray zone, we have to rethink how we approach that. If we’re on the fence, treat them. We need to create a culture where treating pain is the expected norm.”
Sanctioned torture
Why more in EMS are re-thinking the use of backboards
Christopher Colwell, M.D., medical director for the Denver Fire Department and Denver Health Paramedic Division, calls them “sanctioned torture.” Jim Morrissey, supervising prehospital care coordinator for Alameda County (Calif.) Emergency Medical Services, says using them is “almost inhumane.”
Backboards—which for decades have been the standard treatment for patients with possible spine injuries—are falling out of favor among some EMS leaders, who say that not only is spinal immobilization done too often, the method—backboards—are an unnecessarily uncomfortable way to accomplish it. “There are no formal or accepted studies that show that immobilization on a backboard does any good or has any benefit to ultimate neurological outcome,” says Morrissey.
In addition, backboards can worsen patients’ pain and anxiety. “It’s like being duck-taped to the bed of a pickup truck and going for a drive,” Morrissey says. “You can’t move. You can’t adjust yourself … not only does it cause physical pain, it causes significant anxiety, claustrophobia and a lack of control, which will exacerbate any pain you are already having.”
For decades, prehospital providers were taught that patients with a possible spine injury should be treated with full-body immobilization—which typically means being placed in a cervical collar and strapped to a backboard with head stabilizers. The idea is that immobilization prevents further injury, Morrissey says.
But a main fault with this approach is that the decision to backboard is made based on the mechanism of injury, even in the absence of signs or symptoms of an actual spine injury. So, for example, if someone was in a moderate-speed car crash with significant damage to the car but didn’t have any signs of spinal damage, they’d still get placed on a backboard—which is more than likely unnecessary, Morrissey says.
Other problems with backboards are that lying flat on the back can make it more difficult to breathe; if a patient vomits, he or she can aspirate into the lungs; and if advanced airway procedures are needed, a backboard makes it much more difficult, whereas the process of immobilizing the spine itself can cause delays in getting the patient to definitive care.
And not to be overlooked: patients’ distress. “If you look at the profile of a body, you can see these curves. That’s why we sleep on a mattress,” Morrissey says. “Even in healthy volunteers, 100 percent will develop pain within 15 minutes on a backboard.” Cervical collars add to the discomfort, he adds: “Patients feel like they’re being choked by this big thing around their neck.” (At the University of Colorado, med students participated in an experiment in which they were placed on backboards to see what it felt like. Some complained of back pain for weeks afterward, Colwell says.)
Placing elderly patients on a backboard can be particularly cruel, Morrissey says. “If you have an older woman with degenerative bone disease, the worst thing is to strap her to a backboard,” he says. “You are unpretzeling a pretzel. You should leave her in a position where she is most comfortable and most able to breathe.”
Yet despite a lack of evidence that backboards help, more than 5 million people are put into spinal immobilization each year, while less than 1 percent have actual injuries, Morrissey says.
Some EMS agencies have found alternatives. In Denver, responders use a scoop stretcher to move patients and then place them onto a softer gurney for transport. “We don’t leave them strapped to a backboard as they’re being transported,” Colwell says. “Backboards were never intended for long-term use.”
Morrissey’s agency, which oversees EMS in Alameda County, is promoting the use of vacuum mattresses, a type of air mattress that conforms to the patient’s body—rather than the other way around—to immobilize spines. On vacuum mattresses, which are widely used in Europe, patients can be placed on their side, keeping the airway open, Morrissey says. Alameda Fire Department is already using them, and Berkeley Fire Department will start soon as part of what he hopes will be a county-wide phase-in. (A vacuum mattress costs about $100.)
To cut down on the number of patients who have spinal immobilization of any type, his EMS agency has also adopted a new spinal assessment protocol. Put simply, “If the patient is awake and alert and their spine doesn’t hurt and everything works, then they don’t have a spine injury,” Morrissey says. (The actual protocol includes examining the spine for pain or tenderness and conducting a motor-sensory assessment to check for neurological deficits.)
If a vacuum mattress isn’t available or called for, “you could sit the patient on the gurney with a cervical collar alone. If it’s a car accident, you could have them self-extricate out of a vehicle. If a backboard is the only tool available, use significant padding,” he advises. “The comfort of the patient is of paramount focus here.” Since adopting the spinal assessment protocol Dec. 1, use of backboards has dropped nearly 60 percent in the county.
Is there still a role for backboards? Yes, but a limited one, Morrissey says. “A backboard makes a good spatula. But at some point that burger has to get on a bun,” he says. “If you have someone in a major car wreck, there’s broken glass, they’re upside down, you can use the backboard to get the patient out. But they shouldn’t stay on it. They should get put onto a gurney or a vacuum mattress—the bun.”
Watch a video of Alameda County’s spinal injury assessment.
