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<< Pain Management in the Emergency Department

Case Presentation

A twenty-seven-year-old man presents to the emergency department after a motor vehicle crash. The paramedics relate that the mechanism was a rear end collision at approximately 20 mph. The patient was  he restrained front-seat passenger, no airbags deployed, and there was only minor damage to the vehicle. The patient states he struck his knees against the dashboard and he is complaining of knee pain, chest pain, and abdominal pain where he was restrained by the belt. His exam is unremarkable; his x-rays, ultrasound, and CT scans are all negative. His hematocrit remains stable throughout his observation.

However, complicating the encounter is the fact that the patient has sickle cell disease and has been to the department many times in the past for pain crises. His hematologist follows him closely and he is not known to go to any other ED in the city. During his time in the ED, he initially receives 2 mg of morphine intravenously, followed by a repeat dose of 4 mg; afterwhich, his requests for more pain medication are denied and he is told that he has already received more pain medicine than would typically be given for this mechanism of injury. When the patient is discharged from the department he is instructed to use his regular pain medication (which he claimed he was out of) and no new prescription was provided. The next week, the department’s Medical Director receives a letter of complaint from both the patient and his hematologist; you are asked to provide a response explaining your (lack of!) pain management strategy . . .

Conclusion

The patient in the case vignette had sickle cell disease and had become tolerant to narcotics. He received oligoanalgesia for his pain and the treating physician failed to put his acute presentation in context with his chronic disease. The complaint from the patient went both to the ED medical director and to the patient’s hematologist who forwarded a second complaint that he had not been informed of the patient ED visit or consulted on how to best manage the pain and ensure next day follow-up. The system failed and, in this case, the patient paid the price.

Many physicians have been too quick to label patients as “drug-seekers” when the patients are really seeking relief. Many physicians have undertreated pain or have not become knowledgeable about the variety of therapies available. While pain relief may not be perceived as the primary mission of the ED, there exists a great opportunity and many resources to intervene and assist the patient in need. Pain control must take place along side diagnosis, intervention, and education. Even as the stresses of crowded departments and sick patients bear down on emergency physicians, if pain control is kept in mind, patients will “Cry out in good earnest, ‘At last I yield to an effective science.’” (Michel De Montaigne)