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<< Pain Management in the Emergency Department

Risk Management

1. “The patient had abdominal pain, but I did’t give any pain medication because I did not want to mask the exam.”

Pain control should be considered in every encounter, even in patients with abdominal pain. When the patient is more comfortable, the abdominal exam can yield more information. The signs of serious pathology will not become unrecognizable, and it is still possible to follow the evolution of the pain.

2. “The vital signs were normal, so even though he said he was in pain there wasn’t any evidence that it was true.”

Vital signs may be normal and yet patients may still be in significant pain. Common medications, such as beta-blockers, may interfere with the normal stress response. And even in the absence of interfering medications, vital signs are not a reliable predictor of pain severity. A patient’s own reporting is the most reliable means of assessing the intensity of pain.

3. “I didn’t give narcotics because I was afraid he would get addicted.”

There is no evidence that patients treated for acute pain with narcotics are at increased risk of addiction. The trends in federal and state legislations have also pushed the standard of care toward an obligation to treat, and the liability may be greater for not treating than for being lean on pain control.

4. “The patient was not in pain at the time of discharge, so pain control did not need to be addressed.”

Patients may not experience the most intense pain for their conditions at the time of presentation. Some processes, such as the inflammatory response, may increase after the time of discharge. The progress of the patient’s condition should always be considered and the patientshould be discharged with pain medication.

5. “The patient was an IV drug abuser; I knew he was just looking for pain medications, so I sent him right out.”

Patients who abuse IV drugs are at risk for very serious pathology, such as epidural abscess and necrotizing fasciitis, both of which typically present with complaints of pain. Regardless of a patient’s experience with narcotics, he will need to be evaluated every time he is seen in the ED.

6. “The parents did not think the child was in pain, so I stopped thinking about pain control at thatpoint.”

Parents underestimate the pain their children experience just as badly as physicians do. It is important to look for signs that parents may not notice, such as grimacing, guarding, drawing up their legs, or squirming. Certainly, any child complaining of pain needs to be taken seriously.

7. “She was an IV drug abuser, so I gave her the pain meds I would have given anyone else. When her pain wasn’t controlled I told her that was her problem.”

Patients who are tolerant of opiates, either because of recreational use or from chronic pain treatment regimens, may require more medication that opiate-naive patients. The actual doses should not be the primary concern, but rather the balance of therapeutic benefit and the risks of higher doses.

8. “I made the diagnosis, which is my priority. What difference does it make if I treated their pain?”

Making the diagnosis is one of the most important services provided by emergency physicians, but there is still an obligation to stabilize the patient’s pain. Many patients’ reporting of satisfaction is based not only on accurate diagnosis and treatment but also on the overall patientprovider interaction, including pain control.

9. “The patient was too demented to even know if he was in pain, he didn’t need medication.”

Non-verbal patients may be in significant pain despite their inability to communicate it. Physicians should be attuned to other signs of pain, such as moaning, crying, or writhing.

10. “She was allergic to everything but meperidine, that’s when I knew she was a drug-seeker.”

Patients may not understand what constitutes a true allergy. Itching is common when taking narcotics because of the histamine release. When patients list allergies, physicians should explore what is meant. Sometimes, medications may be listed because of misunderstanding. Even if the patient insists on allergies to all other medications, she should still be evaluated for pathology and a need for real pain control.