It seems like a simple thing that’s a given – delivery of good analgesia. Except for the bit where good clinicians fail over and over at this. Here’s Dr Alan Garner checking out a recent study from the Swiss that looks at some of the holes.
As prehospital clinicians I think we all aim to provide as technically sound and evidence-based management as we can. This is a given but when I think about what I would like for my own family or myself I also want “care”. This is what makes health care interactions more than just an exchange of services for money. And this is what sends me crazy when I hear patients described as “clients”.
But I am digressing. A major component of care is the relief of suffering and the most common form of suffering we see in the prehospital world is pain. Good pain relief early might not change the patient’s probability of death in the longer term but it might well change functional outcomes such as symptoms of post traumatic stress disorder. But most of all we should do it, and do it well because we care.
There have been a lot of studies published about management of pain in emergency departments and it almost always looks bad. People with obviously painful conditions either not getting analgesia, getting it late or not getting enough. Given that the most common single presenting complaint to emergency departments is pain of some kind, I would argue that a fundamental KPI of good emergency care should be time to adequate pain relief and this should be reported above the 4 hour rule, access block and any other process indicator. Waiting for a bed for hours is regrettable but waiting for hours in agony is simply barbaric.
If EDs are doing it badly you can be reasonably confident that prehospital is worse given all the additional constraints. A new study has just been published by the guys from REGA (Swiss Air Ambulance) building on some work they have done previously around the prehospital analgesia question. The work arose from a quality assurance project on analgesia that they have been conducting across their organisation to try and improve pain management and they are much to be commended for sharing their work on this. They have allowed us a view into their struggle so we can learn from them.
And it has been a struggle. In this new study they documented that one in six patients with moderate to severe pain (defined as >3 on a 0-10 numerical rating scale as reported by the patient) did not get any prehospital analgesia at all! This is even more noteworthy given that the physician documented the pain score of >3 at the scene but apparently did not act on it for some reason. One clue might be that a predictor of inadequate analgesia was shorter scene times and more severe injury (higher NACA score). I was wondering if hypotension therefore might be one of the drivers for no analgesia but “circulation insufficient” was pretty uncommon being present in only 13 of the 778 conscious patients in this study (this stuff is in Table 1 in the paper).
Several years ago we audited the analgesia given to children by our own service. In some cases we did not give analgesia for clearly painful injuries (like bent long bones) but there was evidence that the road paramedics who had been there ahead of us had done so. There is no mention of this occurring in the Swiss study. Perhaps this might partially explain the lack of analgesia given if this is also occurring in their system. Although even if this did occur the physicians still documented pain scores >3 whilst the patient was in their care which you would have thought would prompt further analgesia.
I am not meaning to be too critical here. In the audit of our own service that I mentioned we also found cases with clearly painful injuries and no record of analgesia given by road paramedics or our doctors. This prompted a major rethink for us in our approach to analgesia in the field including formally recording pain scores on our observations chart to prompt our teams to keep this front of mind. Analgesia is also included as an item in all our Carebundles for traumatic conditions, and for intubated patients regardless of the underlying pathology. One of the risks for inadequate analgesia identified in this new study was that the patient had a non-trauma problem. It might be timely for us to review our Carebundles for non-trauma conditions too.
Another risk factor for inadequate analgesia was severe pain from the outset (score 8 or more). In this situation it seemed a single agent just was not enough. Judicious use of small amounts of ketamine in addition to the opioid appeared really useful here. And it appeared the combination was better in severe pain rather than just ketamine as a single agent.
I am also a little surprised about the narrow modes of delivery utilised with all analgesia given IV. In our system the nasal route for fentanyl is used frequently particularly for children and it works a treat. I also think that regional blocks have a place, particularly where the injury mechanism and your exam indicate that the injury is confined to a limb and the situation is not time critical (the time it takes is probably the major contraindication prehospital).
We have recently formally introduced fascia iliaca blocks to our service. There are lots of other blocks you can utilise , particularly if your service carries an ultrasound machine with an appropriate probe for nerve localisation. This is a skill you are unlikely to learn prehospital (except perhaps for femoral or fascia iliaca blocks) as you will never do enough of the other types to develop any skill. If part of your practice is in the hospital context where you can get lots of practice however, these are well worth learning. Done well they can completely remove the need for parenteral opiates. The context that we have used regional blocks (other than femoral or fascia iliaca) is in limbs trapped in machinery. Not a common circumstance but a useful tool to have in the box when it occurs.
The Other Bits We Rarely Look At…
I don’t think this was the aim of this study but it would also have been nice to see some attention paid to non-pharmacological methods of pain management. Good splinting and packaging is the obvious first line for prehospital services and is one of the basics that is worth doing well. We don’t carry hot or cold packs in our service due to the weight, but they are available from our local ground ambulances. These can also help in the right patient.
Plus a Slightly Unexpected Elephant
And lastly they claim a slightly unexpected elephant is in the room. Treatment by a female physician is reported as being associated with a higher likelihood of arriving at hospital with inadequate analgesia. To be honest I’m not quite sure what made them look at the gender of the practitioner but there it is, written up. Before anyone assumes this was some situation induced by most of the patients being middle-aged blokes, it wasn’t about the patient gender at all.
So what is going on? I can’t quite figure out why this would be the case although the Swiss group has documented this previously in their own system. Is this a Swiss peculiarity or is it more wide spread?
Well to me it looks like there are a few holes in the information provided that make me wonder if it’s a blip rather than an actual pachyderm. For example non-trauma patients were more likely to arrive at hospital with insufficient analgesia than trauma patients. I can’t construct what proportion of those patients got a physician of a particular gender by chance from this report though. Could it be that the real issue is that clinicians interpret the significance of pain differently based on the context or mechanism? If it’s “medical” pain rather than traumatic pain do we tend to wait for the medicine to fix the medical, rather than treating pain separately? There’s at least one confounder for you without even trying so I’m not convinced a strong case is made that provider gender is a crucial determinant of analgesia efficacy.
A question the physician gender stat does raise that is beyond the scope of this study is the need to consider the particularities of the provider in the mix. Beyond breaking things into much larger groups (like physician vs paramedic) I don’t recall seeing much on what characteristics of a clinician make them more or less likely to provide the good juice. If we don’t understand biases that might be in play I’m not sure we can do the most effective job of changing practice.
The bottom line – be obsessed with good analgesia. It’s easy to get obsessed with all those interventions we think of as advanced, but the long-term quality of life of patients will probably be equally influenced by getting this bit right. Use a multimodal approach rather than just the parenteral one. Combine agents if severe pain requires it. Consider local and regional blocks if you have the skill.
And if anyone can figure out if the physician gender difference in this study is a blip or a real thing of some other sort hidden somewhere in the unreported elements, I’d like to know. It’d be good to show that elephant the door.
Yes. That’s a real elephant and the photo is via @AndyDW_
Oberholzer N, Kaserer A, Albrecht R, et al. Factors Influencing Quality of Pain Management in a Physician Staffed Helicopter Emergency Medical Service. Anesth. Analg. 2017.