Time is a core concept in EMS. It is why we have light and sirens. We have all heard of the “Golden Hour of Trauma,”* early defibrillation, and the phrases, “Time is Muscle” for coronary care and “Time is Brain” for stroke care.
But how about this for a priority EMS concept:
Time to Pain Management
Here’s why this is important:
The only purpose of pain is to alert us that we have an injury and to stop doing anything that will aggravate it. Your leg is broken, don’t walk on it. Your back suddenly hurts when you pick up a box, put the box down. You touch a hot burner, take your hand off it. Beyond that pain becomes destructive. It causes inflammation, hinders healing, and sets off a cascade of physiological changes in the body.
I used to think, if someone dropped an anvil on their big toe, their toe would call up the brain and say, “Hey Brain. Did you see that? You just dropped an anvil on me. It freaking hurts.” To which, the brain would respond one of two ways. “Oh, my gosh, yes, I noticed that. Oww! Owww! OH! It hurts! It hurts! I think I’ll swear and cry!” Or the brain would say to the toe, “Suck it up, Big Toe. Don’t be a pansy.”
Eventually, the toe would stop hurting, the injury would heal, and everything would go back to the way it was. But it doesn’t always. Pain isn’t just an annoying complainer; it is, in the simple and eloquent words of the article “Prehospital Trauma Analgesia” that appears in a 2008 Journal of Emergency Medicine issue, “physiologically bad.”
Pain is “physiologically bad.” It is destructive to the body. Untreated, it damages the immune system, hinders wound healing, rewires the neurological system, and can lead to chronic pain.
Consider this from a 2006 emergency medicine text book, Pain Management and Sedation**, “Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.”
This concept and our role in it became clearest to me when I read an article on prehospital analgesia and sedation that appeared in the February 2000 Journal of the Royal Army Medical Care, written by R. McKenzie.
“The effective management of pain in the pre-hospital environment may be the most important contribution to the survival and long term well being of a casualty that we can make. The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.”
Read that last sentence again:
“The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.”
You arrive on scene of a patient with an open tib fib fracture who is grimacing in pain. You can treat the patient’s pain once you get them in the ambulance or you can wait for the hospital to do it because the hospital is only five minutes away. Or you can treat the patient right now where they lay.
You are on the clock. The patient’s body is undergoing a “cascade” of changes caused by PAIN.
Fentanyl in the nose right there. Splint. Get the patient on the stretcher, in the ambulance. Elevation. Ice. Reassess. Pop in an IV. More Fentanyl. Take him to the hospital. Perhaps redose the fentanyl again right there in the ambulance bay, outside the ED doors.
If the patient is singing the “Farmer in the Dell,” you’ve done your job. Vanquisher of Pain. You deserve high fives as much as you do with a prompt defibrillation, a killer door to balloon time or getting a stroke patient to the TPA on time.
Pain Management is not just the humane thing for us to do, it is often physiologically the best thing we can do for the patient.
* While “the Golden Hour” has largely been discredited, there is no doubt that certain trauma patients have a limited window for intervention.
**Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill – 2006