Changing attitudes about pain and pain control in emergency medicine

Emergency department (ED) lore has countless humorous and often self-deprecating stories about the treatments of pain and the seekers of pain relief encountered on a daily basis. A culture of suspicion, limited research, diverse and often difficult patient populations, and challenging clinical environments have plagued our specialty in its approach to analgesia. Additionally, the limited use of advances in analgesia by other medical specialties has afforded emergency medicine the opportunity to lead the efforts for effective patient pain management. As emergency physicians, our focus is often on the underlying diagnosis of painful complaints; however, the single-minded attention on the diagnosis of the underlying cause of pain has resulted in ignoring the pain that prompted the patient to seek care in the first place. Analgesia is often an afterthought to diagnosis and disposition. To improve our treatment of pain in the ED, a fundamental change in the way we practice is required. Treatment of pain should parallel the search for diagnosis of a patient's underlying condition, and has now become the standard of care. Pain is now considered the "fifth vital sign," and should be addressed in the same manner as other time-sensitive events we manage every day. For example, response to pain can be likened to the approach and treatment of myocardial ischemia. Today's well-trained ED physician would not ignore or fail to appropriately treat a 55-year-old male who has substernal chest pain suffering from an acute MI with nitrates, aspirin, beta-blockers, and angioplasty or thrombolytics. Why does other pain not warrant a similar emergent response, such as the hip pain of a 67-year-old female after a fall, the neck pain of a 22-year-old male after a rear-end motor vehicle accident, or the back pain of a 35-year-old male after lifting a couch? Is it difficult to change the focus from the diagnosis of the hip fracture. the cervical strain, or the acute Muscle spasm to the treatment of the pain that brought the patient it the ED? Emergency medical personnel should consider changing focus from the immediate diagnosis of the pain to the immediate relief of the pain. The first step in changing provider attitudes in pain management is the acknowledgment and accurate measurement of the initial pain experienced by the patient. Subsequent measures of patients' responses to analgesics are needed to assess treatment adequacy and to guide further therapy. With these changes in attitudes, providers can enhance not only overall care and satisfaction for the patients, but also job satisfaction for the providers.