Good morning everyone. My name is Iain Beardsell and I am Emergency Physician from Southampton in the UK. As it’s a social media conference I should mention my Twitter handle - @docib – and also that I am an Associate Editor of Social Media for the EMJ and if you ever fancy writing a blog post for an international journal, please get in touch. Quite something this SMACC business isn’t it? I’d like to thank Roger and the team for putting me on after the Professor and the writer of the most viewed ECG blog in the world. I’m very humbled, and ever so slightly intimidated, to be in such esteemed company. SLIDE
As you have no doubt gathered SMACC is sexy. Already this morning we have had some of the biggest and sexiest names in Emergency Medicine and Critical Care. And there’s more to come – look at them all, perfect teeth, perfect smiles, just perfection. Apart from, perhaps, Cliff who looks like someone is tickling his bottom. SLIDE
I was scanning down the list of talks and even the titles are sexy – ECMO, Damage control, airway, Sepsis, airway, Danger, Top gun, and of course, airway. There’s even some words I’m fairly sure are made up. I wondered how on earth I could compete with this critical care erotica, and scoured my photo albums looking for pictures of me looking dynamic, perhaps running through the rain to a helicopter, blades running, on my way to save a life. SLIDE.
As it was this was the best I could come up with - a rather cheesy shot of me with my three boys whilst I was working a shift on our local air ambulance.
In amongst all this academic pornography I was given the title “Pain and Suffering in the ED”. Now this rather miselling what it is I actually want to talk to you about, but when I reveal the real title, please stick with it. I absolutely promise to tell you some things that will be useful the first day you get back to work. SLIDE
So, the real title of my talk is this – “Chronic pain in the ED”. It’s published title perhaps isn’t that far off the mark because I think this is a group of patients who really can cause us to suffer. Let’s start with a case to illustrate my point.
So, it’s a busy weekend evening in your ED and you think you’ll go and see one more patient in minors before you take a well desreved meal break. You pick up the next card “Exacerbation of Chronic Back Pain”. And before you can sneak it back into the stack the sister in charge gives you one of her looks that mean there is no way you can avoid this one. It is with a heavy heart that you approach, expecting a patient with full on ++++++++. When you get there you find a 68 year old woman, Mrs PB, who looks in considerable discomfort. She tells you she has had chronic back pain for 40 years since a RTC, where she rolled over a landrover on rural lane in Yorkshire. She’s sorry she has come to the Emergency Department, but she just needs help. There are no other new symptoms. Just pain. Lots of pain. Her old notes have already been obtained and you’re heart sinks even further. If only you’d snuck off to the coffee room – this really is the last thing you need today. You just want to get back to the real patients, with real problems, not someone wasting your time with their ridiculous drug seeking......
You ask what medicines she is on and she reveals a full on pharmacy of tablets, potions and gadgets. A dose of Zomorph that would knock out a horse, supplemented by oramorph, and benzos and others as well as a dorsal column stimulator. She tells you she lives alone, and you are already mentally booking a short stay bed and looking forward to handing her over the night team.
You do an examination, concentrating on the neurological system (you’ve just read an article about a case of missed cauda equina) and despite this being entirely normal you do a PR examination. As if the patient doesn’t have enough on her plate you stick a finger up her bum and ask her if it feels normal. I am no expert in this, but I am fairly sure this never feels “normal”. Anyway, having reassured yourself that there is nothing serious going on and hoping to turf her to your colleague, you write her up for 10 mgs of oramorph and tell the nurses rather inexplicably that you are going to wait for the blood test results. That should take just enough time to hand her over to the night team and make her someone else’s problem. OK, so let’s just pause a minute to consider patients with chronic pain, it’s definition, pathophysiology, potential treatments and how we can make this more bearable for us and our patients.
Firstly, let me just start by saying that NO PATIENT WANTS TO BE IN THE ED. It is generally not a nice place to be: we put you in a gown that barely fastens at the back, on a trolley previously used by the Spanish Inquisition, and forget about you for a few hours. My eldest son, Archie. when I ask him about what he would like to be when he grows up, has mentioned all sorts of things, but never once mentioned “I’d like to be a frequent flyer in an ED”.
And while we’re at it let’s stop using phrases like frequent flyer – these patients have not chosen to join and, as far as I can tell, get little benefit from their loyalty points. Patient’s who end up frequently attending do so because life has not gone quite as they dreamed when they were small and they are turning to us for help.
I sometimes think it helps to use a different synonym for the word “pain” and substitute instead the word “suffering”. It sounds rather different doesn’t it – “there’s a patient in pain in cubicle 10” compared to “there’s a patient who has come in who is really suffering”. I fairly sure we all want to relieve pain, but we would hate to see anyone “suffer” and not try to do something to help.
Let’s also define what chronic pain is – this is widely accepted to be pain that has lasted for three months, but to which no physical signs or abnormal tests can be attributed. It is an exceptionally common problem
this is data for New South Wales and you can see that the prevalence is almost unbelievable
and when compared to other diseases it is more common than cancer, ischaemic heart disease and diabetes – topics to which we give a huge amount of resource and attention. And yet “chronic pain” does not feature much in medical school or post graduate curriculum.
This tweet illustrating perfectly how some of these patient’s feel about the level of knowledge of the medics looking after them.
Some pain after injury is necessary – it is a hugely important adaptive mechanism that protects us from further harm and aids healing.
This diagram illustrates the pathway we learnt at med school, and gives me the opportunity to say the words “pacinian corpuscle” – surely, two of the most satisfying words in human biology. Just try saying it to yourself. Pain is transmitted from the stimulus at the pacinian corpuscle up fast small A fibres and large, slower C fibres to the thalamus, where these messages are sent off to parts of the brain and interpreted causing us to feel pain. Even at this stage the brain can control how many of these messages you feel if it isn’t in it’s best interests to feel them – imagine stepping on a drawing pin as you are being chased by a snake – you don’t feel the pain of the pin until you have reached safety.
In this case the cognitive processing is helpful, but in patients with chronic pain these mechanisms have gone awry and the messages are amplified inappropriately. The system simply fails to wind down and the signals actually become amplified. Let’s be very clear about this – the patient is feeling pain. This is subconscious and not under their control – they’re not making it up. It is in their head, but it isn’t in their head if you see what I mean.
There are several predisposing factors that make patients more likely to continue to feel pain long after healing has taken place. These are almost inevitably tragic – the patient in front of you really has suffered in the past and is continuing to do so. You will hear stories of terrible abuse and emotional neglect. As we saw in those previous slides it is also more common in women, perhaps due to the effect of oestrogen on dopaminergic receptors. Importantly we can inadvertently also predispose patients to chronic pain if we are not careful in the way we explain the likely prognosis –
if the patient becomes anxious about their recovery from acute injury and has some of these elements in their psychological make up a failure on our part to reassure them may cause further long term damage. The tendancy to develop chronic pain can be seen after just a few days and is firmly embedded after only two weeks if we are not careful what we say to patients after acute injury. This is where the neurobiology gets even more complicated and if I’m honest, way beyond me and thankfully what we need to know to look after these patients well. Reading up for this talk has reminded me just how incredible the human body and in particular the brain is. Just take a minute sometime to pause to think about everything that it does. The senses – even that’s not as straightforward as we were ever lead to believe, and then there’s emotion, language, desire. All sorted out by this most amazing thing in a bony box on top of your body.
Part of our worry sometimes is that these patients can be consciously fabricating their pain in a desire to get us to provide then with drugs, usually opiates. These patients should be relatively easy to spot – inconsistent history and examination, refuses tests, or say that they have already been done, yet the results are not available and insists on one particular treatment. I want to reenfornce that the patient with chronic pain is not malingering or “making it up”.
So these patients with chronic pain truly are suffering, and often have been for years, often on the background of severe psychological stress, so what can we possible do to help in their hour of need when they turn to us in desperation? Hopefully, by now I have convinced you that we need to take this seriously and not just right then off as soft collar, sunglass wearing nuts. They are even some highly successful people who continue to work and lead very full lives despite chronic pain.
I’m sure many of you will recognise this man, here in his younger Navy days. PAUSE John F Kennedy had a multitude of illnesses including chronic back pain, which was probably as a result of minor sports injury earlier in life. He was plagued by pain almost daily, sometimes using crutches and , like many patients with chronic pain, pain seemed to get worse at times of stress since as during the Cuban Missile Crisis. Like lots of chronic pain patients, then and since, he was given concoctions of medications and was seen by a physician Max Jacobson “Dr Feelgood” who gave him injections of who knows what, which when asked about it, JFK stated – “I don’t care if it’s horsepiss it works”. Despite being in constant pain he only missed one of his thousand days as president and that was because of tonsillitis. There’s even a theory that chronic pain played some part in his assassination – on that day in Dallas he was wearing a back brace – after the first shot hit him in the neck, instead of reflexley falling forward he was held sitting up allowing the second fatal shot to hit him in the back of the head. You could say that chronic pain killed JFK.... Hopefully, by now, I am somewhat destroying some of the prejudices you may have had towards these patients with chronic pain – not only is their suffering real, but it with desire and determination it need not limit them achieving very full and active lives.
So what can we do when these patients who may have been suffering for years turn to us in their hour of need. The most important thing is perhaps to listen. To show empathy and understanding, just as you would with any other patient. Only once this is done can you start to make a plan, not just for this attendance, but also for future pain exacerbations. It’s very important not to just take the easy way out and give lots of opiates as this often won’t work and merely reinforces illness behaviours that may not be helpful for the future. Give their usual medications and then start to make a plan for the future. We are very lucky to have an excellent relationship with our chronic pain clinic and we work hard to make care plans for future attendances.
These straightforward step by step guides which are agreed with the patient, their GP and others print out automatically when the patient books in and can then be followed by whichever doctor sees them. This is a plan we have for one of our patients. This prevents unnecessary testing and inappropriate prescribing and immediately reduces stress levels for all concerned. Sometimes this will include giving boluses of opiates, but usual to a ceiling dose.
This method has been studied and been shown to reduce repeat attendances. It can be incredibly labour intense and is often difficult to involve all the parties necessary, but it is time well invested and we are just about to start a randomised controlled trial in Southampton with care planning as the intervention, looking at the time involved to set up each plan and any potential reduction in attendances as well as looking at other quality metrics for patient care, including patient satisfaction.
Looking after chronic pain patients isn’t that sexy, but can be surprisingly satisfying. Let us for a minute go back and consider Mrs PB who we started seeing earlier. So during your meal break you listened to this lecture on the SMACC podcast and decided to go back and see PB with fresh eyes. You go and sit with her and ask about how she is feeling and how she has been recently. You discover that today is the anniversary of her husband’s death and that she has two sons who both live away who she misses a lot. They do what they can, but have their own families now. Ever since they left home 20 years ago she has struggled to find her place in society and feels lost and without purpose. She tells you she was bullied at school and has suffered from low self esteem ever since. You listen and show empathy saying you are genuinely sorry that she is suffering and you want to do what you can to help. You explain that you can give a little extra of her normal medication, but that it is unlikely that this will make a big difference but you promise to contact her GP and her chronic pain consultant to let them know that she is struggling and to discuss a care plan for if she ever needs to come to the ED again. As you are talking she tells you more and more about her sons, who she is clearly very proud of, perhaps even slightly pathologically so. There are both very busy and their careers have taken them far away from their childhood home - One is a successful musician and one is a doctor: a consultant in Emergency Medicine. One of her sons is, in fact me, because Mrs PB is my Mum.
So although this talk may not be as sexy as many of the others you will hear over the next few days, I truly hope it has been just as valuable. I hope that you will remember that these patients are suffering and as their doctor you should see them without prejudice and try to help. That they are truly feeling pain, and although it is in their head it is subconsciously so and the pain they are feeling is real. The mechanism behind their pain is different to that of acute pain so our usual medication may not work. Often they just need someone to listen, but also to help them make plans for how they will cope when things get bad.
And that most of all, these patients have families who will be incredibly grateful when you do all you can to help the ones they love.
Beardsell - Pain and Suffering in the ED
Pain & Suffering in the ED
Iain Beardsell (@docib)
Consultant in Emergency Medicine
University Hospital Southampton
Associate Editor (Social Media) EMJ