Prehospital Pain Control

“We must all die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself.’’   – Albert Schweitzer

It has been observed that pain is part of the presenting symptoms of up to 70% of all EMS patients. One study has even suggested that over 20% of EMS patients are experiencing severe to extreme levels of pain. As EMS providers, it is our duty to routinely recognize and aggressively treat our patients’ pain as it is one of the biggest things we fight against in our professional practice.

In the not-too-distant past, pain was not aggressively treated by EMS. This was partially due to lack of training on the part of responders but was also due to a lack of availability of proper measures for pain control. Since then, more medications have been made available for field use and more medical directors have become open to the prospect of allowing providers to aggressively treat pain. Quite a few respected national organizations have weighed in on the subject and it continues to gather a lot of attention. Prehospital pain control is a complex issue with many factors to consider on all levels of the EMS spectrum. Field providers need the tools to effectively manage their patient’s pain as well as the education to recognize and treat it; medical directors need to provide these tools and education to their field providers in a way that allows them to trust their use of them; and our overall attitudes towards pain control need to be changed. Large national studies have shown that rates of pain control measures taken in differing patient populations decrease on some disappointing criteria, including gender and patient income level. While numbers specifically reflecting our area are hard to come by, it can be assumed that our area may loosely follow the wider trends.

The old adage “Pain never killed anybody” used to be thrown around by some people in healthcare. To them it means that any pain patients may suffer in the name of their more expedient care is reasonable.  I disagree. Patients may not die due to severe pain but it has lasting effects upon a person’s long-term physical and psychological health. Pain is what our bodies use to teach us lessons on how to avoid noxious stimuli and dangerous injuries. By its very nature, pain makes a lasting impression on us. We need to accept that our patients have more pain than we may realize or expect that they do and provide aggressive and adequate relief for them. While assessing pain is difficult, accepting that people tend to have individualized perceptions of and reactions to pain is important for prehospital providers. It is not acceptable for a healthcare provider to judge a patient’s pain based upon their own personal opinion of how they themselves would tolerate it.

In our contemporary EMS toolbox we have a number of methods for achieving analgesia, which is the control of pain without causing a loss of consciousness. Analgesia can be achieved by many methods available in the field. While paramedics have medications such as Fentanyl, Dilaudid, Morphine, Ketamine, and Versed available to administer to patients, all levels of EMS providers have effective pain management tools. Proper splinting and patient packaging techniques, ice and/or heat packs, padding and elevating extremities, and even techniques such as guided imagery, breathing exercises, and psychological support have been shown to achieve pain control. It is always a good idea to use a range of techniques when managing a patient in severe pain in order to achieve good control and not just to rely on one technique or medication. For example, no narcotic in any amount will completely control the pain of a badly fractured and angulated extremity if the extremity is allowed to move freely or is improperly splinted. The combination of the splint and the medication must be used in tandem. Paramedics must consider the use of medications together for severe pain, such as by combining a narcotic with a sedative such as a benzodiazepine or Ketamine. While benzodiazepines (Versed, Valium, Ativan, etc) and/or Ketamine do not provide analgesia in of themselves, they work in conjunction with pain medications to potentiate the effect and maximize pain control. Ketamine can also be used to achieve “dissociative analgesia” in higher doses, where the patient’s level of consciousness is decreased to the point where they are no longer conscious of the pain they are experiencing.

Selecting the proper technique or medication for each patient is not always an easy task as no method is a one-size solution. However, it is obvious that fractures should be splinted and supported as appropriate and that patients should be packaged in a position of comfort. For patients requiring spinal immobilization, padding voids on the backboard is appropriate as is the use of a Back-Raft or other approved backboard padding device. Offer ice or heat packs to patients with musculoskeletal injuries and be sure to keep patients warm during care. Talk to them about their pain and provide psychological first-aid as you are able. BLS and ILS providers may consider calling for an ALS intercept for pain control medications in some cases as appropriate.

For ALS providers, choosing the right medication is not always an easy choice. Having knowledge of the characteristics of each medication you carry makes it easier to utilize clinical judgment. Fentanyl is a popular choice for prehospital pain control as it is fast-acting and has a shorter time of duration than other pain medications. Fentanyl also has less risk of hemodynamic instability when compared to other narcotics. Dilaudid, another option in our toolbox is a longer-lasting pain med that is good for patients with chronic breakthrough pain, or for patients with obviously fractured extremities. There is little risk in the prehospital setting of developing dependence in your patients with episodic use of narcotic analgesia for acute pain control.

Perhaps the biggest part of the job of every healthcare provider is alleviate the suffering of the sick and injured and a lot of that is reducing physical pain. Be proactive and aggressive in managing pain for your patient and become comfortable taking with your patients about their pain. We may not be able to eliminate all pain in the prehospital setting, but we can make a big difference in making this world a less painful place.