Posted by: medicblog999 | May 3, 2009

Another analgesia conundrum.

550px-who_analgesic_ladderThere seems to have been a little discussion about the management of acute pain recently, on both mine and a good few others blogs. Its a topic that keeps rearing its head and Im sure that it will keep coming up for a long time to come. For those who don’t know about it, the image to the left is the analgesic ladder, this gives a framework to prescribe and administer appropriate analgesia and adjunct medication to best relieve someones pain without over medicating them. It is a concept that has been around for a good few years, has limited use in the pre-hospital setting due to the length of time we have a patient with us, but still is very useful when considering the “right type of analgesia”.
Pain management is something that is so subjective both for the patient and the clinician, that it results in many different health care providers having a variety of different views on what is the right way and the wrong way to manage someones pain. Its difficult to say what is the right way to provide the right type of analgesia in the right dose within the pre-hospital environment. I assume we all have our own “rules” that we go by, and ultimately, I guess that we all have to be happy that the choices we make are in the best interests of the patient and are based on sound clinical rationale and a thorough understanding of the pharmakokinetics of the analgesia that we have access to.

To demonstrate this point, here is a job I did this week that had me thinking about “the right” thing to do. 
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I was working on the rapid response car when I was dispatched to a 87 yr old man at a local nursing home who had fallen over and possibly hurt his leg.
As I arrived on scene, I was met by a carer and shown to the patient who was now sitting in the lounge in a chair. As we walked over to him I was informed that he had severe dementia and is either unable to communicate or just didn’t communicate and hadn’t done so for quite some time.

As I approached him, I introduced myself and asked him how he was. 

Carer: “There’s no point in talking to him, he wont answer you”

M999: “That might be the case, but it doesn’t hurt to be polite and he may understand what I am saying to him”

He appeared in pain, he looked upset and was crying a little. The staff state that he is usually a little emotional, but this was completely out of character for him. He kept rubbing his right thigh and seemed to grimace a couple of times when he tried to move his leg. Due to the position he was sitting in, it was impossible to check for shortening or rotation of the leg (a check which when present points to a diagnosis of a fractured neck of femur – broken hip), but the leg did seem to be slightly externally rotated.

Nows the time to decide what, if anything, I need to give him for the pain. I cannot actually ask if he has pain, I cant get a pain score or ascertain where the pain or if it radiates anywhere. My decision this time is based on the patients presentation and guidance from his carers about what his general demeanour is like compared to normal.

I decide that the likelihood is that he appears in pain and therefore it is my duty of care to him to try and relieve some of that discomfort. I place a cannula and get out the Morphine again. After checking his blood pressure and that he is not on any medication that will react with the Morphine, I give him 3mg IV.

After a few minutes, my back up crew arrive. Luckily this crew seem to have the same ethos on pain management as I, and seem pleased that I have already started on something so that we can think about moving him as soon as he appears a little more comfortable. I give a further 2mg and wait for a few minutes for the effect. He seems to relax a little and we take the opportunity to get him on the stretcher where it becomes apparent that his femur is most probably fractured.

Once on the back of the ambulance, the crew give him some more Morphine which now seems to be really hitting the spot and he visibly appears more relaxed and at ease.I go back into the home to gather my equipment to put back in the car, hand over my documentation to the crew and clear for the next job.

What I would like to know, from all of you lovely people out there, is your views on giving strong painkillers to patients with advanced dementia/Alzheimer’s. My belief, is that whatever concurrent conditions that a patient may have,  if they appear in pain, then that is enough to start considering appropriate analgesia. In all honesty, I wish we had something to fit in the middle of paracetamol/ibuprofen and Morphine. It would be helpful to have the full range of options from the analgesic ladder in some circumstances.

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Responses

  1. As you don’t know if he is aware of the pain and just cant communicate, it then I would say morally you acted in the right way to relieve any possible pain.

  2. I tend to be fairly conservative in the giving of pain meds. This is for a two-fold reason; 1) MS is post radio contact w/ Med Control (ER physician), and they tend to be conservative, 2) MS is all I have, and that can be an awful big stick w/ some not so swell side effects.

    I also tend to ask my pt’s what they would like to do (I know that this wouldn’t work in this case). I explain all that I have is MS, and that the ER has a broad range of meds that they can use, and the MS side effects. At that point the ball is in their court as to have the meds or not.

    Now, w/ that being said, I would give meds in this case for sure. It seems plainly obvious that the pt was in distress. I don’t see any reason for someone to be in pain if I can safely alleviate it, no matter their mental status.

    I wish we could get something besides MS for pain. There is talk of Fentanyl (which is also a big stick, but w/ less side effects), but no time frame has been specified.

  3. Our protocol states “Patient does not appear altered” which gives us a bit of a grey area on something like this. He’s altered compared to you and me, but not compared to his normal presentation.

    Tough spot on this one, but the right call.

    I too wish we had something besides MS in my system. I think as soon as a Doc has a field injury needing meds we’ll get better options.

  4. My father had multi-infarct dementia. This had reached an advanced stage when he developed gangrene in one toe (long story, not relevant here!). Amputation was not an option (the anaesthetic would have killed him). For several weeks, he did not seem to be aware of any problem, and consequently received no analgesia.

    When he did show signs of distress, he was very promptly prescribed Oromorph, and was then pain-free. The respiratory suppression led to pneumonia, from which he died a week later.

    The decisions were made by the family, the care home staff and his GP, rather than by ambulance staff, but I think the same principles apply anyway.

    Were the right decisions made? – Absolutely! Would I change our decisions? – Absolutely not, even though we knew that pneumonia was a likely complication

    I believe that you were right to give pain relief to your patient. Just because a patient is unable to communicate with you does not mean it is ok for them to be in pain which you can relieve! (Slightly off-topic, but how do vets make their decisions when animals are in pain?)

  5. My father has severe Alzheimer’s dementia. He would not be able to tell you if he was in pain or how much pain he was in. I would rather he have adequate pain killers than too little.

  6. Good call medic 999. Pain in people with dementia is under recognised and undertreated particularly if the person can’t tell they’re in pain. You were treating the person and made your decision based on your clinical assessment.


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