Algorithm for treatment of acute pain in children in A&E

Emergency Medicine : Basics to Pain Managment

Overcoming  Pain KNOW ABOUT THE PAIN
Pain assessment
Physiology of pain transmission (nociception)
Pharmacologic approaches
Use of analgesics, multimodal-balanced analgesia
Management of side effects and complications
Use and interpretation of monitoring modalities
Use of analgesic devices and catheters
Nonpharmacologic approaches
Role of pain management in multimodal, comprehensive rehabilitation
Patient and family education

Prevention of pain should be the hallmark of any type of medical or surgical  interventions. Appropriate analgesics should be administered whenever possible.
This requires regular and systematic assessment and evaluation of the processes of care and measurement of outcomes using validated instruments for data collection. Some of the identified  aims for pain managment are as follows:
1.Timely—delivered to the right patient at the right time.
2.Patient-centered—based on the goals and preferences of the patient and the family.
3.Beneficial and/or effective—demonstrably influencing important patient    outcomes or processes of care linked to desirable outcomes. 
 4.Accessible and equitable—available to all who are in need and who could benefit.  

 

  5. Knowledge- and evidence-based.
  6.  Efficient and designed to meet the actual needs of the patient and not wasteful of resources.

Emergency Medicine: Barriers to Effective Pain Management

Entrenched beliefs and practices that interfere with optimal pain treatment abound and often are attributed to the following three origins: the patient, the health-care team, and the health-care system. Among the most common obstacles to overcome are a failure to assess and acknowledge the existence of pain, outdated prescribing habits, inadequate quality improvement monitoring, and a lack of accountability for unsatisfactory outcomes related to poorly managed pain. Clinician-related barriers, including knowledge deficits regarding pain assessment and management principles, personal and cultural bias, and communication difficulties between the patient and the health-care team, contribute considerably to suboptimal pain management in the hospital.

Structured Approaches to Pain Management in the ICU

Table 1

Evidence of Pain Management Barriers in Acute Care Settings

Barrier	Description
Knowledge and other deficits	inadequate pain assessment knowledge
	Failure to accept pain as an inevitable part of the disease process and considering pain as an important stimulus for coughing and deep breathing
	Lack of a standardized objective pain assessment for patients who are critically ill and noncommunicative
	Available pain assessments generate single pain score that lacks meaning in relation to treatment goals
	Lack of knowledge related to the pharmacological effects of opioids and nonopioid analgesics.
	Physicians' reluctance to prescribe appropriate and adequate analgesics; nurses administer less than prescribed opioid analgesics because of fears of respiratory depression, sedation, and addiction
	Decision process about pain intervention challenged by the need to optimize patients' hemodynamic and respiratory conditions, to collaborate with medical plan of care, and to act according to patient and family preferences.
	Analgesic interventions influenced by patients' behavioral cues or physiological status despite presence of self-reported pain.
	Inappropriate analgesic prescription by physicians and reluctance to use adjuvant therapy to manage pain
	Inflexible analgesic schedule and minimal use of nonpharmacologic interventions
Personal and cultural bias	Stereotyping or bias based on patients' demographic characteristics
	Preconceived notion about a patient's pain in relation to the type of surgery, number of days after surgery, ventilatory status, and the patient's pattern of analgesic use
	Nurse willingness to spend maximum time and energy to care for patients with cancer and AIDS who are in pain but less willing to spend maximum time and energy to care for patients who attempt suicide or abuse drugs
	Medical-surgical nurses indicating that they would give fewer analgesics to patients who were engaging in socially unacceptable behavior at the time of injury.
	Physicians who treat pain in women and minorities less aggressively than other populations.
	Men and younger cardiac surgery patients receive more analgesics than women or older patients.
	African American patients less likely to receive analgesics than white patients in emergency departments .
Communication difficulties	Communication difficulties identified as the number-one barrier to pain management in older surgical patients.
	Issues with caring for minority patients, including language barriers, lack of pain measurement tools in various languages, and missing patient cues of pain because of unfamiliarity with minority patients' pain expressions and behavioral responses.
	Disagreement between physicians and nurses on pain management plan.
	Miscommunication between physicians and nurses when evaluating the patient's pain .

Source: CHEST June 2009 vol. 135 no.6 1665-1672

Emergency Medicine:Basic Medico-legal Consideration( PARt I)

 

The medical and legal aspect of emergency care is unique and quite complicated. Emergency Physician should be knowledgeable and competent enough to use their skills in a consistent manner with the highest possible ethical standards of the medical practice. Concern for the injured or dying person should be upmost in their thinking. They should act to preserve life and prevent death. Unfortunately, fear of potential legal liability deters some physicians from acting decisively. This article is trying to put the basics of physicians’ right and duties, together to avoid medico-legal problems and to satisfy legal obligation.

This write-up   sets forth the General Legal Perspective regarding emergency care in three different situation,1) outside the health facility, 2) the emergency department  situation and 3) emergency in practice situation. The rights and duties of a physician vary in different situation.  Physicians must understand the Legal Status of patient in evaluating rights and duties in the emergency setting. Next Section deals with responsibility of emergency care physician.

GENERAL PRINCIPLE

Legal obligations generally commence at the beginning of the physician -patient and hospital- patient relationship. In general, physician do not have legal obligation to provide medical care to every person seeking or in need of such care.

The law has regarded the relationship between physician and patient as a voluntary relationship in which both parties freely agree to participate. Emergency Setting bears exceptions of this general principle. 

In a situation, when  an injured patient needs emergency medical care outside of a health care facility, although physician generally have an ethical obligation to provide medical care, but do not have a legal obligation to do so. In the Emergency Department Situation, courts have generally held that a health care facility that operates an emergency department has a legal obligation to provide care to those people who came to the facility with an identifiable emergency and are relying upon implied offer of emergency care. The third situation, emergency in practice, in which a patient who is already receiving medical care becomes in need of emergency medical care, physician-patient relationship existed before the emergency. Therefore legal obligations had already placed.

Once the relationship is established, physicians have a legal obligation to provide an acceptable quality of medical care. In general physician is expected to do what a reasonable physician would do in the same or similar circumstances. It is standard of ordinary and customary practice that is deeply rooted in the standards of medical community (Malpractice system approach).

 Legal Status of Patient:

 The informed competent and voluntary consent of patients before treatment is provided. Consent implies the mechanism by which patients vindicate their right to self determination and participate in health care decision. There are two standards of consent are in practice. First, the traditonal standard is borrowed from malpractice system. A physician is expected to disclose to a patient what a reasonable physician would disclose in the same and similar circumstances. In other words, it is determined by medical community. It includes, nature of medical condition, the treatment proposed, risks of the procedure, possible side effects, and alternative procedure (if any) and their risk and side effects. After evaluating this information, the patient is free to refuse and accept treatment.

 In second least practiced modern standard shifts focus from the physician to the patient. It requires that a physician disclose what a reasonable patient would need to know to make an intelligent decision concerning treatment.  This includes all the above mentioned with traditional consent in terms of “significant “.

In emergency medicine situation, to take consent is dificult. Often steps must be taken quickly to preserve life, to stabiles a dangerous condition, or to prevent possible deterioration.

 Some basic principles are as follows:

 1. The consent of adult of sound mind should be sought, and their refusal to accept treatment should generally be respected.

  2.People who have been declared legally incompetent or who are, in fact, incompetent  without formal legal recognition of the incompetence, the ability of the individual victim to have or to express a preference for treatment  or no treatment is either suspect or clearly not present. If an adult is rendered incompetent and a life threatening emergency exists and neither the patient nor the person with legal authority to consent is in position to give consent, the emergency physician should imply the consent and provide the treatment. Law generally permits that is, to   assume that if the patient were competent she or he would prefer treatment to non treatment.

 3. In the case of minors, mentally ill people, or mentally retarded people, a parent or legal guardian is generally appointed by the court. If such a person is available, his or her consent should be obtained. In life threatening situation, and such a person is not available, the physician should imply the necessary consent and proceed the treatment.

TO NOTE, UNAVAILABILITY OF A CONSENTING PERSON SHOULD NOT BE AN EXCUSE FOR ALLOWING A TREATABLE PATIENT TO SUFFER AN AVOIDABLE DEATH.  

  Next Blog: Emergency Medicine: Basic Medico-legal Consideration (PART II) responsibility of emergency care physician