SUCCESS AND SAFETY OF A PATIENT TITRATED

EMERGENCY ROOM ACUTE PAIN PROTOCOL

Edward Gentile MD

Queen of the Valley Hospital

2006

The ER is Quiet

Once a physician selects the protocol for a particular patient, the nurses can administer and titrate doses of pain medicine to the satisfaction of each individual patient without any further physician involvement. The nurses do all the work. The ER is quiet.

20th Century Oligoanalgesia made me feel sad

• Women and children are under treated• Elderly and minorities are under treated• Large people are under treated• There is no correlation between the doctors nurses and

patients perception of pain.• Papers made me feel frustrated and embarrassed.

They imply problems but don’t pose any solutions.

Visual analog scale poses paradigm shift

The new gold standard of effective analgesia is the patients perception of pain instead of the doctors perception of pain.

The 20th century provided a new gold standard but no methods.

How can we improve? Even our trusted Rosen is vague: after 35 pages of hand-wringing about how NOT to treat pain; WE FINALLY GET TWO USEFUL SENTENCES:

1. “Titrated opioid analgesics should be the mainstay of ED therapy of moderate to severe pain,” and,

2. “For the majority of opioid indications in the ED, morphine is a suitable agent”.

Barriers to Effective Analgesia in the ER

There are many barriers to effective analgesia in the ER: technical barriers, communication barriers and cultural barriers among them. I'll tell you how we treat acute pain, how to make acute pain management simple, safe cheap, and fun.

WE TREAT PAIN (“WTP”) ER PAIN PROTOCOLS

• PROTOCOL M for moderate or severe pain in patients less than 55 years old– First dose: 0.1 mg/kg morphine sulfate IV and 0.5 mg/kg of

diphenhydramine IV.– Second dose: 0.05mg/kg morphine sulfate IV; 7 minutes after

'first dose' ask patient "would you like more pain medicine?" – Third dose: 0.05mg/kg morphine sulfate IV; 7 minutes after

"second dose.'– Repeat until patient states "I have no pain," or "I don't want any

more pain medicine," or patient is asleep.

PROTOCOL M for moderate or severe pain in patients 55 or older

• First dose: 0.05 mg/kg morphine sulfate IV and 0.5 mg/kg of diphenhydramine IV.

• Second dose: 0.05mg/kg morphine sulfate IV ; 7 minutes after first dose, ask patient "would you like more pain medicine?".

• Third dose: 0.05mg/kg morphine sulfate IV; 7 minutes after second dose.

• Repeat until patient states "I have no pain," or "I don't want any more pain medicine," or patient is asleep.

PROTOCOL IS BASED ON WEIGHT

The first thing to notice about the protocol is that all dosing is based on weight. Weight- based dosing allows us to apply the protocol to a broad group of patients. 10kg, 50kg, 150kg, and 200kg patients all receive a first dose of pain medicine that they can feel. When the nurse gets to step two of the protocol and asks, "Would you like more pain medicine?", most patients say “Yes,” some decline, but so far no patient has responded, "What pain medicine?" because they all felt the first dose.

PROTOCOL DEPENDS ON TITRATION

We anticipate that the first dose of morphine 0.1mg/kg will not satisfy every patient. Some patients may require 0.2 or 0.3 mg/kg to achieve a similar effect. We are willing to customize the dose for each individual patient. We plan to find the ideal dose of analgesia in one to four big steps, not seventeen baby steps.

PROTOCOL UTILIZES MORPHINE

We selected morphine because it has the longest half-life. Shorter half-life drugs could be useful if there were any short acting painful conditions. There are no brief painful conditions. A recently relocated shoulder feels better than a dislocated shoulder; but it doesn't feel as good as the other shoulder.

PROTOCOL UTILIZES BENADRYL

Most anti-emetic drugs have antihistamine properties. Many of the unpleasant side -effects of morphine (nausea, vomiting, hypotension, irrational fear of hypotension) could be obviated by pretreatment with this useful adjunctive agent. We like benadryl because there is no dystonic reaction and no akisthesia, it is cheap and no one is allergic to benadryl.

We call it “Pain medicine”

• The word morphine scares some people• Morphine does not mean dying of cancer, drug

addict or war trauma• Pain medicine is a useful euphemism for

morphine

PROTOCOL ASKS A SIMPLE QUESTION

"WOULD YOU LIKE MORE PAIN MEDICINE?” is so simple. It is like a waiter offering you a coffee refill in a restaurant; patients answer without deliberation. This question penetrates the fog of many patients and nurses’ perceptions, fears and judgments. Ask a simple question if you want a simple answer. Anyone can answer with a simple “yes,” or “no,” regardless of their cultural

baggage.

PROTOCOL TITRATED BY PATIENTS

Doctors have some idea how the patients are feeling, nurses have a better idea how the patients are feeling, but only patients know exactly how they are feeling. Our protocol optimizes analgesia for the patients. The brains connected to the pain receptors decide how much pain medicine is optimal

PROTOCOL EXECUTED BY NURSES

Nurses administer the drugs, nurses know when 7 minutes have elapsed, nurses are asked by family members, "Can't you do something?", and nurses do all the work. Doctors choose which patients receive the protocol, and nurses take care of the rest. Life as it should be.

PROTOCOL IS FUN AND SAFE

• I have ordered this protocol approximately 1,932 times over the period 1999-2006. I really know its fun and safe

• I have gone surfing about 1200 times, (fun and safe, hurt ear once),

• I played the saxophone about 1350 times (fun and safe, but painful for neighbors)

• I drove to work 2,160 times (pretty safe, one speeding ticket)

Hospital Map 1

Hospital Map 2

How to start the protocol at your hospital

Administer the protocol yourself

• Start with extremely painful conditions that have objective diagnostic criteria

• Pancreatitis and hip fracture are never mild pain• Lipase and plain x-ray are objective tests

Play with the protocol Get comfortable

• Give 17 mg of morphine over 30 minutes to a big 70 year old with a broken hip; then send him to x-ray smiling without a nurse or monitor

• Give a 14 mg bolus to a fat man with gallstones before ultrasound clinches the diagnosis. It feels good.

• Carry narcan in your pocket if you feel nervous.

LET GO OF EGO DEFENSES

• No more blame patient

• No more blame God• No more “patient is

different than me”• Pain is not my job

• I’m too busy• It’s too

complicated• It’s too risky

USING PROTOCOL FEELS GOOD

• Do you like what I like?

• It’s OK to be skeptical

• It’s not quite as good as sex but it is astonishingly refreshing

Build coalition with doctors

Circulate memo “Hey guys, the new PI project this year is going to be “starting an acute pain management protocol.” Use of the protocol will be entirely at the discretion of the treating physician. It seems like a timely issue now that the state is forcing 15 hours of mandatory study down our throats. If you have any ideas for creation of the protocol, please write or tell me or Paul.”.

Modify Protocol

• Hope to get few written responses• Include their ideas where practical• Remember our idea is the right idea• Identify likeminded doctors• Build coalition

Send out doctors guide

• Pretend there is a consensus• Educate the doctors by deception• Pretend the purpose of the guide is to provide

uniformity in addressing the nurses fears about the new protocol

Pass protocol through committees

• Emergency medicine• Medical executive committee• Avoid anesthesia• Avoid pain committee

Coalition with Pharmacy

• We ran out of morphine

• We ran out of benadryl

In-Service Nurses

• Print buttons with catchy slogan• “We Treat Pain” or your own• Pass out Nurses guide • Cme prizes caterer and live band

OVERCOME BARRIERS

• Technical barriers----use protocol• Communication barrier---”would you like more

pain medicine• Psychological barriers—look inward let go of old

ego defenses. Help other team members release theirs

MAINTENANCE

• INSERVICE NEW PEOPLE

• Say “13 mg wow it doesn’t even look like the same patient”

• “17 mg I want you to be my nurse when I get sick”

• “Did you save anyone today..treat pain?”

20th Century Slogan

Commit random acts of kindness and senseless acts of grace and beauty

21st Century Slogan

Commit systematic acts of kindness and sensible acts of grace and beauty