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Abstract

  1. Top of page
  2. Abstract
  3. Curriculum Objectives
  4. Conclusions
  5. References
  6. Supporting Information

ACADEMIC EMERGENCY MEDICINE 2011; 18:S87–S91 © 2011 by the Society for Academic Emergency Medicine

Abstract

Pain is the most common reason people visit emergency departments (EDs); this implies that emergency physicians (EPs) should be experts in managing acute painful conditions. The current trend in the literature, however, demonstrates that EPs possess inadequate knowledge and lack formal training in acute pain management. The purpose of this article is to create a formal educational curriculum that would assist emergency medicine (EM) residents in proper assessment and treatment of acute pain, as well as in providing a solid theoretical and practical knowledge base for managing acute pain in the ED. The authors propose a series of lectures, case-oriented study groups, practical small group sessions, and class-specific didactics with the goal of enhancing the theoretical and practical knowledge of acute pain management in the ED.

Pain is the most common reason patients seek care in the emergency department (ED).1 Emergency physicians (EPs) need to be well versed in its management, particularly in dealing with acute pain.2 However, the state of pain management in the ED is disturbing: EPs often do not provide adequate analgesia to their patients, do not meet patients’ expectations in treating their pain, and struggle to change their habits regarding the use of opioid analgesics.3,4 Todd and colleagues5 in the Pain and Emergency Medicine Initiative Multicenter Study demonstrated that 60% of ED patients who received analgesics did so only after lengthy delays (median = 90 minutes; range = 0 to 962 minutes), and 74% of patients were discharged in moderate to severe pain.

One of the biggest problems contributing to undertreatment of pain in the ED is the inadequate knowledge of acute pain management in practicing EPs.6 Factors contributing to poor practical knowledge include a lack of formal teaching of pain management in medical schools and residency programs,6 a reluctance of established physicians to change their practice patterns,7–9 and a prejudice toward the use of opioid analgesics in the ED.10,11 Several studies have demonstrated that a brief educational initiative on acute pain can greatly improve overall assessment and management of painful conditions in the ED.12,13 The purpose of this article is to create a formal educational curriculum that would assist emergency medicine (EM) residents in proper assessment and treatment of acute pain, as well as in providing a solid theoretical and practical knowledge base for managing acute pain in the ED. To the authors’ knowledge, this is the first attempt to create a formal educational tool that might assist in overall improvement in acute pain management.

Curriculum Objectives

  1. Top of page
  2. Abstract
  3. Curriculum Objectives
  4. Conclusions
  5. References
  6. Supporting Information

Upon completion of the curriculum, the audience (EM residents, EPs, and medical students) will be able to: 1) review the pathophysiology and pharmacology of acute pain; 2) discuss current problems and barriers of acute pain management in the ED, including issues of “oligoanalgesia” and “opiophobia”; 3) describe the techniques of local and regional anesthesia and pharmacology of local/topical anesthetics; and 4) identify aberrant drug-related behavior in the ED and describe the ways to improve understanding and care for such patients.

Audience

The curriculum is primarily designed for EM residents. A secondary audience will include EPs, medical students, nurses, and physician assistants

Curriculum Description (Table 1)

Table 1.    Curriculum Content
 Week
1234
  1. NSAIDs = non steroidal anti-inflammatory drugs; PNS = peripheral nervous system.

Key conceptsFour distinct processes are indentified in the whole experience of pain: transduction, transmission, modulation, and perception. Coadministration of NSAIDs and opioids is more effective for severe pain, with an opioid sparing effect and reduction of adverse effects. Episodes of acute low back pain are common and usually self-limiting, with 10% failing to resolve over 6 weeks. A pragmatic, evidence-based approach to management of acute lower back pain consists of triad of analgesia, activation, and assurance.Opioid pharmacodynamics and dosing varies wildly between patients and that necessitates titration of dose to effect and close observation. Patient’s self-report of pain intensity is a key guide to management and must be documented using appropriate tools and scales. The state of pain management in the ED is disturbing: EPs often do not provide adequate analgesia to their patients, do not meet their expectations in treating pain, and struggle to change their habits regarding the use of opioid analgesics. The administration of intravenous opioids to adult ED patients with acute abdominal pain safely provides analgesia without impairing clinically important diagnostic accuracy.Local anesthetics reversibly block nerve transmission and can lead to cardiotoxicity, neurotoxicity, and anaphylaxis. Pain relief with nerve blockade results in better pain relief and fewer side effects compared to opioid analgesia. Regional anesthesia supplements enteral and parenteral analgesia and provides effective pain relief with fewer side effects. The scores generated by Pain Scales lack meaning and offer no direction for decision-making. The concept of an analgesic ceiling is often disregarded in the treatment of pain. This is commonly observed with the use of NSAIDs, acetaminophen, and opioids. The optimum dose of intravenous opioid analgesics should be based on titration until pain is optimized (relieved), or side effects become intolerable.A collaborative multidisciplinary approach is needed for the assessment and management of patients with aberrant drug- related behavior.
Lectures and objectivesAcute pain: from periphery to the brain Objectives:Opioid use in the ED Objectives:Local anesthetic in the ED Objectives:Aberrant drug-related behavior and acute pain in the ED Objectives:
Describe the definition and classification of pain. Identify the parts of the peripheral nervous system/central nervous system responsible for pain recognition, transformation, and modulation. Discuss the common pathways of pain transmission from periphery to the cortex and vice versa.Identify the barriers to successful opioids use in the ED: provider and patient’s prospective. Describe the causes of underuse of opioids. Discuss the necessary steps for improving the use of opioid analgesia in the ED.Describe commonly used local and topical anesthetics in the ED. Discuss the pharmacology of commonly used local anesthetics. Discuss the pharmacology of commonly used topical anesthetics.Discuss the common characteristics of the prescription drug abuser. Teach the definitions of tolerance, addiction, and physical dependence. Identify common aberrant drug- related behavior in the ED.
Pharmacology of acute pain in the ED Objectives:Pain assessment in the ED Objectives:Facial/dental blocks in the ED Objectives:Addiction and acute pain management in the ED Objectives:
Brief overview of the common classes of analgesics used in the ED. Description of mechanism of action and common side effects of the classes. Discussion of proper dosing and drug interactions in the ED.Discuss the key points of successful use of pain scales in the ED. Describe the commonly used pain scales in the ED. Identify the shortcomings of pain scales in the ED.Describe basic and advanced facial and scalp blocks in the ED. Discuss potential side effects and technical pitfalls in facial analgesia.Identify one common presentation of a drug-addicted patient in the ED. List four classes of prescription drugs that lead to addiction. List methods of screening for drug addiction and demonstrate techniques for interviewing the drug-addicted patient.
  Problems of acute pain management in the ED Objectives:Regional anesthesia in the ED Objectives:
  Describe the current state of pain management in the ED. Discuss the barriers to successful pain management in the ED. List strategies for improvement of delivering analgesia in the ED.Discuss the common indications and contraindications to regional anesthesia. Describe common regional blocks of the upper and lower extremities. Identify the procedural risk and medications side effects while performing regional anesthesia.
 Case studiesJournal clubClass-specific didacticPractical teaching module
 Acute back pain Acute pain in patient with aberrant drug-related behavior Acute exacerbation of chronic pain Objectives:Opioids in acute abdominal pain Objectives:PGY-1: Do pain scales truly help in managing acute pain in the ED? Objectives: 
Small group session and objectivesDescribe the common etiology of acute lower back pain in the ED. Discuss the current treatment modalities in the ED. Identify red flags in history and treatment in patients with back pain.Discuss the results of randomized controlled trials of morphine use in abdominal pain. Discuss the correlation between opioid analgesia and delayed treatment of appendicitis. Discuss the role of intravenous morphine administration and its correlation with surgical decision-making.Identify the problems associated with the use of pain scales. Describe the evidence refuting the routine use of pain scales. Delineate new concepts of improving pain assessment.Practical module: aberrant drug- related behavior in the ED (2 hours). Identify red flags in history and treatment in patients with aberrant drug-related behavior.
  PGY-2: analgesic ceiling for NSAIDS in the ED Objectives: 
  Define the concept of the analgesic ceiling. Describe the common medications used in the ED that have an analgesic ceiling.  
  PGY-3: What is the optimum intravenous dose of opioids in the ED? Objectives: 
  Describe the current practices of administering opioids in the ED. Discuss the evidence supporting use of various dosages of opioid analgesics in the ED. Determine the optimum dose of intravenous opioids in treating acute pain in the ED. 
Quiz title and number of questionsBasic pain quiz (10), Pharmacology quiz (15)Are you afraid of prescribing opioids? (20)Anesthetic quiz (15)What do you know about addiction? (10)

The teaching module should be presented in a 4-week block incorporated into the regular weekly EM residency didactic schedule. Each week will include two or three didactic lectures with pre-and posttesting. The total time for each lecture, including pre- and postquizzes and questions, should not exceed 1 hour. The lecture content includes pathophysiology and pharmacology of acute pain, problems and barriers of acute pain management in the ED, local and regional analgesia and its pharmacology in the ED, and aberrant drug-related behavior in the ED. In addition, each week will have either class- or group-specific didactics. Thus, the first week includes small group sessions where pain-oriented clinical case vignettes are discussed. The second week includes class-specific didactic where the postgraduate year 1 (PGY-1) class will have a session on evaluating the usefulness of pain scales in the ED, the PGY-2 class will have interactive session on nonsteroidal anti-inflammatory drugs (NSAIDs) and their use in the ED, and the PGY-3 will have an evidence-based discussion on appropriate parenteral dosing of opioid analgesics in treating acute pain. The third week includes a journal club where residents will discuss the issue of administering opioid analgesia to patients with acute abdominal pain. The fourth week has an interactive session on aberrant drug-related behavior by introducing a patient-oriented simulation module. A recommended list of texts and articles for each week is available in Data Supplement S1 (available as supporting information in the online version of this paper).

At our institution, the didactic schedule design is based on the Model of Clinical Practice of Emergency Medicine14 that is incorporated into weekly sessions and extended into 18 months. Thus, the whole curriculum is repeated twice during a residency (36 months). It is the authors’ belief that having the acute pain management curriculum repeated twice during a residency is worth investing the allocated time, as it might enhance the theoretical knowledge and practical skills in acute pain management throughout a career. Running the curriculum twice during the 3 years of residency will also assist in evaluating the progress of the residents in the areas of medical knowledge, patient care, and systems-based practice and will provide data for formative and summative evaluations.

Evaluation Process

The evaluation process incorporates both resident and presenter evaluations. The tools for the resident evaluation include weekly pre- and posttesting, direct resident observation during the practical sessions (small groups and class specific didactics), and a standardized direct observation assessment tool (SDOT) completed for each resident during a shift in the ED evaluating a pain-related chief complaint (Data Supplement S2, available as supporting information in the online version of this paper). The SDOT form designed by the Council of Emergency Medicine Residency Directors is being used for real-time observation of the resident with modifications made related to pain-oriented chief complaint. The resident should focus on acute abdominal pain, acute musculoskeletal pain, and acute back pain. The evaluation of the presenter will include an evaluation sheet distributed at the beginning of each presentation15 and an evaluation tool to assess the effectiveness of the lecture itself. This tool includes the minute paper, one-sentence summary, and application cards.16

Conclusions

  1. Top of page
  2. Abstract
  3. Curriculum Objectives
  4. Conclusions
  5. References
  6. Supporting Information

We strongly believe that education on pain awareness and proper assessment, and treatment of acute pain, has enormous potential in offsetting the “oligonalgesia” in the ED. The proposed curriculum is a first attempt to create a concise and easy to use practical guide to acute pain management in the ED. The curriculum has not been tested in the authors’ institution prior to submission of this manuscript, and thus there is no evidence that this educational initiative will benefit EM residency programs. However, based on the limited published research that demonstrated an improvement in pain assessment in the ED after formal teaching was conducted, this curriculum has the potential to enhance the treatment of acute pain in the ED.12,13 After incorporation into a residency programs didactics, this educational tool might increase the fundamental knowledge of pathophysiology and pharmacotherapeutics of acute pain in the ED, improve acute pain assessment and documentation, sharpen technical skills in local and regional anesthesia, and improve the care of patients with aberrant drug-related behavior. The authors believe that the proposed curriculum is well suited for the Model of Clinical Practice of Emergency Medicine, as it describes clinical signs and symptoms as well as treatment modalities of the condition (pain) that requires emergent care. The curriculum might also assist in acquiring the necessary knowledge level of mastery and proficiency.

References

  1. Top of page
  2. Abstract
  3. Curriculum Objectives
  4. Conclusions
  5. References
  6. Supporting Information

Supporting Information

  1. Top of page
  2. Abstract
  3. Curriculum Objectives
  4. Conclusions
  5. References
  6. Supporting Information

Data Supplement S1. Course bibliography.

Data Supplement S2. SDOT-PAIN.

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ACEM_1069_sm_DataSupplementS1.doc46KSupporting info item
ACEM_1069_sm_DataSupplementS2.doc73KSupporting info item

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