The Delta P
Treating our patients' pain is a priority in the ER, but it isn't our highest priority. And of course all pain isn't created equal. When the waiting room is full and everyone has 10/10 pain, we have to distinguish them somehow. One consideration is the mechanism of pain: an obvious injury like a broken wrist is more convincing than some of the "mystery pain" syndromes like migraine or fibromyalgia. But of course some conditions cause excruciating pain without an immediately apparent source, and all pain deserves to be treated. But in what order?
One philosophy is to consider the change in pain from baseline, a function that I will name the delta P (or ΔP). If a fibromyalgieur or a chronic back-paineur lives at a constant 6/10 pain level and they present with 10/10 pain, then their ΔP=4. Similarly, if a previously healthy and pain-free little girl falls off her bike and scrapes her knee, presenting with 5/10 pain, her ΔP might be 5.
So there you have it, the delta P: a mathematical representation of why acute pain is treated before chronic pain.
ΔP = Pa (acute pain level) - Pb (baseline pain level)
One philosophy is to consider the change in pain from baseline, a function that I will name the delta P (or ΔP). If a fibromyalgieur or a chronic back-paineur lives at a constant 6/10 pain level and they present with 10/10 pain, then their ΔP=4. Similarly, if a previously healthy and pain-free little girl falls off her bike and scrapes her knee, presenting with 5/10 pain, her ΔP might be 5.
So there you have it, the delta P: a mathematical representation of why acute pain is treated before chronic pain.
ΔP = Pa (acute pain level) - Pb (baseline pain level)
Labels: pain, perception
posted by scalpel at 12:43 PM
39 Comments:
I think this is more about your disbelief in the pain reported by sufferers of certain conditions. Conditions which you think are bogus or simply affect those of weak will. Who therefore deserve disdain rather than treatment. The "-eur" prefix is telling. Or do you refer to the little girl as a "childhood scrape-eur"?
Oh the fibromyalgeurs are out again.
Delta P is an excellent idea. We should just replace the pain score, since it means very little.
Oh and those with fibromyalgia - remember when ME was considered 'Yuppy Flu'?
I think the Δ pain scale is actually a very astute way of looking at ED triage. Everyone thinks it is HARSH that we categorize them as not as urgent as the guy clutching his chest or as the kid with the tibia sticking out of the skin...but that is why we're the ones on the other side of the gurney--attempting to put somewhat of an objective analysis on the situation. It's not about a disbelief of anyones pain, it is tacking on a 'is this pain signifying impending death' clause to the situation. And 9 times out of 10 in the ER the answer to that question is 'no' which means: take a number.
Brilliant. Oh, and by the way anonymous, the -eur is an official medical suffix for someone who suffers from migraines.
erp - I'm familiar with migraineur. The use of "eur" in other forms as in the blog is merely an obvious device to discredit sufferers. As in, "Oh the fibromyalgeurs are out again". Seeing as how Medicine has no cure for Migraine or Fibromyalgia, one would expect a bit of humility rather than disdain. Then again, perhaps it can be viewed as compensatory behavior.
The suffix "-eur" is hereby defined as relating to an individual who is addicted to narcotics and who uses a medical diagnosis of questionable validity (the root word) to justify the administration of his/her drug of choice.
So unless the childhood scrapeur has a paucity of objective clinical findings but a history of multiple ER visits requesting narcotics, then I would say that term is incorrect.
Another thing to consider with the delta P is that the chronic pain patient is probably already taking something for pain. It is not untreated pain. While other patients may have taken OTC pain medicine, few have opioid prescriptions at home to take for their acute pain.
While migraine is a disease without a cure, so is diabetes. The idea that fibromyalgia is a disease without a cure is far from accepted, except by those who benefit from that description.
It may be a misdiagnosis, but that does not make it a legitimate disease.
In assessing a patients pain, there are other things that may assist in determining the appropriate starting treatment. Vital signs - tachycardia, tachypnea, hypertension, . . . . Without these signs of stress, perhaps a more conservative approach to treatment is a good idea.
I like the delta P and will use it myself. Great idea! :)
lol, this is...just...funny. Migraineur as a term isn't about diminishing their pain. In fact, the only people I've heard use the term are people who are VERY sensitive to and very supportive of people with migraines. I first heard the term used by a migraine specialist at my medical center and he is one of the kindest, gentlest docs I know.
As someone with a chronic pain syndrome myself, I do sympathize with fibromyalgieurs, but the most effective interventions aren't found in pills for them. And the ER doesn't seem the best place to go when you're having a pain crisis.
Delta P is good, but there's a difference in 9/10 and 5/10, even if the delta P is 3 and 5 respectively. I subconsciously use delta P and variance in P whenever I see a new doc. Average a 6 or 7. Good day are a 4 (rare) and bad days are a 9 (unfortunately not as rare),
Am I misreading your tone? Migraine is excruciating, yet you seem to imply it is a fantasy pain and of little consequence even if "real" and severe.
Migraine is often of little clinical consequence in the ED since recurrent migraine without neurologic symptoms or intractable vomiting does not result in acutely increased morbidity or mortality.
And it often seems that the "migraineur" with perhaps a dozen or more ED visits per year is less likely to benefit from or appreciate prompt medical attention than the little girl with an acute musculoskeletal injury.
But every situation is different, of course, and there are exceptions to every rule or trend. This is simply one approach.
No, not the "exception to every rule!"
Exceptions to trends, absolutely, they are only trends. Dramatic variations are expected, but not required.
Rules are different. Variations are not allowed, or else it is a flawed rule. :-)
Good point - most rules should probably be considered guidelines, and most cliches should probably be avoided.
:)
Again, I'm going to see and evaluate everyone and treat them appropriately. But if I have half a dozen charts in the rack, I have to prioritize them somehow.
For example:
1) 50 year old man with chest pain
2) Abdominal pain with vomiting
3) Screaming baby
4) Little girl with broken wrist
5) Migraineur with no prior ER visits
6) Migraineur with 12 ER visits this year
Patients 2-5 might be seen in a different order depending on circumstances, but number 6 is going to be last for sure.
I try to make it a rule to use cliches only when I can't give 110%. :-)
Why is a little girl with a scraped knee going to the ED, anyway? What are you going to do -- put a bandaid on it? Hmm...
I'm going to perform a moderate complexity history and physical exam, searching for other injuries or problems. I'll probably order some Motrin or maybe some Tylenol with codeine, I'll then probably order an X-ray, have my nurse clean and bandage it, then give her a sticker, along with detailed aftercare instructions.
Mom will eventually get several bills totaling about $1200, including my fee of $225. Unless she has Medicaid, in which case she will not get any bills, and she'll want her other kid evaluated for his cough that just started today.
The best thing about our new EMR is that the chronic migraineurs are easily identified. When I see someone being registered with the complaint "Migraine", "Headache",or "Hurts all Over" - just before I see the patient I click on their visit history and all is revealed. If they have been there once every 4-6 months, no problem. Glad to help. If they were there 4 times last week and twice already this week, they are going to wait and eventually be discharged without a narcatic prescription unless there are extenuating circumstances. Quite simply, they need a pain management MD - not the ER. We have a pain management clinic in our hospital for crying out loud so lack of insurance is not even much of an issue.
Anyone who has a history of migraines should have a pain management plan so as to avoid the ED. It is irresponsible of both the patient and the doctor when a plan is not in place. The ED is not a necessary stop with the proper protocol.
Geez, just make the frickin' drugs legal and available to adults and y'all won't have to worry your pretty heads about who's pain is real or more important than the other sad cases.
Pff! Scalpel. That was my point. Neither the migraine-r nor the skinned knee kid needs to be in the ED. I mean, everyone feels sorry for a kid who is in pain and crying and probably feels less sorry for the overweight, middle-aged woman with chronic migraines. But what does pain actually matter when both patients should be at home? (I mean -- think back! how many injuries did you accrue as a kid? And how many were actually...oh...broken bones or needed stitches?)
Maybe I'm just too drunk or too jaded. But does it even matter when you have this continuous stream of people who just don't need ED services? Isn't all non-life-or-limb-threatening-pain created equal?
All non-life-or-limb-threatening conditions are essentially equal, but I still have to decide who to see first, and I don't always go by who signed in earliest.
Thus the delta P.
Ah, true, true. :)
I suppose that, at the end of the day, it's mostly subjective. Although your attempt to objectify pain is really awesome, actually.
I just get upset that there are no easy solutions to the problem of ED overcrowding. I don't want to deal with /anyone/ who doesn't need to be there, but you have to.
I suppose I am wandering a bit off topic, and misinterpreting some of what you write, but this is what I was thinking about your exchange with Hannah.
I disagree about all non-life-or-limb-threatening, or non-mobility-threatening, conditions being equal. Chronic pain and acute pain have significant differences. One would expect that, as you already described, the patient with chronic pain has taken reasonable steps to prepare for changes in the condition. Only unusual situations should lead to the chronic pain patient arriving in the ED.
Acute pain is quite different. Few people prepare for it. Non-physicians storing opioids in preparation for the possibility of acute pain is not something to be recommended, at least not legally. The types of acute pain also vary significantly. The example of a skinned knee is one that may indicate a more serious injury. If the child is waiting in the ED long enough to be seen, something is unusual there (I hope). Normal activity for a child is to be distracted from the pain after a little while and to want to go out and play, not sit in the ED waiting room. Maybe that is different in our passive stimulation, couch potato society.
Pain management is not something that everyone is good at. Some will narcotize many patients - not good treatment. Others do not even come close to making the pain tolerable - also not good treatment. The long term healing of the injury is probably not significantly different among the various types of management of the acute pain. The healing of the spirit may be the main difference. Those with under-treated pain tend to have increased sensitivity to pain in the future. Not something that should be encouraged if one does not like patients coming to the ED for pain that should not require an ED visit.
Those who are drugged to a narcotic high may have problems with trying to chronically recreate that condition.
Poorly managed pain creates drug seeking behavior. Appropriately managed pain should minimize this. Yet the management of acute pain has little to do with the ability to recover from the original condition. The life-threatening condition can be treated without treating the acute pain. The limb-threatening/mobility-threatening condition can be treated without treating the acute pain.
The different types of acute pain may be treated very differently based on experience. Some acute pain just automatically generates an empathetic response in almost everyone, while others may get little more than a shrug from the same observers.
The acute pain from burns is in a category all to itself, as is the chronic progressive pain of malignancy.
rogue -- I've watched my mom deal with unmanaged/poorly managed post-polio pain for years. Mom would never think to go to the ER for her pain. (And my father, her ex, is a long-time er doc.) I mean...ultimately you're right. But it's interesting to watch my mom; she certainly comes from a different generation. She has taken Tylenol3 for several years, yet she has never expected that her narcs would completely take away her pain. She's housebound, does not drive, depends on her t3 -- on a bad day -- to get her to the bathroom.
The life-threatening condition can be treated without treating the acute pain.
Have I missed something here? Is not the practice of medicine also about relieving suffering? Is pain not suffering? Sheesh.
I categorize patients like this:
1) Immediately life-or-limb-threatening condition (emergent)
2) Potentially life-or-limb-threatening condition (urgent)
3) Painful but not life or limb threatening condition (stable)
4) Painless and not life or limb threatening condition (stable)
There are also subcategories among these groups such as age, acuity, and pain level, but treating pain is ALWAYS secondary to preventing death or disability. If I can't stabilize your blood pressure, I don't care how much you're hurting unless you're terminally ill and ready to die.
In a disaster, all stable patients would be immediately discharged from the ER, whether they are in pain or not. So when push comes to shove, they are indeed all equal. Similarly, if they act out and are abusive to the staff, they can be discharged without any treatment at all after a medical screening exam.
"migraine without neurologic symptoms or intractable vomiting does not result in acutely increased morbidity or mortality."
True, you just *wish* you were dead.
Good to see the issue hashed out though; you sound like a reasonable Doc, even if you want to tack "eur" to whatever ails me.
Bottom line I guess is that ERs are just overwhelmed. By cases, and by being caught in the crossfire of our sad little war on drugs. These societal ills need more than a few sutures, unfortunately. Thanks for all you do.
I think this is an excellent idea.
I've worked in pain management for two years now and it's taken a huge toll on the stores of compassion I have. Many patients are manipulative, deceptive and downright abusive. It's an exhausting and often disheartening way to work. Yes, I know pain is subjective, but the amount of pain hypersensitivity I've seen has become ridiculously epidemic.
I love this idea and tonight when I head to work and do the triages I am going to start using your method.. I am sure it will catch on quick.. Thanks for the new pain scale!!
Having lived with pain all my life---severe migraines, cluster headaches (which I have never visited an ER for) and an aptitude for injuries(some of those have taken me to an ER), I truly feel for people in pain. I have not had a day in over 40 years that I have not had a headache. So it really pisses me off that the drug seeking slime of the world has created the reality that those in true pain can not get the relief they should get when they need it.
I have felt a few 10's but could not even ask for meds because at that point my world was a very dark and lonely place. There is no coherent interaction with anyone or thing outside of that world.
The problem with your simple scale is that THOSE OF US THAT ARE HONEST about our chronic and acute pain are ussually more accurate in describing our level of pain. What most people will tell you is an 8/10 (they may exagerate to get quicker care or to scam the doctor or just be fortunate not to have felt much pain before) I am going to say it is a 3/10. So if I tell you it is an 8/10 I would hope that you as a medical professional would take appropriate steps, give me a dark room and some meds and I will be out of your hair in a few hours. And I will actually stop and say thank you on my way out.
Merrily attempting to ignore the previous 31 comments, I see the value and the need of this 'delta change' thingy of yours. I have CRPS in all limbs and in my face, AVN in all major joints and many of them lesser joints -- so yes, pain is a constant. There are few occasions I can envision seeking pain treatment as an emergent occurence. If -- and God can have His more perverse days -- my pain were to approach 10 for some reason, I would go to the ED to make sure there wasn't something happening that was *masked* by both my habituation to pain, and to pain medications. I am not there for sympathy; Nor am I there for assinine condescension.
I have been delegated to the bottom of the waiting list, after triage, and once ended up in emergency surgery for a small bowel obstruction from adhesions (I was told I was probably constipated from pain medication, with an accompanying sneer), twice ended up comatose in ICU for Addisonian crisis. Just tossing that into the salad.
But, in general, and it is in *generalities* -- unfortunately -- that these discussions take place, your "delta p" is a good thing. Thanks.
One last thing, now that I have had the fortitude to review all the comments --rogue medic makes an important point, one over which my own good doctor (and former ED director) shakes his balding head, as well: the phenomenon of acute-on-chronic pain. Again, you, being the exception to all negative occurences, are excepted--but I urge other emergency professionals to keep an open mind when this is the situation. Encore une fois, merci.
As someone who has had migraines all my life, I'm astounded by people who somehow go to the ER when they have migraines. That someone somehow got to the ER on their own kind of works against taking the migraine very seriously - when I have one, motion, light, sound, smell (and any change in any of those conditions) are all excruciating. The last bad one I had, I would have happily taken cyanide had it been right beside my bed, but I could not possibly have gone to the ER, because I was functionally blind with pain. My parents dragged me to an ER for a relatively mild migraine once when I was 17 and had taken a fistful of Tylenol for it, but that was pretty much against my will.
Now I work in an area of disability law, and the other day I had a file on a woman who said she had migraines and kept going to the ER for them, almost weekly. She had no formal diagnosis, and the word "migraine" doesn't mean what that woman seems to think. They probably see a lot of these migraine=headache people in the ER, though.
I do not think a child with only a scrapped knee is a medical emergency. but you are the doctor so I guess you certainly know best. Although I raised 6 children and have dbl. digits in grand kids and have seen and home treated many of scrapped knees. A little soap , water, antibiotic cream, band-aid and a few kisses usually fixes them up real quick and fast.
Now, Scalpel, one day you will suffer a migraine headache. But, of course when you do, you will be the ONLY person in the entire world who has REALLY ever suffered one. I hope you are out of state on vacation when it happens, so that none of your co-workers are there to usher you straight back, and that you spend 6 hrs. in the waiting room while 15 kids with scrapped knees are being tended to, and then I hope you are talked to as though you are a drug seeker and sent on your way with an OTC Tylenol. That would be sweet KARMA! Do you believe in KARMA, Scalpel?
I do indeed. But I believe that wishing misfortune on others incurs a karma debt.
I don't wish misfortune on others; in fact, my life is devoted to helping others.
You may be old, but you have a lot to learn.
Sometimes wisdom comes with age; sometimes age travels alone.
I prefer the CRAP score:
http://allnurses.com/forums/f18/c-r-p-score-220066.html
That is simply genius.
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