I’ve been discussing pain management options with a friend of mine who’s got an anesthesia background prior to entering the EMS world. We were both bemoaning how EMS doesn’t always excel at managing chronic pain and how our options are, in most cases, limited to one or two opiates. (And let’s not even talk about how some EMS systems still aren’t medicating abdominal pain.)
Let’s take the average chronic pain patient who calls EMS because of an issue involving breakthrough pain. Even in the most progressive EMS systems in the US, the average paramedic’s knowledge of chronic pain is limited and their options are even more limited. I work in a very progressive rural EMS system and my options are, by and large, limited to dosages of Fentanyl, potentially accompanied by Versed for anxiety related to the pain. In these cases, an opiate, whether or not accompanied by a benzodiazepine, is probably not the best solution long-term for the patient. Additionally, you’ve basically put the patient in a situation where they’re now going to be transported by EMS, creating an arguably unnecessary EMS and ER bill.
So, there’s got to be a better way, right? I’m no expert, but here’s my idea. This might be a perfect model for community paramedicine and/or advanced practice paramedics to get involved. My paradigm would have these medics working as adjuncts of the local pain management clinic(s). In a case where the patient is likely experiencing an episode of breakthrough pain related to a chronic pain diagnosis, a community paramedic could be dispatched instead of or in addition to the 911 ambulance response, depending on local dispatch practices. The community medic would have additional training on managing chronic pain and an expanded scope of practice for such. In cases where the patient is already working with the local pain management practice, the community medic would be a resource for whatever “safety net” of medications and interventions exist in the patient’s pain management plan for breakthrough pain. For patients who don’t have a pain management home, a call such as this would be an opportunity for the community medic to provide some enhanced pain management options AND get the patient into the local pain management practice.
Idealistic? Probably. Would it require a lot of groundwork to get this set up? Absolutely. Regardless, I do think it’s an idea that meets an unmet need in virtually every community. And as I understand it, community paramedicine projects are supposed to be meeting unmet mobile integrated healthcare needs.
Tell me how/why this wouldn’t work?
Pain management is a tricky field. I have a cousin (by marriage) who is a board certified anesthesiologist. Some years back he did a two year fellowship in pain management and then went to work in the pain management clinic of a large east coast teaching hospital.
After a few years, he gave that up and went back to anesthesia. I asked him why. The first reason was payment. In his state (and it probably varies) the private insurance companies don’t recognize pain management as a specialty. As a result, they pay what they think is the appropriate fee. Sometimes that’s nothing.
Which means that the perennial question of how EMS will get paid for this could well rear it’s ugly head once again. Plus of course there is the issue of getting accepted in to a pain management practice. Which could well be insurance dependent.
In most states there are also going to be scope of practice issues. Maybe not in your state which has a pretty wide open approach to protocols.
The other problem with pain management, not related to EMS, is that the DEA isn’t exactly embracing the concept with open arms. Doctors have a hard time striking a balance that will keep plaintiff’s lawyers away and at the same time keep the DEA from looking at his practice with a hairy eyeball.
I’m not saying it can’t work. It’s just that I think that the doctors need to get this nailed down first.
My friend, I don’t disagree with anything you’ve said. In fact, I’m inviting naysayers on this one. All I’m saying at this point is that this would address more of an unmet need in prehospital medicine than some of the other community paramedicine projects, many of which seem to exist to chase “free” grant money.
2 comments.
1. I think the reason pain management specialists have such a hard time is because it is for all intents and purposes too hyper-specialized of a task.
2. Pain management, in any condition, acute or chronic, is a tactic, not a strategy. The basic decision point of chronic pain management is To palliate or to maintain function? When it comes to palliation, it basically is accepted this patient is not going to do things like work or maintain any sort of productivity. This is where substances such as THC, opioids, benzodiazepines, and all the other high potency high side effect treatments come in. Before resorting to this, more social aspects of medicine like qualifying for disability need to be pursued and in place. From a community EMS perspective, the role of the medic would be to show up and give people their fix. While this is legitimate medical treatment, most paramedics so abhor these types of patients because of personal morals, I do not see it being accepted or practiced with any level of proficiency, much less with any trace of customer service.
The other option is to maintain functionality, in which case, alternative medications and therapies like intra-articular injections would be the methods of choice, with the occasional opioid or benzo as a break through measure. These methods require additional skills as well as chronic monitoring, because of the long term effects of these treatments. They may also only be temporizing methods which extends the time required before palliation. The major hurdle is this takes away money from people trying to be pain-management experts and most GPs want nothing to do with it. So it raises the question of “who will be the prescriber/supervisor?”
Even if provider will was there, I suspect there would be a public outcry over paying and sending medics to support “junkies and whiners” as the patients would be labeled.
Look at how many ER docs don’t like these patients or how they treat them!
This type of care is probably asking a lot of disinterested providers.