Pain with Major Trauma Injury

The following was originally posted to Psychiatry Talk.

One of life’s biggest misfortunes is to sustain a major trauma injury. This is especially true if that injury is a burn injury. For many years, I was a psychiatric consultant to a large trauma center that also had a world-class burn center.

When patients would be brought into this center, as they are all over the world, the first thing that the trauma team would do is be sure that the ABCs are under control. As every medical student knows, this means:

• Airway control with cervical spine protection
• Breathing
• Circulation and control of hemorrhage

In fact, this assessment and immediate care should have started during the first aid that was given to the injured patient. There may be a need for a breathing tube, replacement of blood, and even emergency surgery to control bleeding. As soon as possible, there will be assessment of the brain and nervous system, as well as examination of the body for other injuries and damage.

The patient may or may not be conscious. If they are conscious, it is possible that they may be in extreme pain. The important question that I want to focus on is whether they will receive adequate pain medication and how important it is that they receive it. I am not just talking about their care in the emergency room, but I would like to address this question as applying to the patient’s entire stay in the hospital.

Pain is an unpleasant sensory and emotional experience associated with tissue damage. Immediate pain may be caused by mechanical or chemical irritation or by tissue damage due to trauma, surgery, disease, debridement, physical therapy, ambulation or any movement. Continuous pain may occur from direct damage or stimulation to the nerve secondary to swelling edema, tissue movement etc.

Peripheral sensations of pain can actually be affected by emotions and the psychological state of the person experiencing the pain. This can be understood by the “Gate Theory“ of pain, which postulates that the pain impulse can be moderated by impulses originating in the emotional center of the brain as well as from the thinking portions of the brain. Obviously, sensations of pain can be altered by medications as well as emotions and thoughts.

Are Doctors and Nurses Trained to Treat Pain?

About 17 years ago I co-authored a book with Margot Schoeps titled Psychological Care of the Burn and Trauma Patient. We used more than 20% of the book to discuss how to manage pain. We came up with various pain protocols for the management of acute pain after consulting with leading experts in the field. Even though we were mental health consultants, we did this because we knew that at least 1/3 of the 75 million traumatic injures in the U.S would result in moderate to severe pain and that more than 5 million critically ill patients in ICUs units especially those recovering from trauma or surgery would be expected to suffer from episodes of acute pain. We also know that many (but certainly not all) of the doctors managing these patients were not well trained in pain management. We also knew that this pain experience for many patients could have lingering long term psychological effects.

I am pleased to say that there is much more knowledge and know how in pain management today thanks to more sophisticated ER training programs, Pain Management fellowships and an increased sensitivity to pain in the new generations of physicians. Nursing education in pain management has also undergone changes. Pain is now considered one of the vital signs that should be taken, measured and recorded.

Psychological Aspects of Pain

A person may consciously focus on the pain as a symbol of the illness and of the threat to his or her life. A patient may use the pain unconsciously to try elicit a caring response from his or her environment (which includes the doctor and nurses). When pain is inadequately managed, the patient can develop a pain symptom complex which can lead to increasing anxiety, depression and hostility. It has been shown that a good social relationship can lead to decreased perception of pain and the need for less pain medication

The pain experience during the acute treatment can become an important part of the subsequent post-traumatic stress syndrome. Emotions related to pain can be incorporated into flashbacks dreams, avoidance syndrome and in the physiological hyper arousal which are the symptoms of PTSD. Pain may be a motivating factor in suicidal ideation

Under-treatment of Pain

Even when doctors and nurse know how to treat pain, it often is not adequately controlled. With the utilization of “as needed” pain orders or self-administered pain medication pumps, patients are still under treated for pain. Medical and nursing staff as well as patients themselves (taking their cues from the doctors and nurses) will feel that is better for them if they can hold off a little longer before taking the next dosage or additional pain medicine. There is often a misguided idea that patients taking pain medication for acute pain will become addicted to the medication and that this can be avoided by delaying or taking a little less pain medicine. This is not true. Patients very rarely become addicted to pain medication because they took it during the acute phase of their injury. Once they are in the recovery phase it is usually very easy to taper off the narcotic medication and switch to another non-addicting drug before stopping completely. It is the chronic conditions, which most often cause drug dependency.

Pain Can Influence Ethical Decisions

I recall one time I was on a panel discussing ethical issues in burn care. On the panel with me was a man who had recovered from a very large burn which left him blind although since he recovered from his burn injury he had become a very successful attorney, married and had two children. However he was making the point that at the time of his acute treatment which had to be quite extensive, with numerous surgical procedures and debridement, he had requested that he not receive the extensive life saving complicated treatment and he be allowed to die. His wish was not granted and although he did not wish to die at present, he believed that his wishes should have been respected at the time of his acute treatment. I asked him during the question period whether his pain had been adequately controlled. He said no and I followed up by asking him if it had been controlled does he think that he would not have asked to be allowed to die. He thought about it for a long minutes and said “probably not.”