Patient Care

Pain Management is the Same for Every Patient

Issue 2 and Volume 40.

Medic 71, a dual paramedic-staffed ALS unit, arrives on scene to find a single-story, multifamily apartment building. The team is met outside by a lady who identifies herself as the patient’s mother. She’s distraught but matter-of-fact, telling the medics her daughter is lying on the kitchen floor with a broken leg. She says her daughter has autism spectrum disorder (ASD) and doesn’t speak. As they enter the apartment, the mother explains her daughter’s condition and says her name is Annie.

Annie’s lying on the kitchen floor in a pool of the water she spilled and slipped on. She doesn’t speak to the paramedics, but looks at them briefly when they say her name. There are no other visible reactions, but they continue to talk to her anyway.

“Annie, my name is John and I’m a paramedic who works on an ambulance. I’d like to take a look at you. Is that OK?”

She doesn’t acknowledge him, but also doesn’t resist as he gently comes toward her and looks her over. She seems to be largely in her own mind and not reacting to the situation. She allows John to palpate her head, neck, back, hips, arms and upper legs, and exhibits no painful reactions.

John doesn’t find any abnormalities until checking her left ankle, which has an obvious gross angulation of the tibia and fibula right above the joint. It looks painful and is obviously a complete transection of the two bones.

The paramedics continue to speak softly, assessing the foot distal to the injury for the presence of pulses and circulation, and find no other abnormalities during their full assessment.

“She’s stayed on the ground since she fell. She knows she hurt herself,” Annie’s mother says. “She may not be able to talk, but she can communicate and she understands quite a bit about what’s going on.”

According to Annie’s mother, Annie hadn’t struck her head on the way down or lost consciousness. She’d been acting neurologically appropriate other than exhibiting what she interpreted as a reaction to pain. She filled them in on the rest of Annie’s medical history as well, which included being on a few medications—daily regimen of Kapvay (clonidine hydrochloride) and multivitamins—and some recurrent urinary tract infections.

The paramedics decide Annie’s injury and anatomy don’t lend well to commercially available splinting devices, so they fashion a proper splint using a pillow, two arm boards and twoinch tape, leaving the toes uncovered to continuously assess distal circulation. Her vital signs are within normal limits for a female of her age, other than some reasonable tachycardia and elevated respirations.

“How does Annie react to medications?” John’s partner asks Annie’s mother. “Has she ever had any pain medications?”
The mother says Annie hasn’t had any untoward reactions to any medications, and that she’s had “a mild sedative they sprayed in her nose” prior to dental work. She also explained some of her daughter’s behaviors associated with her autism: self-stimulation by rocking and moving her arms as well as some selfinjurious behavior when she’s overly stimulated by the environment.

Before they move Annie, they decide to provide pain management. They choose intranasal fentanyl for ease of administration and because Annie is used to medications given that way. They start with a 50 mcg dose, which Annie easily accepts.

The paramedics lift Annie onto the cot, speaking calmly and compassionately the entire time. They let her know what they’ll be doing before they do it and speak to her like they would any other patient. Once on the cot, they brace Annie’s leg in a position that looks most comfortable, secure her with the cot straps and cover her with a blanket. Annie’s mother accompanies her in the ambulance.

Annie appears to be more relaxed since the administration of the fentanyl, but after five minutes, John elects to give another 50 mcg intranasal dose. Annie seems more relaxed and while she maintains a good blood pressure, her pulse decreases a bit.

During the transport to the downtown hospital, John gives an additional 100 mcg of the fentanyl per protocol and receives orders to administer 200 more as needed per the onduty ED physician. He also administers intranasal midazolam to ease any anxiety or self-injurious behavior Annie may exhibit due to the unfamiliarity of the situation or the pain. The transport is uneventful and Annie is passed to the ED nursing staff without incident.

ED Care

Once at the ED, the physician orders the requisite imaging to confirm the fracture. He elects to manage Annie’s pain with Dilaudid (hydromorphone) as a longeracting medication. Annie’s mother stays with her through her admission to the orthopedic floor for surgical repair of her transected tibia and fibula. She’s discharged a few days later.

Discussion

Sometimes people who are in great pain can’t communicate their distress. This can be because of intellectual, psychological, social, physical or neurological causes that limit their communication ability. In the above case, the patient was on the autism spectrum, was nonverbal and didn’t have the ability to speak nor communicate using body language. Her pain, however, could be expected to be just as real and severe as any other person with a similar injury and deserved every bit as much attention and relief. All patients deserve pain management when they hurt; EMS professionals need to be aware of this and attuned to the needs of all of their patients.

ASD is a developmental disorder that’s characterized by significant social, behavioral and communications challenges that present to varying degrees. These symptoms can be very minor in some people yet very significant and debilitating in others. The abilities a person has to think, learn, solve problems and perceive the world around them may all be affected.

The term “autism spectrum” is used to categorize the many manifestations of the disorder, which has evolved to include older diagnoses like autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s syndrome. Researchers don’t know the causes of autism and there’s no specific medical test to diagnose it. Rather, it’s diagnosed using a series of developmental markers and functional and behavioral testing. Autism may be diagnosed as early as 18 months, but usually isn’t clearly diagnosed until a few years later in life.1

Persons with autism commonly have differences in the way they perceive the world and experience sensations coming from within their own body. Many are sensitive to such things as noise, unexpected or unfamiliar touch or tactile sensations, changes in routines, or other stimuli where they’re seemingly oblivious to other things. Some persons with ASD are dependent upon routine and “sameness” in situations, where even a slight deviation in the expected routine can cause negative behavior. When coupled with difficulties in communication, this makes assessing and treating persons with autism difficult, especially in an emergency situation.

It’s important for caregivers to remember that simply because a patient may not be able to communicate about the pain they’re experiencing, that pain isn’t any less severe to the person experiencing it. Although it’s been thought persons with autism may have a diminished pain sensation or an indifference to pain, there’s been little evidence found to support this claim. In fact, evidence shows persons who might be assumed to have insensitivity to pain may actually experience pain quite acutely.2 However, even if some persons with autism indeed have lower sensitivity to pain, it’s not a safe assumption that all do. The fact remains that all patients deserve effective pain management when they hurt.

Although Annie couldn’t directly communicate with the paramedics, she did exhibit some physiological signs of distress such as sweating, elevated vital signs and uncharacteristic withdrawal as described by her mother. It’s important to take such signs into account when assessing reactions to treatments. The obviousness of this patient’s injury also made it easier to recognize the patient was in pain, but the cause of pain isn’t always so easy to detect.

As when treating any person with special needs or diminished communications ability, it’s usually helpful to involve their regular caregivers in the process of your evaluation. They can help describe changes in behaviors that may indicate a painful response in your patient.

For Annie, the paramedics decided the best pain control was intranasal fentanyl. This carried the advantage of not requiring a needle poke, such as with an IV or intramuscular medication, and was something the patient had already experienced. While local protocols and individual patients may vary, EMS providers should use available tools to lessen the trauma of medicine administration as much as possible. Adjuncts such as Versed and other benzodiazepines given intranasally may be effective in controlling negative behaviors, lessening the patient’s anxiety and preventing further injury.3

Paramedics without robust standing orders for pain control may consider calling medical control for approval of a more individualized treatment plan, and BLS providers may consider calling for an ALS intercept.

Conclusion

To alleviate the suffering of others is one of our highest callings. Don’t let your patient suffer in silence simply because they can’t speak.

References
1. Centers for Disease Control and Prevention. (2014.) Facts about ASD. Retrieved Oct. 25, 2014, from www.cdc.gov/ncbddd/autism/facts.html.
2. Nader R, Oberlander TF, Chambers CT, et al. Expression of pain in children with autism. Clin J Pain. 2004;20(2):88–97.
3. Pisalchaiyong T, Trairatvorakul C, Jirakijja J, et al. Comparison of the effectiveness of oral diazepam and midazolam for the sedation of autistic patients during dental treatment. Pediatr Dent. 2005;27(3):198–206.