Dr. Samina Ali examines a child
Samina Ali, an associate professor of pediatrics with the Faculty of Medicine & Dentistry, is scrutinizing pain management in pediatric patients throughout Canada.
Ali is the lead author of a study that examines survey results from 139 pediatric emergency physicians. The survey posed questions related to pediatric pain management policies and procedures and reveals that, throughout the country, children in emergency departments are likely being undertreated for pain. The study is featured on the front cover of the September 2014 issue Canadian Journal of Emergency Medicine.
"Sixty per cent of urinary catheterizations, half of venipunctures (IV insertions), a tenth of lumbar punctures and a very small amount of suturing, or stitching, are done without treatment," Ali says of the results.
The study found that topical anesthetics were commonly used for lumbar puncture, or spinal tap, and stitching. Oral glucose, which is proven to minimize pain in infants, was the least utilized, with a 12 per cent reported use for urinary catheterization, a 14 per cent use in IV insertions, a 29 per cent-use in spinal taps and a six per cent use in stitching.
According to the study, pain is well managed for more painful ailments. Only four per cent of physicians reported using no anesthesia for ear infections. However, surgical abdomen-related pain and femur fractures were largely treated with opioids, with 78 per cent and 96 per cent reported use, respectively.
In addition to pharmaceutical methods of management, the study evaluated the use of non-pharmacologic methods of pain management for infants. The survey revealed that a physician's educational and training background influences their likelihood to utilize certain methods of pain management and distraction.
Emergency medicine-trained physicians are less likely to use a pacifier and glucose to manage pain when compared to pediatrics-trained physicians in the emergency department. Female physicians are more likely to use breastfeeding as a means to distract the child. Older physicians and physicians with more experience are more likely to use swaddling techniques to soothe an infant.
"I can certainly believe that if you do pediatrics for five years continuously, you'll get exposed to pacifier and glucose use more than if the first five years of your training was heavily based in adult medicine, where cardiac arrest or heart attacks are seen more frequently and are a priority," Ali says.
In the survey, physicians report that they felt education could be improved through interactive knowledge translation tools to help them become more familiar with proper use of pharmacologic and non-pharmacologic pain management and distraction methods.
Commonly reported perceived barriers to effective pain management include education issues relating to use of anesthetics in children (36.3 per cent), staffing or human resources issues (31.4 per cent) and lack of access to medications (15.7 percent). Lack of time or disruption of emergency department flow is the most commonly perceived barrier, with 55 per cent of physicians reporting it in their responses.
"If you're not cognizant of flow and you keep every patient for seven hours in a room, you will back up the waiting room down out the road, down the street and around the corner. Flow is always an issue," Ali says. "To me, however, flow is not an acceptable reason not to treat children's pain. We just have to think about how we design [flow management]."
Ali says one way pain treatment can be improved without negatively impacting flow is if triage nurses apply topical anesthetics to pediatric patients who appear dehydrated. Anesthetic creams that soothe pain associated with IV insertion take approximately 30 minutes to take effect and, if the child is not administered an IV, there is no danger connected to the use of the cream.
Ali also encourages parents to advocate for their children and ask physicians if there is anything that can be done to make their child more comfortable or help them cope with the pain. "It is first and foremost our duty as parents [of children using the emergency department] to advocate for our child. I would hope that our health-care providers would be open to receiving that."