Oh, what a pain!

Summary of education activity 24/01/2019 Thursday 1300-1700 hrs

It was a very productive day for all those who attended.

Dr Cameron McClure kicked off the first session of the day with a talk on back pain management in ED.

Presented in the form of a rapid audit (back pain cases from a single shift), his style of presentation was innovative. Even though the sample size was low, the audit was quite useful in demonstrating the concepts of red flags, yellow flags and management variations of back pain in our department. It was good to see we document red flags (or lack of) quite well in our department.

 We then had thought provoking discussions based on the back pain management recommedation (attached below) published in EMA in 2018.

Back pain assessment and management recommendations from review article published in EMA 2018

This could be used as a reference tool (and modified based on our local situation), in combination with common sense. Obviously, nothing beats the latter.

The full review article published in the EMA is attached below.Quite a nice read.

Dr Zac Scollard then presented the most interesting case of the week.

The case of a patient with concealed spinal hemorrhage presenting with back pain. The value of thinking outside the box and a well-timed MRI (in the context of a negative CT scan) was re-iterated in this case. The concept of targeted spinal pressure management was touched upon. However this is best left for Intensive care units.

The second hour saw a remarkably packed audience. Nursing staff joined us for a combined (Medical + nursing) teaching session, as ED consultant, Dr Marcus Yong FACEM gave a fantastic presentation on Pediatric analgesia.

As he took us through the nuances of pain assessment in children, the FLACC pain assessment tool and Faces tool were reviewed.

Non pharmacological methods of analgesia: Systemic and Local techniques were discussed. We noted that we don’t use bubbles here due to workplace safety concerns. Something to think about.

Pharmacological methods ranging from oral Sucrose to intravenous Ketamine were discussed. Newer analgesic methods like Intranasal Ketamine were explored too.

A downloadable pdf with the paediatric analgesia recommendations is available here.

Combining the session between registrars and nursing staff was well received. It created room for innovative comments, views with wider perspectives, and reinforced the value of collective thinking. We shall endeavor to keep the time slot of 1400-1445 hrs for such combined sessions here on.

As the second half started, Dr McClure presented a systematic review of current evidence on assessment and management of back pain. It was thought provoking and reminded us again that we are gatekeepers of people’s well being. Cam reminded everyone to practice restraint in prescribing opioids.

Back pain is a challenging indication that makes analgesia often hard to choose. It was recognised that having a departmental guideline and adhering to it could help empower staff. A departmental back pain guideline shall be reviewed and uploaded on this website soon. In the interim, the ACEM guideline could be used as reference. Excerpts from Cameron’s talk are below. He is happy for staff to access it for academic interest. Thanks Cam.

The last hour was led by Matt Davey, ED physiotherapist. What a superstar; with only an ultra-short period of notice, he kindly agreed to share us his wisdom. He gave us a different point of view on assessment and management of back pain.

He introduces the STarT Back screening tool (Keele University) based on General Practice setting. Matt emphasized the importance of patients being encouraged to return to previous level of activity as soon as possible. In the context of low specificity of some red flags, he explained why a more detailed assessment helps determine if perceived red flags are true or not.

Some Pearls that came out of the sessions from Cameron and Matt include:

 ‘Do not label patients with a diagnosis’. (Patients seem to ruminate on this).

 ‘Provide the right level of analgesia’.  (Not too less; not too much)

‘Use opioids judiciously’. (Review the ACEM guideline on recommendation for opiates)

‘Do not provide patients with misconcepts’ (Many exist in medical and Physio practice)

‘Activity is the key. Stay active and build your activity’ (To pre-existing level)

‘Encourage early/ graded return to activity’. (Especially in sporting)

It was amazing to know that the outpatient physiotherapy services are set up in a streamlined fashion. This makes it possible for patients referred from ED to be seen within a week. Truly international standards! We could utilise outpatient Physiotherapy services for our patients more often.

We recognised it would be useful to have a departmental approved (updated version) of a discharge pamphlet regarding back pain for handing out to discharged patients.

Matt Davey (ED physiotherapist) has agreed to initiate a template. Dr Cameron McClure (ED registrar) and Dr Marcus Yong FACEM (ED consultant) have agreed to modify and submit it to the ED director for verification. Once the leaflet is approved, it shall be uploaded on this website for easy access.

Thanks to all who attended teaching. Your presence and input helps this department leap forward.

“The future belongs to those who believe in the beauty of their dreams.”

–Eleanor Roosevelt

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