The Painful Truth
Why Our Youngest and Oldest Patients Are Overlooked When They Hurt
An elderly woman dozes in the emergency department’s exam room. No grimace. No agitation. If she hadn’t been X-rayed, one would not believe her hip is fractured in
two areas. Her nurse observes her and scores her a value of
zero on the Critical Care Pain Observation Tool. Convinced
the patient is comfortable, the nurse withholds the patient’s
as-needed pain medication.
Across the U.S. in another busy ED is a toddler with a forehead
laceration from striking a coffee table. He is wrapped
in a blanket as the physician readies to suture
his wound. She tells his parents no
anesthetic is needed because she’ll
be done quickly and their son won’t
remember a thing.
While these two patients
couldn’t be more physically
different, they share the
same unfortunate situation:
Their pain was missed.
Despite the proven science
of suffering, we still fumble
pain control for these two
vulnerable groups, especially
in emergency care.
“Both pediatric and geriatric
patients have unique needs, and a
one-size-fits-all treatment plan just
doesn’t work in either of these special
populations,” said Frances Patmon, PhD, RN, whose
research interest is geriatric pain. Patmon is a nurse scientist
at Dignity Health and a member of the ENA Geriatric Work
Team. “Children are not just small adults, and older adults are
extremely complex medically. Pain management and
assessment for either group is challenging.”
It Can Hurt to Be a Kid
Despite the idyllic concept that childhood is bliss, it is often
fraught with painful experiences. Ear infections, contusions
and burns – even physical abuse – are sad realities. Severe
and chronic diseases, such as sickle cell anemia, cystic fibrosis
and leukemia, can place further suffering on a child. Children
are also forced to live with diseases identical to those in older
adults: cancer, HIV, diabetes and even fibromyalgia. According
to a 2015 report published in the journal Medical Clinics of
North America, while the prevalence of pain in pediatric
patients is well-documented, the data usually focus on only
one or two disease subpopulations, such as cancer pain or
discomfort related to painful interventions. Experts say this
creates holes in treatment plans and best practices.
“Often, the thought is if a child has a laceration, you inject it
with lidocaine, which hurts the most, and then you sew it,” said
Heather Martin, DNP, RN, PNP-BC, who works at the
University of Rochester Medical Center in
Rochester, New York, and is a member of the
ENA Pediatric Committee. “At my
institution, a lot of thought goes into
how we care for children, and they
should not suffer any unnecessary
pain or pain inflicted by our staff
members. To do that, we rely on
topical analgesics, intranasal
medications, as well as
nonpharmacologic therapies,
such as distraction and child
life specialists. By applying a
topical analgesic such as LET
(lidocaine, epinephrine,
tetracaine) to the wound for 30
minutes, along with the help of a
child life specialist distracting the
child, the majority of the time they do not
realize their laceration is being sutured.”
As children transition through adolescence, pain begins
reaching a prevalence equal to adult rates. According to the
2015 National Health and Nutrition Examination Survey by the
Centers for Disease Control and Prevention, greater than 17
percent of people age 4 to 18 experience frequent or severe
headaches, including migraines, over the course of a year.
Worse, researchers recently found children with
developmental disabilities, such as autism, cerebral palsy and
other intellectual disabilities, are likely to feel pain more
severely.
According to a 2016 report in the journal Pain by the
International Association for the Study of Pain, what was
thought about pain in patients suffering from late-stage
Alzheimer’s disease could be incomplete. The research
