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Board Review Pain Management

It's All About Perception: Pain Management and the Patient Experience

Scott Hirsh, DPM

Scott Hirsh, DPM, DABPS discusses the need to control pain management through the use of topical anesthetics and how this improves patient satisfaction and enhances their perception of the office experience.

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Goals and Objectives
  1. Define perception
  2. Recognize the types of pain
  3. List the important components contributing to a positive patient experience
  4. List the benefits and types of topical anesthetics
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  • CPME (Credits: 0.5)

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Scott Hirsh, DPM

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  • It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

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  • Lecture Transcript
  • Scott Hirsh: All right. Good morning, everybody. It’s a pleasure to be back here at the Superbones West Conference. My name is Scott Hirsh. I’m a private practice podiatrist from the Cleveland, Ohio area. I do have to disclose that I am a consultant to Gebauer Company who manufactures the topical anesthetic device as a chlorine. This morning’s lecture we’re going to discuss enhancing patient perception and the patient’s experience by controlling pain management through the use of topical anesthetics. Perception’s defined as the organization, identification and interpretation of sensory information in order to fabricate a mental representation through the process of transduction. Similar to this cat, looking into the mirror and perceived himself as a big fierce lion who want her peasants to perceive the podiatric office as a place it’s not going to cause pain but rather eliminate pain and their pathology. Our perception involves signals in the nervous system which in turn result from physical stimulation of the sense organs. Saks and Johns believed there are three components to perception. You got the perceiver, the target and the situation. The perceiver is the individual that has becomes aware that there’s a problem going on. In this case will be the patient. The target is the individual that either perceive or observe. In this case would be the doctor. And the situation is not the guy on the Jersey Shore show but it is the encounter between the perceiver and the target. Another hot topic immense right now is patient experience. Large hospital systems and multi-specialty groups are spending a lot of time and money trying to figure out the best way to create an optimal patient experience. This begins with the first step into the office and continues to the patient leaves your office. It is a step-by-step process of making the patient feel care for and concern about their care. This begins as their first step in the waiting room. You want your waiting room if you can to be spacious that plenty of seeds from not only the patient but for who with the patient brings with them. You want to cherish to have arms; it was easier for the geriatric population to get in and out of. You want to have a positive first encounter with your receptionist. You want to have short wait times. You want to know your paces as a doctor and how fast you can see your patients in the amount of hours that you have set forth. You want a nice and warm greeting by the physician maybe a hand shake, a quick social question before you dive into their pathology. The more you talk about mostly today is decreasing their stress by using proper products to reduce their pain and to improve their efficiency of our office. Studies suggest that the physician’s office is you want to exclude for psychological elements for an optimal patient experience. First of this is confidence, so the patient can trust the doctor to deliver on his promises. Next is integrity so we could treat our patients fairly and well satisfaction trying to resolve any and all of their problems. Then pride, the degree with patients feel good about the office and finally, passion which is patient’s – you want them to feel the office is irreplaceable and integral part of their medical care. And if you do all of these four elements and the patients will be happy and turn tell their family, their friends, the referring doctors, so you want to lean to better office for you. One of the main ways that we could change perception and improve patient experience is by controlling pain management through the use of topical anesthetics. Topical anesthesia could be defined as a superficial loss of sensation in the mucus membranes or skin produced by a direct application of a local anesthesia or anesthetic. And it also called surface anesthesia. Why do I want to use topical anesthesia? You want to use topical anesthesia to increase patient’s satisfaction by decreasing pain. You want to decrease patient’s stress levels. The easy of applying the topical anesthetics and the variety of usages. Pain is extremely relevant to us as podiatric physicians because the number one reason, the patient seek consultation in the United States. It’s usually that the duration is usually transitory and last only until the obnoxious stimulus is removed or the underlying tissue damage or pathology is healed. Term is usually associated with describing duration or acute and chronic pain with acute being your quickly resolving pain and your chronic being your longer lasting pain usually than greater than six months of duration. Different types of pain include nociceptive, neuropathic, phantom and psychogenic. Nociceptive pain most directly relates to our topic today, so we’re going to discuss over the next couple slides. Then we have neuropathic pain which affects somatosensory system as seen in our diabetics. They usually complain of the burning and tingling type of pain. And we have phantom pain which is pain from the part of the body that has been lost or from which the brain no longer receives signals.

    [05:01]

    This is seen in our patients that have had unfortunately amputations and studies suggest that a large number of these 82% in the upper extremity and 54% in the lower extremity are going to have some type of phantom pain. And finally, the psychogenic pain which is pain caused increased or prolonged by mental, emotional or behavioral factors. And examples of these would be backache or a headache. Nociceptive pain is pain caused by stimulation of peripheral nerve fibers that respond only to stimuli approaching or exiting harmful intensity. It’s classified according to the mode of obnoxious stimulation. We have thermal, mechanical and chemical while thermal’s being your temperature-driven was something being too hot or too cold. You have your mechanical which is a little bit more physical, was something being crushing or tearing or it is the kind of pain that we produce during the surgery. And finally, chemical which can be caused absolutely by a chemical and example of this would be like having iodine in a cut. Our body perceives pain in a five step pain pathway process. The first being the signal transduction at the peripheral receptor site following by signal conduction along the peripheral nerve then pain modulation at the level of the spinal cord. Pain perception at the super spinal site and then dissociative sensations, emotional reactions and affective state. Topical anesthetics affective pain pathway by reversibly blocking the conduction near the site of administration thereby producing temporary loss of sensation in a limited area. Here’s the famous picture of a neuron and we have the signals that are being received by the dendrites going to the cell body, the nucleus, the axons and then being transmitted at the end by those axon terminals. Here is an illustration depicting the pain pathway. Again, we’re going to have some form of obnoxious stimuli by being thermal, mechanical or chemical. This is going to go to the levels of peripheral receptor sites down to the peripheral nerves to the spinal cord up to the super spinal levels and then the brain telling our body that we’re having some type of pain or discomfort. Another reason why I want to use topical anesthetics is a decrease stress levels. Trypanophobia is the extreme fear of medical procedures involving injections or hypodermic needles. It was officially recognized in 1994 in a DSM IV. It was estimated 10% in the United States populations that are trypanophobic as more likely that the numbers much higher but it’s also are really have fear of needles won’t seek medical attention and therefore that’s not going to be documented. Different types of needle phobia includes vassal vagal, associative, resistive, hyperalgesic, and vicarious. Vassal Vagal’s one and probably most common with as when you see a rapid increase in the blood pressure followed by a dramatic plunge. Physiological signs for that would include sweating, pallor, nausea and vomiting. Here’s a quick list of some famous people with trypanophobia among them are NBA Star Derrick Rose and Late Night Talk Show host Conan O’Brien. Again why do we want to use topical anesthesia? We want to use the first ease of application. You can achieve topical anesthesia by the following methods. We can simply apply a cream or a liquid. We could use iontophoresis or we could use topical sprays or vapocoolants. Another reason why I want to use them for their variety of usages. We kind of touch on this a lot last year, we could use them for pre-injection anesthesia and for minor surgical procedures. I think as podiatrist, we are all very comfortable using topical anesthesia before we do pre-injection anesthesia and last year we really emphasized the growing role of topical anesthetics used for minor surgical procedures. So hopefully over the last year live, you have been using them as so form of topical anesthesia for. These minor surgical procedures and following your patients to be happy and that you’re going to be more efficient office. Some of the reasons for the pre-injection anesthesias and diagnosis we can use them for but not limited to neuromas, plantar fasciitis, bursitis, capsulitis, any of our many arthritic conditions that we deal with and for the podiatric blocks that we do in the office. So minor surgical procedures that could be used for incision and drainage of a bursa, paronychia or abscess, for ingrown toe nails, aspiration of lesions such as ganglionic cyst, incision removal of superficial foreign bodies and excision of skin growth or skin tags. Different forms of topical anesthesia. We have that we’ll talk about today are the creams. We’re talking about EMLA. Topical devices. We’re going to talk about iontophoresis and sprayer or topical vapocoolant. We’re going to discuss ethyl chloride. First we’re going to talk about EMLA. EMLA is a pneumonic for Eutectic Mixture of Local Anesthetics. These local anesthetics are lidocaine and prilocaine which are both a 2.5%.

    [10:02]

    EMLA works by relieving pain of normal intact skin and numbing the skin to pain from injections and other medical procedures. Lidocaine and prilocaine are both EMLA type local anesthetic agents. How EMLA works is it producers a transient biphasic vascular response involving initial vasoconstriction followed by vasodilatation at the application site. The onset, depth and duration of derma anesthesia depends on duration of application. And for minor surgical procedures it’s recommended that EMLA should be applied under occlusion for approximately one hour before you do the procedure. So again the onset of action is going to be 60 minutes. Duration is going to be up to five hours. We got a good depth of penetration of 4 to 5 millimeters and it’s a proof for ages 37 weeks gestational and up. Contraindications include in patients with a known history of sensitivity to the local anesthetics of MI type and should not be used in patients with congenital or idiopathic methemoglobinemia, it’s a very tough word to say. And that’s usually associated with patients that has sensitivity to prilocaine. Some precautions. Repeated doses may increase blood levels of lidocaine or prilocaine. You want to avoid contact with the eyes. You want to use in caution in patients with hepatic disease because of their inability to metabolize the local anesthetics normally. Drug interactions for EMLA. EMLA should be used with caution in patients receiving Class 1 antiarrhythmic drugs. There are toxic effects or additive and possibly synergistic. It’s a pregnancy category B drug and in lidocaine and probably prilocaine are excreted in human milk, so you want to avoid in mothers that are breastfeeding. Some side effects are abnormal skin sensation, burning, change in hot or cold sensation, pale skin, and redness or swelling at the application site. So now I can go over the quick step-by-step process of doing EMLA cream. You’re going to apply a generous portion of the cream to the site where your minor surgical procedures can be performed. Then you’re going to apply under occlusion with something like a tegaderm or similar product for approximately 60 minutes. Remove the tegaderm, wipe off the EMLA and then you’re going to use antiseptic to clean it down and begin your minor surgical procedure. Now we’re going to discuss iontophoresis. Iontophoresis is a technique using a small electrical charge to deliver a medicine or other chemicals through the skin. It’s also known as electromotive drug administration or EMDA. It’s a non-invasive method or propelling high concentrations of a charged substance transdermally, so basically it’s an injection without a needle. How it works? You have one or two chambers are filled with a solution containing an active ingredient and a solvent also called the vehicle. In this case for using for anesthetic purposes, we’re going to use a lidocaine or if you want to use a slightly longer acting anesthetic, we’ll use Marcaine or Bupivacaine. So you have a positively charged chamber called an anode which repels a constantly charged chemical. Now we have a negatively charged chamber called the cathode which would repel a negatively charged chemical into the skin. So here’s a typical iontophoresis unit. You have your current source and your anode and your cathode. It’s indicated for numbing the skin before performing a certain medical procedures. Onset of action is approximately 10 minutes and a duration can last up to an hour. Contraindications are cardiac pacemakers or other electrically sensitive implanted devices. Known sensitivities to drugs to be administered and you don’t want to use undamaged skin or recent scar tissue. Warnings and precautions. We want to avoid applying over hair follicles or nevi. You don’t want to shave the application site if necessary, you can just clip the hair in that area. Do not want to use the presence of flammable gases like oxygen. The current settings should never exceed the patient comfortable levels or the maximum current setting unless you really don’t like the patient. Then you could advise patients to remove all jewelry from the treatment area. You do not allow any metal that come in contact with the electrodes during treatment. You do not remove the electrodes from the patient before terminating the current source and we do not get the electrodes wet as it may cause the electrodes to short. So here’s a picture of on left, your traditional iontophoresis unit again with your current source and your anode and your cathode. In right, they’re kind of – in the right side developing some new way, units are kind of all in one and simple to apply units. Finally today, we’re going to discuss the Gebauer Company’s product ethyl chloride. Ethyl chloride is a topical skin refrigerant that creates an instantaneous cooling effect on the surface of the application site by the immediate evaporation of the product from the skin surface. The coldest created by the spray decreases the nerve conduction velocity of the C fibers and the A delta fibers that make up the peripheral nervous system thus interrupting the nociceptive inputs to the spinal cord.

    [15:02]

    Is the FDA cleared medical device and indicated for injections? IV starts in venipuncture, minor surgical procedures, and minor sports injuries. Well ethyl chloride really separates itself from the other kind of generic cold sprays is that it is a clean product. Meaning that you can have the area swab down before you’re ready to do your injection or your minor surgical procedure. Then you could spray the ethyl chloride and immediately start either your injection or your procedure. The other kind of generic cold sprays are not clean so you would have to spray first then swab it down and then start your procedure when you’ll be losing most of your cooling effect to that. Contraindications for ethyl chloride are individuals with history of hypersensitivity to the product and if skin irritation develops, you want to discontinue the use. Risk and safety information include public clinical data supports the use of ethyl chloride and three years of age or older. For external use only. You do not want to store above a 120 degrees and you do not want to place near flame or any hot surfaces. You do not want to spray in the eyes, contagious sensations may occur in rare cases. Freezing can occasionally alter skin pigmentation and overspray may cause frost bite. Long term exposure may cause liver or kidney damage. Other precautions inhalation of ethyl chloride should be avoided and it’s flammable, so you do not want to use it in the presence of an open flame or electrical cautery device. So proper uses for ethyl chloride. You want to have your syringe or your instruments ready for injection or your minor surgical procedure. You’re going to swab the treatment area with an antiseptic. Want to spray continuously for approximately three to seven seconds from a distance of around three to nine inches away. You want to spray the area until it just turns white or blanches. You do not want to frost the skin and then you’re immediately able to start your injection or your minor surgical procedure. So here we have your traditional amber bottle. On your left which you all familiar with I’m sure and then we have the new Acustream it’s kind of took over their can product of the ethyl chloride which the Gebauer Company launched last year which has the same kind of nice grip. You can hold it at any angle and spray it at any angle and it has now a locking mechanism because you can see around the neck of the bottle. By using ethyl chloride, we could also have a possible beneficial impact economically in our practices. Again, we’re going to increase our patient’s satisfaction which is very important which we also going to have some better time management which will lead you to an increase patient load and hopefully an increase revenue. Ethyl chloride can increase patient’s satisfaction again by having a calming effect on patients to have this topical anesthesia used prior to injection therapy. And we eliminate the fear of needles from minor surgical procedures which is also a safety issue because you could be avoiding needles as a safety precaution for both you and the patient. Also can have a better time management and increase patient load. So by using ethyl chloride for minor surgical procedures, you don’t have to waste time loading up anesthesia in syringes. You’re not going to have to walk over to your cabinet, take a lidocaine but I’ll swab the top, stick an 18 gauge needle and drawing it up. If you want to use a cocktail, Marcaine do the same thing with that then put a 27 gauge needle on and then begin. We also have to wait for the anesthesia to take effect and so we don’t have to a room while we’re waiting. So a lot of people they’re going do a minor surgical procedure will numb their patients up and then they’ll have to wait for that to take effect, so that you do not leave and go to another room to see a patient or go to some of their paperwork. But we can eliminate that just begin right away. So here’s just a potential economic benefit. This is increase revenue based on a working 250 days per year and the left if you would be able to improve your efficiency by, you or your group, by improving your efficiency by either one patient per day, three patients per day or five patients per day. On the right would be your kind of per patient revenue whether you’re making $50, $755 or $100 per patient. In the bottom would be the possible thousands of dollars more per year that you could earn. So if you’re able to add one patient a day and your per patient revenue is $75, you could add just a sign of $20,000 more per year and if you’re able to add five patients a day as you became more efficient then it could be upwards to $90,000 per year. So finally we have, I believe that kind of seeing is believing so we have four short videos of some pre-injection anesthesia and some minor surgical procedures. Again these are short videos because we’re using a topical anesthetic, we don’t have to wait for the injection to take place. Is there any way that we could get the videos? Great. Thank you. So first is just a typical plantar fascia patient. You got the area swab down before.

    [20:00]

    You have your area of max tenderness already marked off. You got to spread the ethyl chloride to just blanches then you’re going to just do your trigger point injection. Next is a patient that comes in with a nail trauma. We start with this one too please. So we have the patient that comes in. There was the nail as lytic medially here and still here laterally and proximally. So instead of having to numb the patient up, wait for it to take place. We simply apply the ethyl chloride and then avulse the remaining portion of the nail. Here’s a patient that has irritating skin tag, so instead again of having to take it out, give a digital B block and go just spray the ethyl chloride to the area of blanches again. You’ll have the proper anesthesia that you need for it, then you could go in and excise your skin tag. And finally, we have a patient with an ingrown nail or paronychia that we see all the time. So again we’re just going to spray the area and avulse the offending nail border that’s bothering the patient. So I hope by today’s lecture that we learn by controlling pain management to this topical anesthetics that we can help improve our patient’s satisfaction and enhance their perception of the patient office and their patient experience. I hope you all enjoy the rest of the conference and I thank you very much for your time.