Introduction
In 2014, the Wilderness Medical Society (WMS) published guidelines for the treatment of acute pain in remote settings. We surveyed wilderness medicine providers on self-reported analgesia prescribing practices.
Methods
We conducted a prospective, anonymous survey. Respondents were recruited from the WMS annual symposium in 2016. All willing attendees were included.
Results
During the symposium, we collected a total of 124 surveys (68% response rate). Respondent age was 42±12 (24–79) years (mean±SD with range), 58% were male, and 69% reported physician-level training. All respondents had medical training of varying levels. Of the physicians reporting a specialty, emergency medicine (59%, n=51), family medicine (13%, n=11), and internal medicine (8%, n=7) were reported most frequently. Eighty-one (65%) respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale being the most common (54%, n=67). Most participants reported preferring oral acetaminophen (81%, n=101) or nonsteroidal anti-inflammatory drugs (NSAID) (91%, n=113). Of those preferring NSAID, most reported administering acetaminophen as an adjunct (82%, n=101). Ibuprofen was the most frequently cited NSAID (71%, n=88). Of respondents who preferred opioids, the most frequently preferred opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preferring oral transmucosal fentanyl citrate (9%, n=11). Twenty-five (20%, n=25) respondents preferred ketamine.
Conclusions
Wilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.
Keywords
Introduction
Background
Pain is the most common complaint encountered in wilderness settings.
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In 2014, the Wilderness Medical Society (WMS) published clinical practice guidelines for the treatment of acute pain in response to recurring reports of inadequate pain management in the prehospital setting.6
Previous reports attribute insufficient analgesia administration in the austere environment to transportation restrictions, medication storage requirements, vascular access challenges, patient monitoring limitations, limitations due to cold-weather clothing, provider comfort with specific medications, and lack of evidence specific to this setting.6
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, Research has found that uncontrolled pain is associated with significant stress responses, deleterious health effects, and psychologic disorders.6
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The WMS recommends a tiered approach to pain management.
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Initial interventions include comfort care, cryotherapy, compressive bandages, and splints. First-line medication should be the combination of acetaminophen and a nonsteroidal anti-inflammatory drug (NSAID). Providers may advance to oral formulations of opioids—oxycodone, hydrocodone, or oral transmucosal fentanyl citrate—if moderate or severe pain persists. If these medications are insufficient or the patient is in moderate-to-severe pain, the WMS endorses intranasal (IN) or intramuscular (IM) administration of opiates, with IN preferred over IM because of the slower and variable absorption rates with IM administration. Finally, intravenous (IV)- or intraosseous-administered opiates, such as morphine and fentanyl, should be considered for moderate-to-severe pain when vascular access can be obtained and the need for repeated dosing is likely. The WMS considers ketamine an advance-tier analgesic agent that is particularly useful for painful, short-duration procedures. Local and regional anesthesia is recommended if the provider is properly trained.Our survey of pain management practices was designed to assess the current provider preferences for analgesia management practices in the wilderness setting. We describe the practice patterns as reported by providers in this survey study.
Methods
Study Design
We conducted an anonymous, voluntary survey assessing the pain practices of wilderness medicine medical personnel. The protocol was submitted to the Colorado Multiple Institutional Review Board. This study was determined to be exempt from Institutional Review Board oversight (COMIRB protocol 16-1259). Surveys were offered to all wilderness medical providers attending the Wilderness Medical Society annual summer symposium in 2016. Incomplete surveys were included if the demographic information was complete to accurately stratify participants into groups. We designed a survey targeted at collecting provider demographics, pain assessment methods, and reported preference of various analgesic agents in the austere, wilderness setting (see Appendix).
Analysis
We performed all statistical analysis using Microsoft Excel (version 10, Redmond, WA) and JMP Statistical Discovery from SAS (version 13, Cary, NC). Ordinal variables are reported as medians and interquartile ranges. Continuous variables are reported as means and standard deviations. We set significance at P≤0.05.
Results
During the symposium, we collected 124 completed surveys of the 182 distributed, for a 68% return rate. There were 421 conference attendees in total. The average age of respondents was 42 (±12, range 24–79) years, 58% were male, and 69% reported physician-level training (Table 1). Of the physicians reporting a specialty, 59% were emergency medicine (n=51), 13% family medicine (n=11), and 8% internal medicine (n=7). Of the physician assistants, most were trained in emergency medicine (18%, n=2) or orthopedics (18%, n=2). Of the nurse practitioners, 1 was emergency medicine and 1 was family medicine based.
Table 1Characteristics of survey participants
| Variable | Participant statistics % (n) |
|---|---|
| Demographics | |
| Age, y | 42 (±12) |
| Male | 58 (72) |
| Education | |
| Physician | 69 (86) |
| Physician assistant | 9 (11) |
| Nurse practitioner | 2 (2) |
| Nurse | 3 (4) |
| Medical student | 5 (6) |
| EMT (all levels) | 12 (15) |
EMT, emergency medical technician
The majority (65%, n=81) of respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale (NRS) being the most common (54%, n=67). Most participants preferred oral NSAIDs and acetaminophen; parenteral agents were infrequently preferred (Table 2). The most frequently reported NSAID noted was ibuprofen (71%, n=88). Most reported using acetaminophen either alone or as an adjunct (82%, n=101). Of respondents using opiates, the most frequently noted opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preference of oral transmucosal fentanyl citrate (9%, n=11). When specifically asked about ketamine, most reported no preference for this agent (80%, n=99). Of those who prefer ketamine, the most frequently reported route was IV (76%, n=19) and IM (44%, n=11).
Table 2Reported preference of specifically queried analgesic agents
| Drug | All responders (n=124)% (n) | Advanced provider (n=114) % (n) |
|---|---|---|
| Oral NSAID | 91 (113) | 90 (103) |
| Parenteral NSAID | 9 (11) | 9 (10) |
| Acetaminophen | 81 (101) | 81 (92) |
| Oral opioids | 45 (56) | 47 (54) |
| Parenteral morphine | 5 (6) | 4 (5) |
| Parenteral hydromorphone | 4 (5) | 4 (5) |
| Parenteral fentanyl | 9 (11) | 10 (11) |
| Oral transmucosal fentanyl citrate | 9 (11) | 9 (10) |
| Parenteral ketamine | 14 (17) | 14 (16) |
NSAID, nonsteroidal anti-inflammatory drug.
a Advanced provider includes doctor of medicine/doctor of osteopathic medicine, nurse practitioner, physician’s assistant, and emergency medical technician; this excludes nonadvanced practice nurses and students.
Discussion
Overall, we found that respondents reported analgesic preferences that are recommended by the WMS. Most participants prefer NSAIDs and/or acetaminophen to treat acute pain, which mirrors the recent guidelines. The frequency of analgesic preferences reported by respondents coincides with the tiered approach to acute pain control recommended by the WMS, with the majority of respondents reporting a preference for NSAIDs.
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We must note, however, that we did not survey on the use of pressure, rest, ice, compression, elevation practices, the first-line therapy noted in the guidelines, before prescription of NSAIDs.A low proportion of respondents (20%; 25 of 124) reported preferring ketamine. Research studies on acute pain control in the emergency department have reported that low-dose ketamine (<1 mg·kg-1) is safe and effective
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; IN ketamine is as effective as IV ketamine14
; and IN ketamine is as effective as IV and IM morphine.15
Because wilderness medicine providers may be limited in how much they can carry with them, a multipurpose medication is advantageous. Ketamine is effective for a multitude of painful medical and trauma conditions as well as procedural sedation and airway management.16
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The lower response rate for this analgesia agent is fitting with the escalation of medication pyramid noted in the guidelines.Most respondents (54%; 67 of 124) reported use of the NRS as a pain assessment tool. Although the visual analog scale is typically used in clinical trials, the NRS is acceptably reliable and valid, and its psychometric properties are similar to those of the visual analog scale.
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The WMS guidelines endorse the use of NRS and define moderate pain as 4 to 6 and severe pain as 7 to 10.6
The WMS guidelines also note the use of a verbal rating scale that corresponds to the NRS that was most frequently reported.Limitations
This study carries several limitations related to both study design and the inherent challenges with survey-based studies. First, we limited this population to those attending the WMS annual symposium. Although we attempted to capture a broad base of that population, voluntary participation may have provided a limited sample. We did not track how many potential subjects were offered a survey, nor do we have data on how well our sample matched the overall training/experience level of conference attendees. Response bias may be present. Second, we accepted surveys even if they were incomplete and used the data that were provided. Third, we did not assess the providers’ escalation of treatment in a stepwise fashion, which may carry limitations as personal algorithms may vary. The ability of providers at different levels to carry some drugs is limited both in licensure and by state, which may have led to challenges in answering questions in such a blanket fashion. We only assessed stated preferences in a single, nonprogressive question−design manner. Respondents may have provided different answers if survey questions occurred in a series of progressive questions (ie, Delphi-like method). Fourth, we only assessed provider-reported preferences and were unable to assess actual use and administration rates. It is possible that providers may have varying preferences and actual use rates, depending on location and travel circumstances. Fifth, we did not assess the circumstances and frequency at which respondents care for patients in the wilderness. Lastly, we did not keep data on how many potential participants were offered a survey and declined. The survey was voluntary and thus may be limited to those with a special interest in wilderness analgesia.
Conclusions
Wilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.
Author Contributions: Protocol development (SGS, DJB, RVG, IS, TC); data collection (DJB, RVG, IS); data analysis/interpretation (SGS, JFN, TC); manuscript development (SGS, JFN, DJB, IS, TC).
Financial/Material Support: None.
Disclosures: Opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force, the Department of the Army, or the Department of Defense.
Appendix A. Supplementary material
Supplementary material
References
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Article info
Publication history
Published online: March 22, 2018
Accepted:
January 23,
2018
Received:
August 31,
2017
Identification
Copyright
All rights reserved.
