Persistent and Severe Pain

Pain is a frequent complaint that brings patients to the ER. Abdominal and chest pain are some of the most common. I often get asked by patients, usually at the end of a negative abdominal or chest pain workup, when they should come back.

This is difficult to answer. The older the patient and the more chronic medical problems they have, the higher the chance that something significant is causing their symptoms. The younger and healthier they are, the lower the chance, but diseases and disasters don’t exclude anyone 100%. Everyone knows a story of someone, often young, dropping dead with no warning. Is it likely when you are young and healthy that you can ignore most symptoms? Yes, but there are no guarantees.

So what should my answer be? Telling a patient with known coronary artery disease to ignore chest pain is obviously risky. Patients like those who are prescribed nitro at home by Cardiology are often encouraged to take up to 3 doses of nitro for chest pain and call 911 when they take the 3rd dose or if the 3rd dose doesn’t work.

If a patient has chest pain that is thought not to be cardiac in nature, and has had a negative workup for the most serious things but still has pain, when do I tell them to come back? When should they follow up with primary care? What’s the safe answer that limits unnecessary ER visits but doesn’t miss disasters that can strike at any time?

There is no clear answer.

What is the patient’s pain tolerance? What is actually causing their pain? There is a lot of diagnostic uncertainty in the ER. We are in the “rule out” business more often than the “rule in” business. 20-30% of patients that come to the ER get admitted. Truly critical patients are usually only single-digit percentages for all comers. That means up to 80% of patients go home. Many, if not most, have no definitive diagnosis, but we are reasonably reassured on that particular day that they don’t have an actual emergency or serious condition that needs further treatment in the hospital for either their symptoms or their condition.

Abdominal pain is also problematic. The older you are, the more likely we will find a cause of your abdominal pain in the ER because things like diverticulitis and bowel obstructions (among other things) are more common. The younger you are, the less likely we find anything diagnostic despite our best efforts with labs and radiology. Estimates are that 40% of abdominal pain is undiagnosed in the ER, and that number is higher the younger you are.

Things like GERD, gastritis, esophageal spasm, and constipation, gas/bloating, and biliary colic are not things we can definitively diagnose in the ER most of the time. A CT will sometimes show significant constipation but “normal” appearing amounts of stool and gas in the bowel doesn’t tell us much. I believe it can still cause significant pain but can’t prove it. It’s the same with upper GI symptoms. A CT can show a ruptured gastric ulcer or severely eroded gastric ulcer but run-of-the-mill gastritis or esophageal symptoms don’t have a definitive test.

Biliary colic can be severe but can come and go, and an ultrasound of the gallbladder can rule out cholelithiasis (gallstones) or cholecystitis (infection/inflammation) but can’t say for sure what caused the patient’s presenting symptoms. Gallstones make biliary colic more likely but it’s not 100% definitive.

Back pain is similarly problematic. Sensory symptoms are not a true emergency. They may require IV opioids for pain control but that does not mean there is actually a structural problem that needs emergent imaging or that can be easily fixed. Back pain may persist for hours to days; for some patients it becomes chronic and at times severe. Back pain red flags are drilled into doctors’ heads way back in medical school—bowel or bladder dysfunction, abnormal perineal sensation (the sensation under your underwear), saddle anesthesia (numbness on the inside of your thighs), fever, major or minor trauma relative to your age, immune-compromising conditions, history of cancer, and actual weakness of your lower extremities. Limited movement secondary to pain is not the same as actual weakness.

If you have no red flags, you likely don’t need imaging in the ER. This is one of the hardest things to have a conversation about with patients. And here’s a little secret… providers are disincentivized to order imaging for back pain or prescribe opioids. Our metrics are tracked by hospital systems and CMS. The conversation usually goes something like this:

Patient: My pain is so severe I can’t walk or move.

Me: I understand and I realize we gave you opioid pain medicine here and now things have improved (slightly or significantly). Despite how bad you feel and despite not having a precise reason for your pain, you don’t need any testing and I can’t send you home with opioids. Any questions? Good luck with the OTC meds, physical therapy and chiropractic referrals.

Patient: WTF!?

I’m being facetious but you get the point.

This is one of my least favorite conversations and one of the hardest. I can’t tell a patient what is definitively going on, but I’m not supposed to look further with XRs, CTs, or MRIs. And I’m not supposed to send them home with stronger pain medicine even if that’s what got their pain to a tolerable level in the ER.

You can imagine this often does not go well.

So back to the question of, “What do I tell patients about their pain that warrants coming back to the ER?”

If they are receptive, with back pain, I can explain the red flags and reassure them they don’t have any right now and if they continue to not have any, they don’t need an ER visit. I can’t make them tolerate pain as that is uniquely individual to every patient. There is no objective test for how much pain a patient is truly having. It’s too complex. With chest pain and abdominal pain, the answer is harder. Again, I often don’t have a definitive diagnosis. There are plenty of things in the chest and abdomen that can be serious. Refer to my post about referred pain. The location of pain can overlap between different structures in the body so non-serious left-sided chest pain can be from the chest wall. But it can also be cardiac in nature and they might feel very similar.

Persistent and severe pain is often a hallmark of many medical emergencies. Things like appendicitis, for example, tend to keep getting worse and generally don’t resolve on their own. Aortic dissections are often not subtle in presentation with severe chest and tearing or ripping pain that goes to the back. But there are no guarantees.

(Chronic pain is different and warrants its own post. Stay tuned. Generally, the more intermittent and chronic, the less likely it is a true emergency.)

Context also matters. See my prior post about that.

So when should pain make you go to the ER? Persistent and severe is a good rule. And I realize that is vague. How long? How severe? But that’s the truth. There is no universal answer that applies to all patients.