I went on to see other patients in the emergency department when the mother of the patient came up to me. She hugged me and started crying on my shoulder, thanking me for taking care of her child. She told me that she could not have watched her son suffer any longer. Seems trite, but the case made me realize that taking an active role in offering great pain control to my patients is central to my job. I have taught these ultrasound-guided blocks to numerous emergency medicine physicians around the country, and I often get emails of similar stories. This reinforces my desire to continue my educational efforts to help clinicians understand the importance of using ultrasound to assist in great pain control.

It seems to be a nebulous term—doctors taking care of somebody’s pain—as it should be something all doctors do. But it’s not always easy. Giving doctors different methods to address pain, be it an ankle sprain or a tooth infection, is an important skill to teach. Having pain control tailored around the injury rather than just a simple algorithm of pain meds must be something we teach the next generation of clinicians. Learning how to incorporate ultrasound specifically for nerve blocks is an important skill for any emergency medicine provider today.


HCB News: Let’s talk more about the multimodal approach you hinted at. Many parts of the United States are reeling from the opioid epidemic. How can ultrasound for pain management help groups impacted by this crisis?
AN: This is a complicated question. I think the opioid epidemic is a complex problem and I don’t want to ascribe it to one thing because it removes its complexity and difficulty. It goes deeper than just pain, but some data point out that giving patients long-term opioids for pain control can lead to dependence. Thinking of pain as monomodal with increasing opioid doses as the only pathway has been shown to cause downstream problems.

If clinicians are thinking more about multimodal therapies, we have more choices: opioids, ketamine, acetaminophen, NSAIDs delivered intravenously, nerve blocks, etc. This multimodal way of thinking of controlling our patients’ pain reduces the reliance on opioids. A simple example is when we manage pain in elderly patients after suffering a hip fracture. The classic teaching is to give intravenous morphine (or another opioid), but we have learned that along with increasing rates of confusion, this monomodal pathway can cause patients to stop breathing or lower their blood pressure to a dangerous level. I want more physicians to use the minimal effective dose of a drug, add in another drug or perform an ultrasound-guided nerve block. It’s the job of the clinician to think about the patient and offer them great care, which is the central tenant of multimodal pain management.

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