Favorite Procedures

Matthew DeLaney, MD, FACEP, FAAEM, Andy Little, DO, and Drew Kalnow, DO

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The summary below is from an episode of ERcast: Clinical Perspectives

Emergency department procedures are often more painful than clinicians expect, especially in awake patients. Nasogastric tube placement, abscess drainage, fracture reduction, and urethral catheterization rank high for procedural pain, while routine immobilization measures like cervical collars and backboards can also cause substantial discomfort in older adults.

Procedural Pain in the ED

Patient pain ranking: Nasogastric intubation, abscess drainage, fracture reduction, and urethral catheterization were the most painful common ED procedures by patient report, a useful reset when planning analgesia before touching the patient.
Clinician pain underestimation: Practitioner and patient pain scores correlated only poorly to fairly, underscoring that bedside intuition is an unreliable gauge of procedural suffering and worth hearing about in the episode.
Local anesthesia gap: Local anesthetics were used in just 12.8% of procedures, yet more patients said they would want analgesia for a similar future procedure, pointing to a clear treatment gap.
Pain versus distress distinction: Not every difficult procedure is driven by nociception alone; separating pain from distress helps decide when anxiolysis, not just local anesthesia, may be the missing intervention.
Low-cost comfort measures: Simple options like LET and vapocoolant spray can meaningfully reduce procedural discomfort without slowing flow, and we get into where they fit best in the chapter.

Hidden Pain From Routine Care

Elderly patient pain triggers: In older ED patients, urinary catheterization, cervical collars, and immobilization mattresses frequently caused moderate or severe pain despite being framed as routine supportive care.
Collars and backboards: Cervical collars and backboards are easy to overlook as pain sources, but they can be more distressing than many diagnostic studies and should prompt earlier reassessment and relief.
Imaging contrast point: X-rays, CT, and bedside ultrasound were associated with a median pain score of zero in one cohort, sharpening the contrast with the discomfort from restraint and immobilization.
Ask before proceeding: A simple offer of analgesia before routine procedures can uncover unmet needs, especially in older adults who may otherwise endure significant discomfort without volunteering it.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

Singer AJ, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med. 1999;33(6):652-658. PMID: 10339680
Baril L, et al. Pain induced by investigations and procedures commonly administered to older adults in the emergency department: a prospective cohort study. Emerg Med J. 2021;38(11):825-829. PMID: 34344731

Faculty

Matthew DeLaney, MD, FACEP, FAAEM
Dr. Matthew DeLaney is an emergency medicine physician and educator based in Birmingham, Alabama. A native of Mobile, he earned his medical degree from the University of South Alabama and completed his emergency medicine residency at Maine Medical Center.Dr. DeLaney has experience in both community and academic emergency medicine and is known for his commitment to teaching and medical education. He lives in Birmingham with his wife, Erin, who is also a physician, and their two daughters.
Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.
Drew Kalnow, DO
Dr. Drew Kalnow is an emergency medicine physician and educator based in Columbus, Ohio. He completed his emergency medicine training at OhioHealth Doctors Hospital Emergency Medicine Residency. Dr. Kalnow is passionate about advancing emergency medicine through high-quality education, with a particular focus on simulation, learning theory, and innovative teaching.