The ER Will Tell You You're Not Dying. That Is Not a Diagnosis | The Pained Brain, Chapter 10

ER visit for chronic pain

After an ER Visit for Chronic Pain: What Was Never Measured

An ER visit for chronic pain measures whether you are in danger tonight: vital signs, a pain score and often an image. It does not measure why you hurt or your metabolic terrain, so in the week after, ask your physician about fasting insulin next to glucose and HbA1c, and body composition.

The emergency room is built to rule out what could kill you tonight. The questions about why you hurt, and what your metabolic terrain is doing, usually leave the building with you, unasked.

An ER visit for chronic pain usually ends with news that should feel better than it does: you are not dying. Your heart, your breathing and perhaps a scan came back acceptable, and you went home with a diagnosis that names the place that hurts. A week later, the pain is still there.

The video above, The ER Will Tell You You’re Not Dying. That Is Not a Diagnosis, is Chapter 10 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. It follows one long night in the waiting room. The question here is narrower: what the emergency department measured, what it had no way to measure, and what to ask for next.

When should you go to the ER for chronic pain?

Emergency departments are designed to catch the rare catastrophe, and they are good at it. Of 41,320 emergency back-pain patients pooled from 22 studies, 2.5 to 5.1 percent had something needing urgent treatment: a fracture, a cancer, an infection or a squeezed spinal cord. At one Melbourne department reviewing 1,000 consecutive back-pain visits, the signs that most raised the chance of serious spinal disease included numbness in the saddle area, sudden inability to pass urine and loss of anal tone. For any serious cause, fever led by a wide margin.

If you have those signs, go now. If you were sent home and you get worse, with a fever or new weakness, go back. A spinal abscess is the classic miss: among 457 confirmed cases, 71 percent had been seen for a related complaint in the month before.

What does an ER visit for chronic pain actually check?

Every measurement in an emergency room serves one decision: admit, treat now, or send home. Vital signs, a pain score, often an image. Nationally, 39.4 percent of emergency visits for back pain included a plain X-ray, and the average stay ran 236.6 minutes. An observer who shadowed emergency physicians found that about a quarter of their shift minutes, 26.9 percent, went to patients, while 34.1 percent went to the computer.

What you carried home is often a label rather than a cause. In national data representing 164 million adult emergency visits for chest pain, abdominal pain and headache, diagnoses naming an actual pathology fell from 72 percent in 1993 to 63 percent in 2009, while testing grew. Back pain was not part of that sample, but the most common back-pain discharge labels also describe a location. A label is a starting point that somebody else has to pick up. What a test result can and cannot tell you is worth reading with your discharge papers in hand.

What can the ER not measure about chronic pain?

Dr. Padda asks three questions of any persistent pain: which structure, which mechanism, which terrain. The emergency department is not built to answer any of them, and it should not be expected to. Proving that a particular spinal joint is the source takes an image-guided diagnostic block, which is a pain specialist’s procedure. The terrain question is different. It can be put into numbers without a needle in the spine.

Terrain means the metabolic background that keeps a nervous system primed for pain: insulin that runs high for years while glucose stays normal, fat stored around the organs, and the food, sleep and stress patterns that feed both. Fasting insulin does not appear on emergency order sets for back pain, and Dr. Padda knows of no emergency department that draws it for that complaint. It does not change the decision made that night, so it never gets drawn.

That is the gap Measura [Cardiometabolic and Autonomic Health Analysis] addresses. It is a testing service, not a treatment, and results go to your physician.

Laboratory panels can include fasting insulin next to glucose and HbA1c, the pairing explained in what insulin resistance looks like before diabetes.
Bioimpedance body composition separates fat from muscle, which a weight and a BMI blend together.

Neither test finds the structure that hurts, and neither replaces a pain evaluation. They answer the question nobody in the waiting room had time to ask. The page on chronic pain and metabolic health explains why that question belongs in a pain workup at all.

What should you do in the week after an ER visit?

Leaving the building does not end the problem. In a New York cohort of 556 people discharged after back pain, seven in ten could not function normally one week later, and nearly half were still impaired three months on. In a second group, people whose pain persisted at the one-week point had 2.42 times the odds of being impaired at three months. The first week is when the course of the next season is still easiest to change.

Many people return to the same room instead. One hospital saw 14 percent of these patients return with the same complaint inside twelve months. Part of that is a missing destination, and emergency physicians say so themselves: when Canadian emergency physicians were surveyed, 96 percent reported no effective chronic-pain pathway in their department and 70 percent said they did not know where to send these patients. The care is not evenly shared either. Pooled American studies found Black patients 40 percent less likely than White patients to be given analgesia for acute pain.

The fault is not the emergency physicians, who rate their own pain care lower than physicians in any other specialty surveyed do. The fault is a system with no door between the waiting room and a plan. A measurement visit in that first week is one way to open it, because a plan built on your own numbers is harder to lose than a phone number on a discharge sheet.

What to ask for after the visit

Did my discharge diagnosis name a cause, or only where it hurts?
Which red flags were checked, and were any positive?
Has anyone measured my fasting insulin, not just my glucose?
What does my body composition show, apart from my weight?
Who will see me within a week if this pain is still here?

For help putting those questions in order, see questions worth asking your doctor. The book’s companion lays out every study behind these figures and what each cannot show. If the pain that sent you to the ER spread beyond one spot, what central sensitization symptoms can show in your numbers covers that side.

Frequently asked questions

Should I go to the ER for chronic pain?

Go when something new and dangerous appears: numbness between the legs, sudden trouble passing urine, loss of bowel control, new leg weakness, or fever with back pain. Without those, the emergency room can confirm you are not in danger but is not set up to find the cause, so a physician visit and measurement are the better next step. See who should be tested.

Why didn’t the ER check my insulin?

Emergency order sets are built around conditions that must be found tonight. Insulin resistance develops over years and does not change whether you are admitted or discharged, so it is left for later. A laboratory panel ordered afterward can include fasting insulin alongside glucose and HbA1c, giving the metabolic side of the picture. Read about insulin resistance and metabolic health.

My X-ray was normal. Does that mean nothing is wrong?

It means the X-ray did not show a fracture or the other things a plain film is designed to show. It cannot show a sensitized nervous system, the source joint, or your metabolic terrain. Imaging for emergency back pain has increased for years without a matching rise in diagnoses that name a cause. Learn how a measurement report is read.

What happens to my Measura results?

Measura measures; it does not diagnose disease on its own or treat. Your results are sent to your physician, who puts them together with your history, examination and any imaging to decide what they mean for your care. If your pain came with a new red flag, the emergency room still comes first. Understand how your results are reported.

How soon after an ER visit should I follow up?

Within about a week is sensible if the pain has not settled. In one study, pain still present at the one-week mark more than doubled the odds of problems functioning three months later. Arriving with your discharge papers and a list of the questions above makes that visit far more useful. See how to prepare for testing.

Why does the ER send me home when I am still in pain?

Every measurement in an emergency room serves one decision: admit, treat now, or send home. Once the dangerous causes are ruled out, the job is done, even if the pain is not. Emergency physicians know the gap: in one Canadian survey, 96 percent reported no effective chronic-pain pathway in their department, and 70 percent did not know where to send these patients.

Why do chronic pain patients keep going back to the ER?

Partly because there is no door between the waiting room and a plan. One hospital saw 14 percent of back-pain patients return with the same complaint within twelve months. Pain that persists a week after discharge more than doubles the odds of still being impaired at three months, so a measurement visit in that first week gives the pain somewhere else to go.

What does my ER discharge diagnosis actually mean?

Often it names where it hurts rather than why. In national data covering 164 million adult emergency visits for chest pain, abdominal pain and headache, diagnoses naming an actual pathology fell from 72 percent in 1993 to 63 percent in 2009, while testing grew. The most common back-pain discharge labels also describe a location. Treat the label as a starting point for your physician.

Measure What the Waiting Room Could Not

If you are home from the ER and still hurting, ask about testing that measures the metabolic terrain behind persistent pain, starting with laboratory panels and body composition. Your results go to your physician.

Send a message

4477 Woodson Rd, Suite 201, St. Louis, MO 63134. Monday to Friday, 9:00 a.m. to 5:00 p.m. Please do not send symptoms, diagnoses or images through a web form — a website form is not a secure medical channel. Send your name and number and we will call you back.

References

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