Pain Profiles: Intranasal Analgesics: What’s Your Pick? – Part II

Author: David Cisewski, MD (@PainProfiles – EM Resident Physician, Icahn School of Medicine at Mount Sinai) // Edited by: Manpreet Singh, MD (@MPrizzleER), Alex Koyfman, MD (@EMHighAK), and Brit Long, MD (@long_brit)

Welcome to Part II of the Pain Profiles series evaluating intranasal analgesics! Part I contains a great look at studies evaluating intranasal medications. Today we have an interview from Dr. Stacy Reynolds.

Intranasal Analgesics: What’s Your Pick? Part II

Last week on Pain Profiles we discussed a feasibility trial assessing the use of intranasal ketamine for pediatric musculoskeletal pain.  A few weeks ago I had the pleasure of talking to Dr. Stacy Reynolds regarding her research with intranasal ketamine pediatric analgesia. [Recall: In 2017, Dr. Reynolds was the lead author on a landmark study presented at the SAEM Annual Conference assessing the feasibility of intranasal ketamine use among pediatric patients with extremity injuries.  The results of this study provided supporting evidence for a large-scale, multi-center pediatric trial to assess the safety and efficacy of intranasal ketamine among pediatric population with extremity injuries.] The following is a re-print of an SAEM Pulse interview I did with Dr. Reynolds regarding her research, career interests, and advice for future research-driven students and residents interested in following in her footsteps.

Link to original interview

Stacy Reynolds, MD, is the division chief of pediatric emergency medicine at the Carolinas Medical Center and Levine Children’s Hospital as well as
 the program director for the Pediatric Emergency Medicine (PEM) Fellowship. Dr. Reynolds is a board-certified pediatric emergency medicine physician, completing her PEM fellowship at the Children’s Hospital of Pittsburgh. In 2017, Dr. Reynolds was the lead author on a landmark study, presented at the SAEM annual meeting and selected as the Editor-in-Chief’s Pick of the Month for Academic Emergency Medicine (AEM) journal.

To start, can you give us a little background on your particular interests in pediatrics emergency medicine and how you got involved in PEM research?

I love that pediatric emergency medicine is an intersection between the diagnostic expertise of pediatrics and the resuscitative skills of emergency medicine.  My goal was to be a fellowship director and to bring those elements together for my trainees.  After my karmic retribution as a fellowship director began, I realized I now needed to find research for 6 fellows and provide their research education.  My interest in research grew from working to build the program.  Honestly, I didn’t have laser focused career interests.  I had a certain level of desperation and some great opportunities to get involved.

Could you briefly summarize this your work on intranasal ketamine and what lead you to this project?

My husband works internationally in Tanzania and I have had the opportunity to work there with him.  In Tanzania, ketamine is not a controlled substance and it is cheaper than in the US.  It’s the drug most readily available for sedation or analgesia besides paracetamol. The wide therapeutic window of the drug makes it a great ally for treating sick and injured patients in a resource limited environment without monitors.  We felt it would be a great asset to EMS providers in the US for these same reasons. I initially pitched this study with my partners in the Charlotte, Houston, Milwaukee Prehospital Research Nodal Center (ChaMP-RNC) of the Pediatric Emergency Care Applied Research Network (PECARN). Unfortunately, the regulatory hurdles in the US make prehospital study of the drug extremely complex.  We decided instead to perform this trial in the hospital setting.

The results of this study were quite promising. Are you currently involved in any follow up study to complement this research?

We are planning additional follow up work to demonstrate that EMS providers have the knowledge to use ketamine safely in the prehospital setting.  A multi-center, hospital trial will be needed to establish ketamine’s position in the line-up for analgesic medications.  Currently, the existing trials are too small to establish non-inferiority and may underestimate the potential for side effects.

What have been the major challenges in your research career as an EM physician-researcher?  Do you find certain aspects of research dealing with the pediatric population particularly challenging?

I’m not sure this question belongs in the past tense.  It’s incredibly challenging to find time and money for research and I am still cultivating my research expertise.  The fiscal pressure in medicine is making it harder to find your way without a structured path into research.  Pediatric patients are a vulnerable population, and this makes trial designs more complex and compounds some of the regulatory hurdles.  Recruitment is challenging. For instance, in our ketamine trial we had to design and implement a protocol that allowed us to rapidly screen, enroll, and treat children presenting to our ED in acute pain. To do this, we worked with our institutional review board and the Food and Drug Administration (FDA) to design a short-form informed consent process that did not significantly delay study drug administration.

What have you found most satisfying about incorporating research to your medical career?

I didn’t really set out to do research. It’s really been by luck that I have had opportunities for internal funding and opportunities to learn with others, including my colleagues in the CHaMP node.  I really love the problem solving.  I also like the administrative hurdles of getting the folks around you to jump on board and make a study run.  It’s fun to cobble together an unexpected opportunity.  We’re fortunate to be able to shape the work that we do as emergency physicians.  Not everyone can say that about their job.

Many people find it a daunting task to know where to start in a research career.  Did you have a mentor when you first started out your research career?

I was lucky.  I found the nicest guy in my department and asked him for help.  Ten years later he’s still a great mentor and is now also my husband.  Although he occasionally thinks he gets to make all the decisions – that’s when I become his mentor.

What advice would you have for someone seeking out a research mentor?

My route isn’t for everyone.  It’s always solid advice to find a kind person that enjoys building up other people and learn as much as you can from them.  I would say to surround yourself with good people and work hard to emulate what they’ve built.  Jeff Kline, for example, can build a tower out of sand.  If you’re looking only for other doctors, you’ll miss some great opportunities.  Our research manager, Melanie Hogg, is one of the best mentors I’ve had in my career. I’m grateful to work at a place with a department full of people like her.  I trained in Pittsburgh with people much smarter than me and now I am fortunate to work at CMC with a department full of engaged, dynamic people.  Mentors are all around you.  The question is how much and how often you want to learn.

[Dr. Jeffrey Kline is a professor of emergency medicine and physiology and the vice chair of research at Indiana University. Dr. Kline is perhaps best known for his creation of the Pulmonary Embolism Rule out Criteria (PERC Rule)]

Any specific advice for aspiring research-oriented medical students or residents interested in getting involved in research?

This depends.  If you know you love research, then I’m told you need to pursue dedicated training under skilled mentors with a federal funding track record.  However, it’s easy to love research if the most productive person in the department carries you along in their work.  You’ll find out your real passion (or not) for research if you flounder around on some dead-end projects and then find that you keep going back. I might say worry less about the perfect pathway and jump in and see what happens.

You impressively divide your time between clinical shifts, research, and your role as a program director of the PEM fellowship. What sort of time-management strategies do you use to balance these different roles?

Balance might be the wrong word.  I’m not sure my world is ever in balance.  It’s sort of lopsided on a priority driven basis.  My time management is an ongoing work in progress, but my skills have grown since I had my girls.  I have become considerably more focused and productive during the daytime, so that I am able get home in the evening to my daughters, Ellie and Emma.

Pain management is a hot topic in right now amidst the opioid-reduction initiatives, particularly among the pediatric population. What do you anticipate are the future opportunities in pediatric pain management research?

The physiological pain circuits are complex pathways.  It’s not surprising that focusing too heavily on the opioid receptors has led to so many problems.  I think future strategies will target a broader array of receptors earlier in treatment, with attention to dampening pain as early as possible.  We need to streamline the process of recognizing and treating pain by doing a better job assessing pain and measuring the response to interventions.  There are countless opportunities to improve our understanding of pharmacodynamics, mechanisms of pain amplification, the efficacy of analgesic medications, and the operational processes that improve the patient experience without indiscriminate use of medications.  We’re fortunate that the timing is excellent to address these types of problems.

Special thanks to Dr. Reynolds for the fantastic interview and continued work in the field of pediatric analgesia!


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