Pain management

Specialties Emergency

Published

How do you maybe a provider that is either unwilling to treat a patients pain or is under treating a patients pain.

Example: patient waits 8 hours in the lobby to be seen. Provider orders Motrin for the patients chronic hip pain. I know the condition is chronic but the patient appears to be very uncomfortable. Provider is approached and is unwilling to listen to or collaborate with nurse. Patient leaves unhappy.

Example: patient c/o headache. Given toradol and is ineffective. Discharge. Again provider unwilling to listen to nurse.

Example: patient fell, negative xr of knee. Given Motrin after waiting 10 hours to be seen. Patient appears uncomfortable but provider not willing to discuss pain management plan.

These instances are all involving the same provider. But how do you all speak to a provider when they don't want your input. This particular person hates when nurses approach and will not listen. At times the nurse is made to look bad because the provider is not willing to listen to our assessment of the patient. How do you all handle?

Specializes in ER, Corrections, Mental Health.

You make good points here as well. I do agree that the wait should not dictate the meds you are given. But when I see a 60 or 70 year old get wheeled back to my room in wheelchair for something that they perceive an emergency, my first thought is "how can I help this person," not "man they should have waited to see this family doctor" or "ill just give them Motrin and tell them to have a good day." This particular patient was ordered the Motrin and discharge at the same time, so who knows if this would have been enough pain relief for them?

And yes, the provider is a very valuable member of the team. My question here though is how do you approach providers who don't treat the nurse as a member of the team.

Specializes in Critical Care.
You make good points here as well. I do agree that the wait should not dictate the meds you are given. But when I see a 60 or 70 year old get wheeled back to my room in wheelchair for something that they perceive an emergency, my first thought is "how can I help this person," not "man they should have waited to see this family doctor" or "ill just give them Motrin and tell them to have a good day." This particular patient was ordered the Motrin and discharge at the same time, so who knows if this would have been enough pain relief for them?

And yes, the provider is a very valuable member of the team. My question here though is how do you approach providers who don't treat the nurse as a member of the team.

The issue is that if a legitimate reason for the use of opiates has been ruled out, then it really doesn't matter if they find motrin sufficient, that's all they are getting (although I would argue acetaminophen is actually a better non-opiate analgesic than NSAIDS).

Specializes in ED.

These were just a few different examples, but my real question is how do do you go about negotiating with a provider when you feel that you need to advocate for a patient, particularly one that does not like to be asked about their orders?

I'd say, "Mr Room 7 still seems to be in a fair amount of pain even after I gave that dose of X drug. His pressure is 158/74 and his HR is 94. Think we can maybe try some morphine or maybe XYZ non-opioid med?" I'd say this while nodding my head up and down just a smidge.

Specializes in Pediatric Critical Care.
And btw, these instances were patients in their 50s and 60s, not a 20 year old that had nothing better to do than generate an er visit. These were reputable people that sort of just got passed off and somewhat ignored.

Wait, huh?

You make good points here as well. I do agree that the wait should not dictate the meds you are given. But when I see a 60 or 70 year old get wheeled back to my room in wheelchair for something that they perceive an emergency, my first thought is "how can I help this person," not "man they should have waited to see this family doctor" or "ill just give them Motrin and tell them to have a good day." This particular patient was ordered the Motrin and discharge at the same time, so who knows if this would have been enough pain relief for them?

Agree. I think about how I can help, too. It starts right off the bat with developing a rapport; everything can hinge on that - including, many times, whether your patient trusts you and feels satisfied when you explain the Motrin/rest/ice/elevation/compression/follow-up instructions.

With regard to your last sentence - - there are some (many...many) conditions for which home measures +/- OTC meds are all that is indicated, period. You don't get sutures for scratches, you don't get surgery for a URI, and you don't get a bag of goodies for an annoying/minor musculoskeletal injury. That's really just all there is to it. You'd be better off asking for an ace wrap order than meds stronger than Motrin.

Be kind and respectful and educate patients.

And yes, the provider is a very valuable member of the team. My question here though is how do you approach providers who don't treat the nurse as a member of the team.

You have to try to work on a rapport. Just like with patients. For your part, think about all the issues we've been discussing and see where you might be able to meet in the middle on some of this as far as the provider in question is concerned.

If there is a larger problem with an individual and constant grumbling about patients then maybe you need to talk to your manager about it; personally I'd do a bit more observation first.

One thing that I have to constantly remind pt's of is the length of time it takes a medication to work. I will give Motrin 600 - 800 for muscle pain/ortho injuries and the pt will say 20 minutes later: "It didn't work, I want something stronger". Part of being a patient advocate isn't just going to the MD and asking for a stronger pain medication at the same, it's sitting down with the patient and discussing realistically how the medication works and how long it takes to work. With motrin it can take up to 1 hr! I tell patient's that and explain that it's working by reducing the swelling, and when the swelling reduces the pain lowers. That is also when I talk about RICE and other necessary information to assist the patient.

Now, if the medication has taken it's full time and the patient is still in obvious pain, I'll approach the MD and say: "Hey, Mr. so-and-so in room X, the one with the hip pain? The motrin didn't work as well as we wanted it to. I checked and he does have a ride home with XYZ and I think he'd benefit from a one time dose of a stronger medication to get the initial pain under control. His VSS and documented in the chart." and that tends to work.

HOWEVER, and this is a big HOWEVER, I also sit with the patient and explain that they will not be getting a prescription for this medication necessarily, but instead they'll be getting XYZ (maybe motrin and a medrol dose pack) and explain that they need to take the motrin before the pain gets to a certain level for it to be truly effective. I also explain that while Medrol isn't a pain medication, it reduces swelling, etc. and EDUCATE them about why they're feeling the pain.

Last but not least, I explain they can see their PCP for follow up and that they are ALWAYS welcome to come back if something changes or the medication isn't effective. But I also tell them to be realistic--if they're their for back pain, the best thing they can do is walking around, getting the blood flow to the back and not laying still in bed. Education, the name of the ER game.

Opiate crisis? What we have is a law enforcement agency, the DEA, which needing a fresh infusion of money having not made a dent in their 'war on drugs' with methamphetamine et al and figured out doctors keep good records and don't shoot back, declared a war on pain medications. We have 85 year-olds hobbling into pain management and treated like junkies.

Oh and heroin addicts, we have heroin addicts. Now when we had a 'cocaine crisis' we threw inner city crack cocaine addicts in jail and threw away the key. We still have heroin addicts in the poor, predominantly black neighborhoods but we also have white middle/upper class kids on heroin thus, due to the latter, we had to declare a crisis and rename it 'opiate use disorder.' If anyone had an emergency requiring pain to be treated I would not suggest an ER to them, after all they can get ibuprofen at CVS...pain is no longer treated (unless you call sending home folks with terrible but non malignant pain being handed an Rx for ibuprofen and yoga 'management.' Color me cynical but that is my take on it and one of the reasons I don't do acute care anymore. Too many patients asking why I had to do the pain scale when the doctor feared the DEA such they no longer prescribe. As with everything in this country we do not mess around with swinging the pendulum.

I'm an ER Nurse and have been for years. The ER is an exceptionally poor place to bring your chronic pain patient. If it is being treated already by a provider that provider should be contacted and adjusted to the medication regimen should be considered. For way too long these long term pain patients have been showing up in ERs (typically after they took all their pain meds early and are out) looking for a few pills to tide them over until their next refill is filled.

Opiate crisis? What we have is a law enforcement agency, the DEA, which needing a fresh infusion of money having not made a dent in their 'war on drugs' with methamphetamine et al and figured out doctors keep good records and don't shoot back, declared a war on pain medications. We have 85 year-olds hobbling into pain management and treated like junkies.

Oh and heroin addicts, we have heroin addicts. Now when we had a 'cocaine crisis' we threw inner city crack cocaine addicts in jail and threw away the key. We still have heroin addicts in the poor, predominantly black neighborhoods but we also have white middle/upper class kids on heroin thus, due to the latter, we had to declare a crisis and rename it 'opiate use disorder.' If anyone had an emergency requiring pain to be treated I would not suggest an ER to them, after all they can get ibuprofen at CVS...pain is no longer treated (unless you call sending home folks with terrible but non malignant pain being handed an Rx for ibuprofen and yoga 'management.' Color me cynical but that is my take on it and one of the reasons I don't do acute care anymore. Too many patients asking why I had to do the pain scale when the doctor feared the DEA such they no longer prescribe. As with everything in this country we do not mess around with swinging the pendulum.

THANK YOU --- 100% AGREE. I'm not a nurse nor am I in the health care business. I take care of my mother who is in pain every day and not one of many "doctors" will help her. Pain management wants to do injections, physical therapy....yada, yada...IT.DOES.NOT.HELP. This woman technically qualifies for hospice care with her list of co-morbidities, but she is not ready for death and that is what hospice specializes in (flame me for that comment, IDC. It's true). She does, however, deserve some sort of quality of life. We are really in a sad state of affairs with this "war on drugs". It's actually a "war on chronic pain patients".

Opiate crisis? What we have is a law enforcement agency, the DEA, which needing a fresh infusion of money having not made a dent in their 'war on drugs' with methamphetamine et al and figured out doctors keep good records and don't shoot back, declared a war on pain medications. We have 85 year-olds hobbling into pain management and treated like junkies.

Oh and heroin addicts, we have heroin addicts. Now when we had a 'cocaine crisis' we threw inner city crack cocaine addicts in jail and threw away the key. We still have heroin addicts in the poor, predominantly black neighborhoods but we also have white middle/upper class kids on heroin thus, due to the latter, we had to declare a crisis and rename it 'opiate use disorder.' If anyone had an emergency requiring pain to be treated I would not suggest an ER to them, after all they can get ibuprofen at CVS...pain is no longer treated (unless you call sending home folks with terrible but non malignant pain being handed an Rx for ibuprofen and yoga 'management.' Color me cynical but that is my take on it and one of the reasons I don't do acute care anymore. Too many patients asking why I had to do the pain scale when the doctor feared the DEA such they no longer prescribe. As with everything in this country we do not mess around with swinging the pendulum.

Wait...so you honestly believe that the opioid crisis is fictitious? I'm not being sarcastic. I truly am curious how people think. My brother truly believes the earth is flat! I engage in conversations with him all the time, not confrontational...just fascinated.

So, you think all the data which shows a steep rise in opioid use/deaths is fabricated? The increased use of narcan, both in ER and EMS, is a lie? And, this lie is for the sole purpose of giving a government bureaucracy more money?

That is interesting. I, personally have spent a decade in ER nursing. I at least perceive that the statistics of opioid use/death and narcan use are true. I also witness what I perceive to be an over use of narcotics within the ER, such as ordering Morphine IV for a c/o "abd pain" before the doctor even assesses the patient or sees any results. I witness doctors prescribing narcotics just because the patient requests it, not because the dx would suggest a need for a narcotic to treat the pain. Of course, sometimes diagnostic test may be negative and the patient is truly in pain, but that is not necessarily something that can/should be addressed in the ER. The ER is not a prompt/urgent/pcp care. It is there for life threatening emergencies, right? Life or limb?

I learned in nursing school that pain is whatever the patient says it is; however, I also learned that I am to care for the patient as a whole!! My point is...if that patient is "seeking narcotics" then assisting them in obtaining said narcotic is...well...against what I am suppose to be...there to give them the best nursing care that they NEED...not WANT!! Medicine/nursing is a science...not magic...and not about giving patients every test they think they need and every Rx that they want. Sure, giving every patient that walked through the door a full body CT and discharge with narcotics would find many undiagnosed conditions and leave them pain free....but it would also lead to increased cancer, higher insurance cost, and yes....more narcotic addictions!!! You can't always tell the "seeker" from the sincere. What is your solution? Again, I am truly curious.

To the OP:

I understand the frustration. You want to help the patient! The ER that I work in has wonderful providers that listen/value nursing input. Of course, you will always run into people that are "difficult personalities" to work with. The only thing that I can suggest is to present the patient's subjective and OBJECTIVE data to the doctor and then ask if there is something else he would like to order for the patient. That is not "questioning his/her orders," it is providing him/her with new data and seeing if he/she would like to order any additional meds/treatments. I wish you all the best.

I remember, I do not necessarily think it was due to Tramadol being abused more that they put Norco in same category as Fentanyl and Cocaine so hey, they thought they had to do something with Tramadol. I used to get it for my 65 lb German Shepherd and now veterinarians are unwilling to prescribe it. That the entire DEA drug scheduling laws are absurd was pretty much my point, the DEA was signed into law by Richard Nixon to aid law enforcement over the general hysteria about Marijuana. Alcohol and cigarette companies made sure they were given a pass never to get on the drug scheduling list.

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