pain management

caroladybelle, BSN, RN · Feb 20, 2003

It happens in all departments.

We kept having a terminal cancer pt, come in with issues related indirectly to uncontrolled pain. As our physicians' are pretty good with giving good pain control care, we wondered why.

Found that the patient's husband was stealing the drugs, calling the MDs for replacements, whenever a different one was on duty, and selling the drugs on the street.

Also, a favorite, the patient that asks me for a sleeping pill, and I return with it, to find he and his buddies with white powder up their noses, and his BP through the roof.

AngelGirl · Feb 20, 2003

Thanks, I.rae and caroladybelle, for the input. I suggest that ER's develop a central database, listing inappropriate "frequent flyers," and documenting the treatment they've received. If we offer them the same advice and treatment uniformly, (including a psych eval) which will obviously not be to their liking, they will hopefully lose interest in the what we have to offer them and leave the few remaining resources for those who are really in need.

kaycee · Feb 20, 2003

Originally posted by AngelGirl
Thanks, I.rae and caroladybelle, for the input. I suggest that ER's develop a central database, listing inappropriate "frequent flyers," and documenting the treatment they've received. If we offer them the same advice and treatment uniformly, (including a psych eval) which will obviously not be to their liking, they will hopefully lose interest in the what we have to offer them and leave the few remaining resources for those who are really in need.

We actually do have a little box with drug seekers names and what they are there for and what they received. Not supposed to have it but we do. I know other ER's do too.

pappyRN · Feb 21, 2003

Good evening,

I don't think anyone disputes the fact that addicts do exist. I was under the impression that addiction was considered an illness. Have nurses now turned into the addiction police? If a person is an addict do you automatically treat them meanly? There isn't a nurse on this board who is so stupid that they would expect you to dispense narcotics to a known drug addict or to a patient you know is flying higher than a kite. I can't imagine there being any dispute about that. I think wherein the dispute lies is the attitudes about those who require the use of narcotic medications.

I always ask what medication I am being given, good thing because it has happened before when I have been about to be given a drug I am unable to tolerate(neurontin). I ask how much, in case something goes wrong AND in case it works well so I can tell my doctor, AND Ido have the right to know what I am either putting in my body orally or what you are injecting into my body- don't say that you wouldn't ask, because as a nurse I know you would, too. Nurses do make mistakes as we all know.I could also tell you what doses have worked for me before. It's not that by asking I'm trying to tell you what to do but I have been at this for over 8 years so if you are about to give me say 10mg and I do not get therapeutic relief at anything lower than say 30mg I can save both of us a lot of time and trouble and expense because each single dose will cost more than one. I am responsible for a portion of the bill and it is a real concern to me since the markup on drugs in a hospital is so high. I also check all my bills and request itemized statements so I will know what stength to look for. Patients have EVERY RIGHT to ask questions and it's NOT to ruin your day. Federal law guarantees our right to ask and to know. I am very knowledgeable about my illnesses and treatments mostly because I've had to be but I am also not going to play dumb just to stroke someone else's ego. I won't contribute to a power trip.

In regards to multiple allergies surely you aren't going to hold that against us, too? Chronic pain patients know they are allergic to drugs in the categories that were mentioned in an above post because- those are the drugs that are used to treat chronic pain so those are the drugs that have been prescribed for us. I'd be less likely to say that I am allergic to meds that are used to treat lung problems because I don't have current lung problems so no history with pulmonary drugs. Also, many patients who also happen to have fibromyalgia ( and MANY chronic patients also have FMS/CFS or CFIDS)also suffer from multiple chemical sensitivities including multiple drug allergies and intolerances. In my own case I am made severely ill by ALL of the SSRI's- I develop "serotonin syndrome" aka "serotonin storm" Not a pretty sight and hell to go through if you're the patient but frequently NOT recognized by the medical community. I also have numerous other allergies such as Dilaudid, iodine-from all the imaging studies, codeine, trazadone, doxepin, but are those somehow "my fault" or are those held against me with eye rolling behavior in disgust when I have to name them for you? Don't think the patient doesn't notice, because we do. By the time many of us even decide to subject ourselves to the degradation of the ER we know what we will be up against and we know that it will require some measures to bump our self esteem back up. We've been through visual guidance, biofeedback, relaxation, aquatherapy, distraction therapy, myofascial release, lymphatic facilitation, meditation, etc. BUT... sometimes through no fault of our own these things just don't work and we have to take the plunge and go to the ER.

I knew I had RSD but no doctors would believe me SO my window of opportunity was missed for receiving the blocks that could potentially put this disorder in remission. Then at the hands of two different surgeons I have been subjected to permanent nerve injuries- one during a brachial neurolysis and sympathectomy which left me with more nerve damage and scar tissue and an unimaginable worsening of the RSD and then during a pseudoaneurysm repair a VASCULAR surgeon LIGATED my femoral nerve which even after he repaired his mistake and removed the ligatures the damage to the nerve was done and it also caused RSD symptom migration to my right lower extremity and right abdomen which by the way includes the internal structures in my right abdomen. These were at the hands of DOCTORS. So, to be treated as I was by NURSES was the final blow. Walk a mile in my shoes for even one day, or hour or minute. Step up to the plate- I will gladly give any one of you my experience with RSD. In fact, you can have it so I can go back to trying to live a normal life without pain and with some money. Can any of you make it on $150.00/month? My husband has been out of work and unable to find a job. We are barely eating because my medicines cost over $700.00/month. And yet, you would still begrudge me a few hours of comfort?

I have only ONCE IN 8 YEARS made the mistake of going to the ER ON THE ADVICE OF MY PAIN MANAGEMENT PHYSICIAN and was treated like s**t. I followed every step that was required of me and I was still treated like I had crawled out from under a rock. Why? Because I had the audacity to have a breakthrough episode of pain. I'm real happy for whomever it was that said you have back problems, you are so fortunate to be able to function without putting mind altering chemicals in your body but unfortunately, I have a neuropathic pain problem that prevents me from being able to function as you do. I hope you realize just how lucky you are. In fact, I am lucky to be able to perform the ADL's necessary to take care of myself on a daily basis. Prior to this I was a charge nurse in a 48 bed NICU/Special Care nursery.

We are just as disgusted to have to recite our history and our litany of medications. I even thought I would do them a favor. I typed up my history with previous surgeries, hospitalizations, physicians with specialty, name, address, phone #, meds, allergies and the reactions, meds that had been tried ...well you get the picture. THE NURSE AND THE DOCTOR MADE FUN OF ME.

JOKE WAS ON THEM! My PM doctor was fuming at them when he heard about it because it had been his suggestion when I first started going to him. Said it would make it easier for any new docs I went to and even for my current specialists. Said he really appreciated me taking the time to consolidate the info and organize it. Besides, it made me feel useful. The doctor and the nurse were at my next pain management appointment along with the hospital administrator to present their formal apologies. The administrator asked me what I wanted

out of all of this. I told her I didn't want money, I wanted the nurse transferred out of the ER and the doctor reassigned to a different area along with mandatory pain management/palliative care inservices and not just one.

I guess what bothers me the most is this unbelievable cynicism. Why on earth do you all continue to work in the ER if 3/4 of your patients are such dirtbags and are so distasteful to you and are viewed by you as such drains on society's resources? Did you forget that these are human beings somewhere along the way? Yes, they have some real problems but these aren't problems that ER nurses can solve.They have an illness and they've made mistakes. I agree that something needs to change but don't take it out on EVERYONE. I think it entirely appropriate to get psych consults for some patients. I hope those of you with your little boxes of names never get caught with them by the JCAHO.

I haven't visited this site in quite a while. I'm glad that I did. Every once in a while I will get to thinking about my experience in the ER and wonder what I did for them to treat me like they did. It took me MONTHS when I first started dealing with the RSD to be ok with taking pain meds. I was in miserable, burning agony. My husband and children watched their wife and mom change right before their eyes and they didn't know what or whom she was becoming. My PM doctor finally said to me "Would you apologize if this was diabetes" Would you apologize for taking the medications you need to control this disease" Of course, I told him "NO". "Well, then", he said "then start taking this like I prescribed so you can begin to get some of your life back. You have a very hard road ahead of you because there is no cure and you are going to have to work at keeping the pain at bay every minute and hour of your life until someone comes up with something better than pain medication. It will be trial and error until we come up with a combination of things that work for you. You will tolerate some meds and others you won't. We'll just keep working at it until we find ones that work." That's why a lot of us have tried so many different med combos and have either found out they work or don't work.

After reading this thread you can be sure that it is very likely that I would probably rather stay home and take my chances on surviving whatever is wrong with me than go to the ER and be subjected to the attitudes, eye rolling etc. One thing is for certain, I could be screaming with pain and I won't go to the ER. I will NEVER AGAIN subject myself to the degradation and humiliation I felt that day from colleagues in the profession I used to revere.

Like I said in a different post. RSD affects a disproportionate number of nurses and it seems to be nurses that get hurt on the job. So, the potential for walking in my shoes one day is definitely there. I hope not for your sakes because it certainly isn't a lesson you want to learn the hard way.

Regards,

Pappy

AngelGirl · Feb 21, 2003

Pappy, you have expressed a great many things here that show that you have a valid illness and a workable plan of treatment. The opinions previously posted have nothing to do with YOU. I'm sorry that you have taken this all so personally. My statements are directed to the problem, and it is not yours. Many, MANY people with valid pain do arrive in our ED. They are treated kindly and professionally. My statements have to do with those who frequent and intentionally MISUSE the E.D. This is not YOU. The treatment you received in the ED you visited was horrid, this is obvious. However, should you find yourself headed to the ER again, a telephone call from your MD to the ER MD could change everything. A recommendation from one doc to another is generally well received AND seems to cut through a lot of the ER red tape.

TRobert · Sep 13, 2003

l.rae said presented an interesting list of points that may be characteristics of the mo of a "drug seeker." i'd like to respond to some of them below:

there is so much more to it than that....for instance, do you:

1.ask the nurse as soon as she comes with the med...what is that?

absolutely! i'd ask the same question if i had to go to the er with an infection of some kind and were being given antibiotics. additionally, i've had nurses bring me the wrong meds on two separate occasions when i was inpatient. it's my responsibility and my right to know what i'm taking or being given.

2. followed by ...how much am l getting?

you bet. again, it's my responsibility and my right to know.

3.then proceed to tell the nurse...l always need more than that dose, or.....that never works.

only when that's the case. i'm the one who knows my body and what does and doesn't work. if i give the nurse or the doctor that information, i'm saving everyone time and saving myself even more time spent in pain.

4.have no ligitamate hx of your problem documented with a pmd

5. present to the er having tried nothing for pain relief prior to coming

please let me tell you one reason this can happen with a patient who has migraine disease. if they work for us, triptans such as imitrex, etc., are far better for us to use than pain meds. however, many insurance companies limit how many doses they'll pay for in a month, and many doctors don't prescribe rescue meds for such situations. what else is that patient to do?

6.never follow up with your pmd

7.present to ther er asking which md is on duty

i know some migraineurs who do this, and i don't blame them a bit. if they've seen a doctor before, and know that he's going to be disrespectul and no help, then why would they want to be treated by him or her again?

8.allergic to tylenol, ibuprofin, nubaine, compazine and toradol

9.do not have a pmd

10.vary your er visits between different local er's

all of this said, i have a great deal of respect for er nurses. they're understaffed, underpaid, underappreciated, and do more patient treatment than the er docs do in many cases. however, i know too many people who have presented in the er with severe headache or a severe, unrelenting migraine attack, but have either been told it's "just a headache," sent home with no relief or even been accused of being there seeking drugs. believe me, with all the noise, bright light, and knowing that we'll have to wait while more urgent patients are treated, the er is the last place someone with a headache or migraine wants to be. sometimes, we have no choice. did you know that the pain of a migraine attack is caused by dilated blood vessels in the brain? if that pain continue 72 hours or more, the international headache society classifies it as status migrainous, and recommends emergency care because it dramatically increases the risk of stroke. yes, people actually have died from migraines.

another short example: my mother was transported by ambulance to the hospital with a pounding headache and bp 210/140 when her apartment building manager found her sitting in front of her door crying. she was waiting for me to come get her, but was crying so much the manager couldn't understand her. once i was at the hospital, even though i have her medical power of attorney, i was told i had to remain in the waiting room. well, i think not. i went back and found her. she has a long history of hypertension, has had several strokes, but has not had a migraine for over 20 years. they had decided she was having a migraine, and i walked in just as the nurse was going to give her iv dhe, which is contraindicated for patients who have had strokes and for those whose bp is uncontrolled. had i not literally taken the syringe out of the nurse's hand, she would have administered it over my objections. once i talked them into treating her elevated bp, the headache began easing off.

it is my firm belief that we are ultimately responsible for our own health and optimal health care is achieved only when all medical personnel and the patient work together as a team. that's why i say it's my responsibility and my right to know how much of what someone is administering.

do medical personnel deserve respect? of course they do, but not just because they are medical personnel. i always start with the assumption that they're professionals deserving of my respect, but for that respect to remain intact, i expect to be treated with courtesy and respect in return.

if you've read this far, thank you!

teri

z's playa · Sep 15, 2003

Teri and pappyRN;

Well said, both of you. Nice to see people stand up and speak for those who never get heard. (because they're probably being ignored )

Z

TRobert · Sep 15, 2003

Thanks, Z! :cool:

I'm fortunate that I don't have to go to the ER often for a Migraine. In fact, I haven't had to do so for about four years now. The lights and noise are horrid. I've always been treated with the utmost consideration and respect in the ER here, but almost daily, I work with a patient who has encountered a problem, usually being suspected of "drug seeking."

I know there are lots of fabulous nurses and other staff in ER's, but some of the experiences patients share with me make me wonder what every happened to human decency and how many ER's are ignoring the JCAHO Pain Assessment and Management Standards for Hospitals. Two sections of those standards are:

RI.1.2.9

Patients have the right to appropriate assessment and management of pain.

Intent of RI.1.2.9

Pain can be a common part of the patient experience; unrelieved pain has adverse physical and psychological effects. The patient's right to pain management is respected and supported.

Thanks again!

Dave ARNP · Sep 16, 2003

I frequently go into ER to manage pt's.

A few times, nurses have expressed concerns to me that they felt one of MY patients was there for a purpose other than actual pain.

Firstly, when one of my patients comes to the ER for pain, they do so in two cases.

Before arriving, as one of patients, or a patient of the MD I work with; they are considered a Pain Management PT.

They must follow a protocol as such, and are required to only visit ER in these two instances:

1. They must contact their primary provider; be it my MD, or myself. This must be done ALWAYS before going to ER. We can triage them on the phone, and we can either direct for more medication or send them to the ED.

2. If we are unreachable within 1hr, they may go to the ED. (We KNOW if we can't be reached)

On a side note, I think another member on this board said it best.

By HOTSPAM:

I would rather medicate an addict than deny a sufferer.

Some of you who would like to play God with pain medication, might should take that statement and evaluate it.

David Adams, ARNP

-ACNP, FNP