Pt demanded a stronger pain med

[AstrosFan]

:angryfire I'm a little steamed. The other night I had a pt present with an "ankle sprain." Yep, that's it. When I went to discharge this "fine, upstanding, well-groomed" individual , his rolly-poley little wife advised me that the APAP#3 wasn't going to be good enough. She stated that he was a 250lb. man that needed much stronger pain medication. I replied that it was a sprain and that we don't normally prescibe a narcotic for a sprain. His wife was adamant that I go ask the doctor for something stronger. She was that type of person that doesn't know half of what she's talking about and you can't get a word in. She developed a quick case of diarrhea of the mouth. So, I walked out and advised the doctor of the situation. He responded exactly as I expected. Yep, you guessed it, they're not getting anything stronger. I went back into the room with the bad news. She became angry and proceeded to orally defecate :barf01: some argument that since they were paying cash for this visit that they should be able to get whatever they requested. The pt advised that he didn't have a regular doctor and that this would be his doctor visit and so he needed medication. To tell you the truth, they both went off on a tangent and I sort of quick listening. They yapped the entire time while leaving, but did leave. I know I shouldn't have (you know the old saying about argueing with a fool), but I argued with the two of them about how it was just a sprain and that I had never had anything for the many sprains that I had had, yadda yadda yadda. I just don't get it with this entitlement attitude of these folks. I've been putting up with this for a few years, but it still pisses me off. If my ER director wasn't so eaten up with PressGaney, I wouldn't have even taken the request to the Doctor. I would have said, "here are your discharge instructions, here is the medication that has been prescribed to you, there is the door, if you continue to argue, security will be happy to escort you to your car."

So, now to a question. How would some of you respond to this situation? What would you have said to a pt demanding a narcotic for a minor injury?...Beside, "Suck it up, wuss!" Oh, how I wish I could say that.

Thanks in advance for your replies.

[htrn]

Personally I would have went to the doc, said something like they are not happy with the T3 rx. Get him to write one for motrin or naproxen and then enjoy walking back to the room asking to see the narc rx. Then saying oh i'm sorry he did give you the wrong med as I rip up the T3 rx and hand them one for the others. Have a nice day.

Rj

:roll :roll :roll

OMG - I would love to be a fly on the wall next time you do that!!!! Call me and I'll just slip in behind the curtain with a video camera so we can send it into Funniest Home Videos and we can split the winnings:clown:

[htrn]

I wonder though, if that makes us less empathetic when we come across patients that are justified in needing a higher level of relief and are not getting it? Not everyone deals with pain as well as others. When I had my pancreatitis and a lap chole with ERCP done I definitely saw the brief flicker of judgement pass over my nurses faces when I asked them for my PRN meds. The guilt vibe I was getting from them was so stressfull I wondered if I should just lay there in pain so they would not classify me as a weenie!

If a patient has a hx of narcotic use, i.e. chronic pain, they usually reveal this during the H&P and the MD will realize that pain may need to be treated with something stronger than T3. The OP has described either a case of an overprotective, harping wife trying to control yet another part of her hubby's life or a wife with just enough knowledge and probably hx of narcotic abuse that thinks she knows how to get ahold of some more without being identified as a 'seeker' herself. Either way, she handled it very appropriately.

[cheshirecat]

I would have stated that if I gave stronger analgesia the patient would not know if he was overusing the strained limb and may cause himself further injury.

Forgive my ignorance, but what is PressGaney? I have heard it mentioned frequently on these posts.

[Myxel67]

Press Ganey is a company used by many hospitals to send out patient satisfaction surveys to discharged patients (random) from each area of the hospital. The pt rates "service" on a 5 point scale. Areas surveyed include efficacy of pain control, courtesy level of staff, cleanliness of area, waiting time, even difficulty of finding a parking space & finding your way around hospital. Many hospitals give or deny bonuses based on survey results. Last quarter our small department was rated lower because it included as valid the pt's complaints relating to his recent treatment in X ray department.(and mgr of xray was going all over hosp crowing about her dept's improved results). Pt had had two recent visits (1 to x ray & 1 to Diabetes Care Center). He responded to his disatisfaction with x ray department on the survey he got for our department. Surveys are random, so he probably did not get one for x ray visit. My biggest complaint about relying so heavily on this survey is that it basically equates a hospital visit to a hotel stay (I think it was modeled on Hilton Hotel policies of service excellence). We're not hotels, many people don't want to be here in the first place, and results are affected by so many variables: pts mood that day, traffic, depression, etc.

[CraigB-RN, MSN, RN]

The patient was lucky to get the t#3, (one of the most useless pain medications out there). In my facility the patient would have gotten a prepack of 6 vicodin (We dont carry apap#3) and told to take scheduled Ibuporophen and use the vicodin for breakthrough pain. In simalar situations I've actually had security escort the patient out of the ER. They are more than welcome to go somewhere else and wait in that ER for who knows how long.

[nursebrandie28, BSN, RN]

THANK GOODNESS, I am not the only nurse who hates seeing drug-users.

The sad reality is, and the pro-testers can protest all they want about pain being subjective. And, yes pain IS SUBJECTIVE, but when the VS are normal, they are texting on the phone, laughing with their friend....THEY DO NOT NEED NARCOTICS.

We are really looking out for their best because, when they use pain meds that they don't need, their pain receptor sites get use to response over time and then when they really do have pain, NOTHING WILL WORK!!!

My most hated pain med: tie between demerol/dilauded

and 90% of our surveys we get back are from guess who? People who did not get appropriate pain relief. Now, i always try to be a good nurse, please my patients, however, i am not going to go against my ethic principles to please administration. Because the sad truth is an RN is not replacable. In 2006, for every RN a hospital hired, 4 RNs quit/retired/fired/died.....

And another issue with pain meds is what kind of society are we creating that NOBODY CAN EVER HAVE ANY PAIN....pain is natural. Is is pleasant, NO but part of life. I don't mean to be so cold-hearted, but I hate seeing taxpayers dollars feeding the addiction.....

sorry that is my venting soapbox ....thanks for your time...

[charebec65]

With Migraines, the way I can tell what's up is how the patient reacts to being administered a Triptan. Because if you are a true Migraine sufferer, no narc will kill any migraine the way a triptan will and they are always so relieved to feel better.

I have a hx of migraines and the only med that truly helped was Imitrex (one of the triptans in case someone's not familiar). Unfortunately, my HTN is no longer under control and stays quite high so I can't use it anymore.

In February of last year I began experiencing abd pain. At first I just figured I was ovulating from the location but over a couple of days it became so bad that I could not walk or even straighten up without excrutiating pain. I broke down and went to a local ER because at that point I figured it was a large ovarian cyst and knew that our urgent care doesn't have ultrasound that would be needed to dx it. I was right in my self-dx. The doctor and nurses were awesome though I'm sure it was quite obvious that I was in some serious pain. I got through the whole ordeal with 4 hydrocodone 5/500's and Advil.

[LeahJet, ASN, RN]

I would have NOT.... have been.... judgmental, I would NOT have taken what you seem to have taken, which is a one-size-fits-all, holier-than-thou attitude.

Does anyone else see the irony here? :chuckle

[morte, LPN, LVN]

yup....

having had a recent ankle sprain myself....fell at a local store...amb ride to local ED....actually after the initial pain, didnt hurt too much as long as it was elevated.....wasnt given ANYTHING for pain, ibuprofen was suggested.

my only objection is/was, is that nsaids reduce inflamation, thus i would think interfere with healing, perhaps APAP would be a better choice.

PS. i am allergic to codiene....pretty little "sunburn" rash over nose, and fine petichael rash across back, and i swear it didnt do anything for the dental pain i was in.....havent ever taken any other narc....

[djewel6]

I saw plenty of that when I worked at an ER on the Coast of NC as a PCT. The amazing thing is the ER docs in a couple cases let loose on one patient in a very nice manner. They were being such pain in the butts he gave them a 4 pack of what we prescribed and then proceeded to take 4 pills off his script he wrote. They also started handing out a flyer that stated "As medical Doctors we are NOT REQUIRED to prescribe any medication we feel is not necessary this includes Narcotic Painkillers" and gave them to our frequent flyers.

[CCL"Babe", BSN, RN]

Pain is what the patient feels. It is not up to you to decide whether their pain is real.

I was an ED nurse >15 years and gaurded the narcotics in my holier than thou attiude until I discovered pain for myself.

I was distressed to read your post. Unfortunately there are many nurses with the same attitude.

[djewel6]

Please dont mis-interpret what I said as being callous or negative. I indeed am an advocate for pain management however it seems that alot of people view the ER as their own personal dispensary for Contolled Substances. Having been in a situation where I was out of work due to a very serious back injury and was on heavy pain meds and controlled substances I understand the meaning of being in significant pain (After injuring my back the MD had me on 10/500 percocets plus Zanaflex in the daytime and Valium 20-30mg at night). I also have to admit that during that time I was totally unable to recall most of what went on for a 6 week period of my life which to this day scares me. Like I said Im not against pain management when appropriate especially having seen patients badly burned, both while in the field working EMS and also in a facility setting, it just comes down to what is appropriate at the time and whether it matches the nature of the injury/trauma vs unreasonable requests for Sch II narcotics just because somebody thinks they are "owed" it.