Pt demanded a stronger pain med - page 6

: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 :no:, his... Read More

  1. by   postmortem_cowboy
    For all of you who are upset with all these ER nurses, including myself, you might want to read this.

    The ER is for EMERGENCIES.

    Pain medication is also not the only type of pain management.

    I broke my hand in two places, never went to the emergency room, pain up the ying yang. Personally, I didn't feel that it was broken until the next morning when my hand had swollen up like a balloon. ER's get OVER RUN, and alot of the time for silly things that can wait for the urgent care to open up or for the doctors office in the morning.

    Patients don't listen!!!! And as it seems here some of the people who are reading this thread don't listen nor do they bother to read. Do you really think that an ICU or a med/surg unit operates on the same premise as an ER. Guys, how many times have you seen patients doubled over in pain can't even get up to go fill a urine specimine cup, is that BS? i'd say no, but for a patient that has their cell phone on calling everyone in the world, complaining about the wait, screaming and yelling, i'd say that's a bit less than acute abdominal pain, more like discomfort. Too many times we ER nurses see bogus claims from patients who are either out seeking narcs, this is my favorite, i'm allergic to toradol, I need that medication that starts with a D, or they know all the meds better than any nurse does and it's I want 2 miligrams of dilaudid through an IV... I mean c'mon where do we draw the line? Should we just say everyone gets dilaudid straight out the gate? and put everyone into a happy bliss? or should we try and see what takes the pain away, tylenol first, then toradol, then maybe some morphine if that doesn't work if it seems to be a genuine c/o pain.

    Perfect case in point, I had a young man roll in on a stretcher one night sickling. That kid couldn't keep still, and everything we tried wouldn't kill the pain and we started with 4mg of IV morphine. Did I believe him, hell yeah I did, I've had sickle cells before, I know it's painful just by watching them, I don't need anyone to tell me that they're in pain, it's very evident.

    All of us have sprained something in our lives, hell as a kid i'd sprained more ankles than i'd known what to do with. The whole point of the matter is that everyone who walks through the ER door seems to think that no pain at all or any type of discomfort is the only acceptable pain level. And just because your in pain does not mean you hold an MD's license either. And truthfully if that's what they want, dope their butts up with versed now and let's get them tubed and up to ICU and they can just wait out the pain for that ankle. You might be thinking is he crazy? No i'm not, either we have to go all the way one way or the other, or stay in the middle. What works for one may not work completely for all, this is very very true. But the whole point of the ER is to treat the emergency at hand, and the patient to follow up with the PCP as soon as possible. Everyone expects the cure all pill. Alot of people expect the ER to run like a doctors office. And this is not the case at all. It's like being a cop, after a while you get the gut feeling that something just isn't right, and alot of the time your suspicions are correct. Why is it so bad to think that someone might just be a seeker? Should we blanket send everyone home with 20 vials of Dilaudid and sharps so they can self dose? Is that what we should do? Would that be morally ethical to do when someone is c/o ankle pain that has no difinitive diagnosis other than a strain or a sprain? Besides that, and i'll bet you almost every one of the ER nurses here will tell you on the d/c paperwork it'll state for something like that to stay off of it, ice it down, apply heat intermittently, take your pain medications and follow up with your doctor. Your PCP is to handle long term pain management, not the ER. While we're dealing with this ankle that could have waited till the morning to be seen by the PCP, a code gets wheeled through the door, and all the staff goes to help that patient, but yet when you return after loosing that code this ankle has the gall or tenacity to ask, what took you so long? As if... I totally can relate.

    And to the original poster, you did nothing wrong, you kept your cool and backed your doctor up 100%. The way I see it, those who aren't seekers, will at least try the medication to see if it works, part of my general d/c instructions are if the symptoms return/get worse, come back and see us. I usually will tell someone like that, i'll ask the doctor, but i'm fairly sure he'll say no. (as if I haven't asked 100 times already on other occasions) If they continue to press the issue and argue, I close my mouth and wait... You cannot be written up if your mouth is closed and you are listening intently to a complaint, whether valid or not... i'll look at my watch, smile, nod my head, look at my watch, smile, nod my head... and when they finally stop or ask, "aren't you going to say anything?" that's when I usually ask, "are you done?", if not they keep going, if so, I will say... "you have been arguing over this for (however long beings i've been keeping track of how long the rant is) the doctor has written your prescription, if you don't want it, your more than welcome to give it back to me, I will not argue with you about this." Once a patient or a family member sees that you will not be steam rolled for any reason whatsoever, they usually tend to quietly make their way to the door. I've had patients go for almost ten minutes, and personally speaking, if they want someone to hear them out and let them rant, ok, go for it... I'll listen, get it out of your system now. But your still not getting another script.

    And as for a statement to the "cash" comment... "so your ensinuating that a patient who cannot pay at all would leave here without the very same prescription?" That statement has worked well for the "I have insurance" crowd.

    Wayne.
    Last edit by postmortem_cowboy on Feb 13, '07 : Reason: .
  2. by   ZippyGBR
    Quote from Email4KH
    We STILL don't give pain meds until the MD assesses. Too many walk out after getting "fixed."
    the previous poster was referring to not analgesing 'belly pains' until they had had a surgical / gynae consult regardless of who had seen them in the Ed ( even senior Ed docs)
  3. by   tiggerforhim
    Quote from gauge14iv
    But triptans truly do not work for every patient. And not all triptans work for every patient. Brand X may work for one patient and Brand Y may work for another but niether of them may be effective for the third patient.

    You can't count on triptans to relieve all migraines. And then there are rebound cycle migraines...

    Some migraines truly do need narcotic pain medication.
    AMEN to that!!!! I am one of those for whom the triptans don't work and yes, I've been to the ED for migraine pain before, no, I didn't ask for narcs. HOWEVER narcs are the only thing I've been able to take for the migraines during my pregnancy. Please remember you can't always slot everyone into the same slot for a common complaint.
  4. by   teeituptom
    Make life simple
    As they come in the door
    Give them a menu
    Be sure to tell them about
    The Daily special

    Never argue with them
    say here it is
    or the doctor said yes or no
    and walk away
  5. by   wildmountainchild
    I'm rather disgusted by this post myself. I too have had my ankle "sprained."..it was very, very painful. NSAIDS have never worked for me, not even for muscle aches or headaches.

    That sprained ankle went on to get surgery within 6 months, and that was followed by hip surgery a year later. I'm really thankful the nurses at the urgent care center I went to believed me when I told them that NSAIDS didn't work and could they recommend something else. They recommended Vicodin, which took my pain from a 7-8 to a 2-3, very manageable.

    What did I do differently than your patient? I didn't get upset, but then again, I didn't have to....the nurses were caring, attentive, and they listened to what I had to say.

    My body chemistry is very particular as to what pain relieving meds work. Vicodin works, but it keeps me awake all night long so I prefer it only for daytime pain. Demoral is O.K. for nightime......my point being, who are you to decide what is going to work for an individual. Being that less that 1% of people who use pain meds for pain relief become addicted, who does it harm to give someone in pain the benefit of the doubt?

    I would be pissed off if someone told me I wasn't in pain when I really was and I would act accordingly. Is it so surprising that wifey got angry? She was trying to protect her loved one from pain and suffering.

    This reminds me of a time I was in the hospital for a ruptured ovarian cyst, I kept asking the doc for pain meds......it hurt so bad. He kept saying no (he thought I was overeacting to a UTI). I was crying and almost hyterical w/ pain. When the ultrasound came back.....boy he hustled in there with that morphine like his arse was on fire. My husband was so angry HE was almost crying as well. He never apologized for the nearly 3 hours I went w/o pain meds. If he had I would have chalked it up to circumstance, but b/c he didn't apologize we made a formal complaint againt the doc (not the nurses, who were trying to get me meds, the doc just wouldn't listen).

    Anyhoo, long story, but I think I've made my point.
  6. by   postmortem_cowboy
    I had a patient that came into ER one night, stated she was terminal with cancer via an ambulance, and that her hospice hadn't come out and that her "ovarian cancer" was giving her pain 10/10, yet all VS normal. We worked her up just like any other patient, she was fine all the time we were giving her pain meds. When the doctor went to discharge her, he called her home to make sure she'd have someone to let her in the door, as it was 3am. Come to find out this person who looked like she was on deaths door and her claims to being terminally ill with cancer were justified, but she was in a car accident back in the early 80's and got hooked on opiates and has never worked since. She simply roamed ER to ER seeking her fix of medication.

    I ask this: is it fair for someone who is deceitful, and lying about something such as this to recieve a discharge presecription for pain medication to go home with?

    I had someone dear to me loose their life due to ovarian cancer, to me, to lie about something like that is plain flat wrong. If some of us seem like we are skeptical on those who come in and don't seem to be in genuine pain, that's our perception of the situation, not yours, unless you are there and can say without a doubt that this person isn't faking it, you don't know the story at all. Pain is subjective, but you can also tend to see who is and who isn't in pain, if they're up out of the bed wandering the ER halls screaming and yelling about how hungry they are; and then are back in the bed doubled over when you go in, and back up and out of their bed as soon as you leave the room, that has to be a red flag that goes up.

    Personally speaking, I have a high learned pain tolerance. I've been sutured for 26 stitches without any anesthesia, i've broken bones and not had any vicodin, no pain meds of any kind, had a 2 pin placement without taking one of the vicodin prescribed afterwards, had a severely ingrown and infected toenail removed and cautery with the machine set on the highest setting just to get the wound to stop bleeding profusely with no pain meds afterwards. ER docs are very very cautious to give pain meds when they don't know the cause. And rightfully so, if someone comes in with a complaint they cannot explain, and we give pain meds, it goes away, how are they to assess the pain later on, maybe it moved, maybe it's now not burning, now it's stabbing. Quality of pain can sometimes lead to a diagnosis, IE rebound pain from the right lower quadrant. I've seen no appy's get pain meds before surgery, two reasons that have been explained to me, #1 if the patient goes into a surgery, then it can make anesthesia difficult and may have to wait out the pain med. #2 If you mask the pain before you know what is wrong (if anything) then you've shot some of your diagnosing assessment. I've had a couple of ER docs tell me this. So yes just because someone comes in complaining of generalized pain, doesn't necessarily mean they get 2mg IV Dilaudid to kill the pain. Some of you think having pain isn't a good thing. To you I say nay-nay. Pain is a good thing, it may be uncomfortable, but if you didn't feel pain, you wouldn't know when something was wrong. Give the doc a chance to find out what's wrong first, it may take time, it might be miserable while he does, but he's doing it for a reason, not just simply to make you suffer because he doesn't believe you.

    And as I recall from nursing school, we're patient advocates, but we're not doormats either. I can't tell you how many times i've given someone their D/C prescription which was ever so appropriate, and sometimes more than appropriate and it hasn't been to their liking and an argument ensues. As I see it, this is what the doctor whos been to medical school, taken a residency, and practiced medicine for many years has prescribed. He's recommending you see your normal doctor ASAP. If the med needs to be changed, it's up to that doctor to manage it and change it. Alot of ER doctors are limited as to what they can write. For instance, our docs could not write for tylenol 3, only vicodin, they were not allowed (by hospital policy) to write for MS contin for any reason whatsoever. Their pain meds that they can write for were very limited as per the hospitals policy for ER prescriptions. We have built a society that thinks a pain pill is the cure all. Maybe we should just start sending people home with pain meds and not make any attempt to diagnose the problem. We'll just mask the pain and when you keel over from a problem that started out as pain and all you wanted was to kill the pain, not treat the problem behind it, then it's your own fault. And if you who are angry with the nurses that work ER REGULARLY and see this type of thing over and over and over again, and get tired of people arguing well before they even try the medication to see if it works or not and follow up with their doctor, please remember this, that there are other forms of pain management other than chemical therapy. Also, that pain should not be overblown from discomfort to pain. People who walk in acting like nothings wrong and stating their pain is 10/10 with no elevation in BP, Pulse or anything else raises a red flag with ER nurses. ER nurses have to be skeptical, we see this regularly.

    ER docs also take it very seriously when people are seekers. They don't like being used to support someone's habbit. As for the lady in the first paragraph, when D/C'd home she demanded to see the doctor, who in fact did not write any prescription for any medications. Per her mother, she had plenty at home. She argued with the doctor, called him (who is black but a great doc) the "N" word among other things on her way striding out the door. Now I pose this question to you, should someone like that get a prescription for narcotics?


    Wayne.
  7. by   Franksters
    I hear ya. The vast majority of my career, I worked in Critical Care. It wasn't until I moved to med surg that I learned "I hate people!!!". We also get drug seekers. Today, the PCA is rolling this guy down the hallway to his room. Before he gets to the room he yells toward the nursing station, "HEY YOU!!!! I need 4mg Dilaudid, 25mg Phenergan IV and a cheeseburger with fries and a large coke. I will be ready in 5 minutes." First, I looked at the orders. He was admitted with HA R/O TIA! HHAAAAHH!!! Second I walk to his room and try to explain to him why I could not give him narcotics. This went no where. After about 10 minutes of listening to him call me everything but a woman, I say,"Listen to me. You are not getting narcotics. You will not ask me for them again. I have educated you regarding narcotics with possible neurological etiology. I have Tylenol for your HA. Would you like it now?"

    He turned me into my director, VP and CEO. They made me apologize but they agreed with my assessment. He left AMA! I am here to serve the public, yes. I am not here to be a punching, spitting, foul mouthed, stupid, killer nurse. The patients and a lot of times their families, are verbally aggressive and borderline physical aggressive.
  8. by   Franksters
    Nope!!
  9. by   CritterLover
    Quote from wildmountainchild
    i'm rather disgusted by this post myself. i too have had my ankle "sprained."..it was very, very painful. nsaids have never worked for me, not even for muscle aches or headaches.

    that sprained ankle went on to get surgery within 6 months, and that was followed by hip surgery a year later. i'm really thankful the nurses at the urgent care center i went to believed me when i told them that nsaids didn't work and could they recommend something else. they recommended vicodin, which took my pain from a 7-8 to a 2-3, very manageable.

    what did i do differently than your patient? i didn't get upset, but then again, i didn't have to....the nurses were caring, attentive, and they listened to what i had to say.

    my body chemistry is very particular as to what pain relieving meds work. vicodin works, but it keeps me awake all night long so i prefer it only for daytime pain. demoral is o.k. for nightime......my point being, who are you to decide what is going to work for an individual. being that less that 1% of people who use pain meds for pain relief become addicted, who does it harm to give someone in pain the benefit of the doubt?

    i would be pissed off if someone told me i wasn't in pain when i really was and i would act accordingly. is it so surprising that wifey got angry? she was trying to protect her loved one from pain and suffering.

    this reminds me of a time i was in the hospital for a ruptured ovarian cyst, i kept asking the doc for pain meds......it hurt so bad. he kept saying no (he thought i was overeacting to a uti). i was crying and almost hyterical w/ pain. when the ultrasound came back.....boy he hustled in there with that morphine like his arse was on fire. my husband was so angry he was almost crying as well. he never apologized for the nearly 3 hours i went w/o pain meds. if he had i would have chalked it up to circumstance, but b/c he didn't apologize we made a formal complaint againt the doc (not the nurses, who were trying to get me meds, the doc just wouldn't listen).

    anyhoo, long story, but i think i've made my point.

    the major point that i get from your post is that different people have different levels of pain tolerance, and that people metabolize drugs differently; what works for one may not work for another.


    i don't think very many people would disagree with those points. some might, but not many.


    but at the same time, i don't think the original post was about those issues.


    as i read it, the op was taking issue with the following:
    1. the pt's wife, not the patient, was not satisfied with the original script (tyl #3).
    2. the patient hadn't even tried the tyl #3 to see if it would work.
    3. she thought that the fact they were paying cash entitled them to a stronger pain medication.


    yes, some of the ensuing discussion did talk about not needing narcs for most sprains or other "minor" ailments. i was one of the posters that made that assertion, and i stand by it. for most, nsaids work quite well for sprains. there are exceptions, we all know that. that is why it is so essential to have an established relationsihp with a pcp that knows their patients' histories.

    i'm not sure if it was mentioned in this thread or another, but providers have to be careful when prescribing controlled substances. those kind of things are monitored, and they can get in a whole lot of trouble with the fda for indescriminate prescribing of narcotics and other scheduled drugs.

    edited to add:
    adding on to my list above:
    4. there was no indication -- other than pat size -- as to why tylenol #3 wouldn't suffice. didn't mention low pain tolerance, history of nsaids not working, or a valid reason for requiring something stronger.
    Last edit by CritterLover on Feb 20, '07 : Reason: another thought....
  10. by   maryloufu
    Quote from Franksters
    This went no where. After about 10 minutes of listening to him call me everything but a woman, I say,"Listen to me. You are not getting narcotics. You will not ask me for them again. I have educated you regarding narcotics with possible neurological etiology. I have Tylenol for your HA. Would you like it now?"

    He turned me into my director, VP and CEO. They made me apologize but they agreed with my assessment. He left AMA! I am here to serve the public, yes. I am not here to be a punching, spitting, foul mouthed, stupid, killer nurse. The patients and a lot of times their families, are verbally aggressive and borderline physical aggressive.
    WHAT did you apologize for? Were you not being truthful? What did they make you say? That is crazy- I have a difficult time with people who demand or act like they are at a hotel- and have requested training- all of that 'can I get you anything else because i have time' is complete crap! I dont have time! I am busting my tail trying to please you while I need to be getting a B/P on my patient with a cardizem drip and my other patient is on the Bedside toilet. Those 12 family members you have in here with you commenting under their breath about me can be your waitress!

    (Thinking good thoughts... bunnies in a meadow.....)
  11. by   Kim O'Therapy
    Quote from santhony44
    You did fine.

    If there was a remote possibility shame would work, having a shocked expression on your face and saying something like, "Oh, no, our doctors are watched very closely on their pain medication prescribing; Dr. Stethoscope could lose his license!" However, since lots of people these days wouldn't know shame if it had 18 wheels, was bright red and ran over them in the parking lot, that probably wouldn't work.

    Just repeat, with a smile on your face, "I'm sorry, Dr. Stethoscope isn't going to give you anything else today." And repeat, as often as necessary, until they give up and go away. Don't discuss or argue further, just keep repeating the same thing.

    People do get tired of beating their heads against a brick wall and stop.

    I agree and do what you do. I like to call it "the broken record approach"!
  12. by   Kim O'Therapy
    Quote from kiyasmom
    Why are all abdominal pain considered BS? I had a LOT of abdominal pain near my ovaries-radiating to the middle of my abdomen. I put up with the excrutiating pain because I was afraid to go to the ER because of this board and comments like this. I was afraid of how I would be received. One day the pain became so intense...went away for a second...and came back full blast. I made an urgent care appointment because it was after hours. I waited over 2 hours until my appointment doubled over in pain. My mom drove me to the appointment. I had an elevated BP and pulse, but no temp. The nurse kind of rolled her eyes. Dr. came in palpated, blah, blah. Didn't request a urine until the end of the appointment~AFTER he said maybe it's PID we should do a pap. No, sir, I don't I think so! Urine dipsticked for pregnancy as a formality because I'm tied up. Faintly positive...maybe not... let's get an ultrasound. The story ends with my left fallopian tube removed>>>>>>Wow. Dumb ass abdominal complaint people.:trout:
    I know this is a little off topic, but I know what you mean. I went four years with crippling abdominal pain and was treated like a "drug seeker" by the doctors I went to see, the ERs my husband took me to, and my insurance company. We lived in a very small state, so my hubby drove me to the next state over and took me to an ER there. The doctor there took me seriously, admitted me, put me on a PCA, and scheduled a laparoscopy first thing in the morning. I had massive abdominal adhesions r/t two C-sections. The adhesions had developed their own blood supply. The doctor recorded the surgery to show his colleagues and told me he did not know how I had continued to walk for so long. I asked him why the other docs had never picked up on it. He said, "Oh, adhesions don't show up on ultrasounds, so sometimes, I just have to listen to the patient."
  13. by   ginger58
    " I replied that it was a sprain and that we don't normally prescibe a narcotic for a sprain."
    Do you mean a narcotic besides Codeine??
    As a nurse that has been to the ER and said that an ASA won't take care of my stabbing pain in my ear (my eardrum ruptured on the way home) and having the doc tell me no one needs more than an aspirin. I know how those people felt. I knew what I needed and it wasn't ASA. If someone handed that line now I would have spoken up.
    Tylenol #3 is a narcotic. Maybe that drug hasn't worked for him in the past. Who are we to pontificate what works for a sprain when we aren't in his body. I think we need to quick looking at everyone that comes in as a drug seeker. Personally I don't like codeine and would have asked for something different and I am not a drug user.

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