The Emergency Department: Where pain isn't what the patient says it is.

joyful_wanderer · Jan 13, 2015

I keep coming back to your post. I really wish I could answer your question. Yes, pain is what the patient says. Their perception is their reality. Not sure of the exact situation you mentioned plus I wasn't there to see it. I have no idea what the patients injuries were but I do know that at the different ERs I have worked at we don't always give narcotic pain medications to patients just because they say their pain is a 10/10. Part of me wants to respond and say "if the staff knew this patient that well he probably is a drug seeker". I know I have personally made the same assumptions about other patients that I have taken care of frequently. At the same time I have seen patients induce vomiting to get different meds or more pain meds. It is sad but maybe some of us ER nurses do get jaded.

As far as it being the patients right to be pain free..... there are some "pains" that no matter what we give or do will not make a patient pain free.

In regards to not letting a patient get their fix. Is it in our best nursing practice to further enable a patient with their addiction? If they truly are a drug seeker. There has been times that doctors have written narcotics for patients (ones we considered drug seekers) just to appease them simply because they are acting out or giving their nurse a hard time. In that case is it appropriate?

Unfortunately you are going to see and hear things you may not agree with or that may cause you to question your own beliefs and I guess all I can really say is be the best nurse that you can be. Treat patients they way you would want to be treated as a patient. Be the nurse that you would want to have.

Maybe make a list of all the reasons that you became a nurse or all the things you value about nursing so that you can reflect on it in the future if you ever find that you have become slightly jaded or running low on compassion. Perhaps its something that we should all do.

BTW congratulations on the new job and career!

AJJKRN · Jan 13, 2015

All that I can really say is that YOU guide your practice and treat YOUR patients the way YOU want them to be treated. I personally treat my patients as the way I would want to be treated with sometimes having to place boundaries and realities when I need to. For one, we cannot always provide absolute pain control but can provide adequate pain control. I also know (typically) when to draw the line on how many hoops...er advocating...I will go through for a patient that only wants more or is never satisfied or becomes a threat to themselves! These patients start to get boundaries put in place during their care...

allnurses Guide · Jan 13, 2015

When you see the same fellow over and over, who makes no effort to get help for chronic pain and/or addiction, you get tired of being used for a "quick fix". Especially if they are rude, abusive, entitled, demanding, demeaning, and generally unpleasant. You may not have had much to do with this one, but it sounds like the others have.

This particular person in the accident had a legitimate reason for pain, and likely exaggerated his pain complaint since he is likely inured to his meds and knows he will need more to get the same relief you or I would for the same level of pain. Nonetheless, his pain should have been addressed and relieved.

In the long run, we do them no favors by providing an easy fix, being enablers. But there should be plans put in place for the chronic abusers, one more demand on our time. We have had social services and primary docs involved with certain patients, and with a written plan available in the EMR achieved some consistently in attitude and care. It works but takes a lot of effort.

Other times and patients with no plan in place, they actually ask which docs are on, refuse care from some and literally leave if they have to see the only available doc with whom they have a history of, shall we say, confrontations. Some will never be happy nor admit to being pain free even when so sedated they need oxygen support, can barely speak, have a crash cart outside the door but still want more drug. You as the advocate need to protect airway before treating pain.

CaptCrzy · Jan 13, 2015

Thank you! Great advice. As a patient, I wouldn't want my nurse to treat me with suspicion when it came to needing pain meds.

One time I had kidney stones and asked my doctor if I could get something for the pain. He said, "drink cranberry juice". hahahahahha! I'm like, "Are you kidding me?" I was in nursing school at the time so I knew I had to be my own advocate. After making the doc feel like a complete ass I got exactly what I needed and wanted.

I refuse to suffer especially when I know there is no reason for it. I hope I never forget to treat my patients the way I would want to be treated.

SubSippi · Jan 13, 2015

Although I don't think it's up to a nurse in an ED to try and regulate someone's drug problem, I will say that I understand how aggravating it is to feel like you (and your coworkers and the entire healthcare system in general) are being taken advantage of, over and over, by the same people, often times for years on end.

Pain is subjective, and I would never tell anyone flat out not to give someone pain medication because I think they are a drug seeker. Addicts can certainly still be in pain, no doubt after a motorcycle accident. But, I think nurses can get fed up dealing with certain types of people, because it can feel like you're just rewarding bad behavior.

I can pretty much guarantee that each of the nurses whose behaviors you mentioned probably had similar thoughts when they first started working when they watched the more experienced nurses deal with addicts. People get jaded over time, and some handle it better than others.

With certain types of patients, it can be very difficult to find a way to be compassionate without letting them take advantage of you. It is most definitely something I'm still working on...I can be a huge push over.

In the mean time, I say just go with your gut. If it's your patient and you want to give them pain meds, give them.

zmansc, ASN, RN · Jan 13, 2015

I know several nurses and providers who go overboard on the pain seeker paranoia, and conversely I know several who are at the opposite end of the spectrum as well. Contrary to nursing school, in the real world pain is what the patient says it is but.... When the patient says they have 15/10 pain but they have no signs of pain, no etiology that would be causing this massive pain, etc., the nurses suspicions get aroused. Are we perfect? Nope, never gonna be, it's a subjective finding with high inter-rater variability, always will be.

So, can it be improved? Absolutely. We as ED nurses must be (and most are) careful to not become too jaded about pain med seekers, yet to also not be too fast to feed the pain med seeker with supplies of narcotics. When the patient comes back to the ER for the fifth time during your shift, your probably giving pain meds out too easily (true story, we had to have the rest of the providers talk to that provider), when someone crashes their motorcycle or has other trauma with obvious etiology of pain and you tell them, "um, can't give you nothing until we do a UDS", or "I have two tylenol po for your pain", probably not treating their pain.

Incidentally, anyone using Tylenol IV to reduce/eliminate the need for narcotics in certain cases? If your ED isn't using it, it seems to be very good in alot of situations and if the provider is reluctant to give more opioids to a patient or to even give any opioids, then it's something you can advocate for your patient.

NurseOnAMotorcycle, ASN, RN · Jan 13, 2015

We get people who come in daily for narcotics and benzos. We get pts who don't come in as regularly, but ours is the fourth ER in one day and they've gotten prescriptions at each one. (providers can check pretty easily). We also have eyewitness accounts of patients who have deliberately punched walls or otherwise injured themselves to get narcotics. We have many people requesting detox because their dealer has gone to jail and they want to ask the others where they buy from. I personally have more than a few patients who were stealing or trying to steal needles out of IV and Phlebotomy trays to use for shooting up with.

While I do understand where you are coming from and agree that we have to be compassionate, it doesn't stop us from also having to be street savvy.

toomuchbaloney · Jan 13, 2015

Modern medicine and pharmaceuticals have created an entire population of people who are dependent upon medications. Opiates are but one group of those medications.

I would not ever want to visit your ED with a complaint of pain if the only person there who is going to listen to my concerns without a "jaded" opinion of my status is the newbie, I'd rather go somewhere where the staff actually treat the patient and NOT their own burnout or fears.

Yes, we have people who are drug seekers.

Yes we also have a large compliment of people with REAL pain issues which are not adequately treated or relieved.

Sometimes they are the same people, but not always.

Nurses are not gatekeepers for the opiates, we are health advocates.

NurseOnAMotorcycle, ASN, RN · Jan 14, 2015

True, nurses are not gatekeepers. The providers are. If they order something, we give it. End of story.

zmansc, ASN, RN · Jan 14, 2015

True, nurses are not gatekeepers. The providers are. If they order something, we give it. End of story.

I certainly hope not. Both as a RN and a future NP, I would disagree that the provider orders it, the RN gives it blindly, and I'm hoping you didn't mean it that way. I'm sure you advocate for your patient when you feel the provider's order is not correct, just as the rest of us do.

Both the provider and the RN must treat the patient as the patient presents, not a number on a pain scale. That includes the patients history, assessment, exam, labs, and other tests. What often confuses new grads is that they have been taught over and over if the patient says 6, pain is a 6, and in the real world, that's not the case for many reasons, one being that the pain scale is a very subjective scale that has poor inter-rater reliability.

I live in a very rural area, we have alot of ranchers who haven't seen anyone medical since they were born, if then. When they play with power tools, they get hurt. Invariably they come to the ER with some nice big trauma, usually against their will. Now these guys, all believe they must be tough guys and when asked about pain answer: "It don't hurt much." If you push them for a number they will answer 2 or 3, all with a grimace on their face, clenched fists, veins popping from their necks, diaphoretic, etc. Do we assume their pain is a 2 and go on my merry way without treating it? Of course not, the number is no where near as reliable as our assessment of the patient is.

It's no different for the patient who is eating chips, sipping a coke, playing on their cell phone, yet complaining of 11/10 abd pain. Do I treat based on a number, or a whole picture? I think this is what most of us try to do. Sometimes we get too jaded and don't treat pain we should, and sometimes we get played and treat non-existent pain.

Another part of this that is always fun is the documentation. I don't know about your systems, but ours is terrible about treating pain. We have a screen we have to fill out, it takes a number and selecting an action from a drop down list. So, I have on occasion gotten the nasty email, you had a patient with a 10/10 pain and you didn't treat it?!?!?! My response is typically, did you read the nurses note made at the same time? That note will say something to the effect of "pt reports 10/10 abd pain, exam shows....provider notified". With the description of what indicates the patients pain is not requiring treatment at this time. The desk nurses who review charts for a living still didn't like this because it messed up their numbers, but I successfully argued that if they didn't like it change how they want me to document the pain assessment as I wasn't going to lie on the medical record so that their numbers looked better.

NurseOnAMotorcycle, ASN, RN · Jan 14, 2015

Unfortunately, if the provider orders pain medication for a patient who I think is not in that much pain, I am not the nurse who's going to stand there and refuse to give it. I may question it, but i never withold pain medication.

Congratulations on working for your NP. :)