[ssouthernyankee]

Thank you Karen G. Once I graduate nursing school I only pray that I never get so hardened that I start to treat my pts as criminals. Although I suppose I can sort of see how frustration could set in especially being an ED nurse when there is such a problem with drug seekers, it's just a shame that many "innocent" and honest patients get the raw end of the deal so often.

[sociostudent]

Dear whoever,
I'm a 25 year old female and have had a history of recurrent kidney stones since age 17 (at least 3 per year ; 2 cystoscopies for obstruction so far) and ovarian cysts (dermoid and functional ; had a laparoscopy in 2005 to excise/test a dermoid cyst that wouldn't go away), which has sent me to the ER many, many times. I went to 4 different hospitals (not at the same time--my husband had to keep moving for work, and apparently, documentation for CT scans isn't required. The pain medication was usually either withheld completely (toradol, instead) or not given until after a CT "confirmed" a source of pain. I would estimate that I've had at least 30 CT scans of the abdomen (many with oral and IV contrast), but it could be even more. I really don't know. Of course, b/c of my preexisting conditions, I can't get health insurance. I found an OB-Gyn that would take me without it, so I paid the $200 and found out that I've developed a complex 4 cm cyst in my left ovary that will need an exploratory laparoscopy for excision/pathology to determine if it's malignant, as well as reduced kidney function (GFR = 69). Apparently, the doctors at the hospital ED don't look at previous admissions/radiological studies until the damage has already been done. I was doing ok until January, when I started having abdominal/joint/flank pain, went to the usual ED, who diagnosed the cyst, as well as another stone. I’ve had a low-grade fever for the last month or so, weight loss (from 110 pounds to 95 in 3 months), fatigue, and now, my hair is falling out. And I don't mean a few strands at a time, I mean CLUMPS of hair are falling out without even brushing it. I saw a rheumatologist back in '02 who said he thought I had either lupus or a connective-tissue disease (arachnodactyly, hypermobility, dual-positive ANA with homogenous and speckled patterns with titers of 1:320 and 1:160, respectfully), so I'm thinking it's either autoimmune, medullary sponge kidney, or cancer. Labs have been abnormal (only slightly, but chronically). metabolic panel shows high levels of calcium, albumin, total protein, low ALP, Sodium, and Potassium, and BUN/Creatinine ratio (been tracking for 3 years). CBC shows only high MCH and MPV, rest is normal (from past year). UA's, however, are all screwed up: cloudy urine, alkaline, moderate proteinuria at 1 g/dl, chronic, intermittent hematuria (on/off for almost 5 years), and occult amorphous crystals.
I don't know what all of this means, but I do know that I AM sick, I just don't know what with. Can't get medicaid (we make $100 too much per month) and insurance doesn't kick in til January 1. So what should I do when I'm bleeding out my rectum and nose and am having severe abdominal pain? What would you ED nurses want me to do? Stay home, possibly worsen and die of infection, or come in, put up with the nurses' snide remarks, eye-rolling, paternalistism, and refusal to even give me toradol after the doctor specifically said that I was going to receive pain medication? I'm not looking for opioids, I'm looking for relief until I can get to a nephrologist! What would ya'll do?

[allaboutthefamily]

Originally Posted by sociostudent

Dear whoever,
I'm a 25 year old female and have had a history of recurrent kidney stones since age 17 (at least 3 per year ; 2 cystoscopies for obstruction so far) and ovarian cysts (dermoid and functional ; had a laparoscopy in 2005 to excise/test a dermoid cyst that wouldn't go away), which has sent me to the ER many, many times. I went to 4 different hospitals (not at the same time--my husband had to keep moving for work, and apparently, documentation for CT scans isn't required. The pain medication was usually either withheld completely (toradol, instead) or not given until after a CT "confirmed" a source of pain. I would estimate that I've had at least 30 CT scans of the abdomen (many with oral and IV contrast), but it could be even more. I really don't know. Of course, b/c of my preexisting conditions, I can't get health insurance. I found an OB-Gyn that would take me without it, so I paid the $200 and found out that I've developed a complex 4 cm cyst in my left ovary that will need an exploratory laparoscopy for excision/pathology to determine if it's malignant, as well as reduced kidney function (GFR = 69). Apparently, the doctors at the hospital ED don't look at previous admissions/radiological studies until the damage has already been done. I was doing ok until January, when I started having abdominal/joint/flank pain, went to the usual ED, who diagnosed the cyst, as well as another stone. I’ve had a low-grade fever for the last month or so, weight loss (from 110 pounds to 95 in 3 months), fatigue, and now, my hair is falling out. And I don't mean a few strands at a time, I mean CLUMPS of hair are falling out without even brushing it. I saw a rheumatologist back in '02 who said he thought I had either lupus or a connective-tissue disease (arachnodactyly, hypermobility, dual-positive ANA with homogenous and speckled patterns with titers of 1:320 and 1:160, respectfully), so I'm thinking it's either autoimmune, medullary sponge kidney, or cancer. Labs have been abnormal (only slightly, but chronically). metabolic panel shows high levels of calcium, albumin, total protein, low ALP, Sodium, and Potassium, and BUN/Creatinine ratio (been tracking for 3 years). CBC shows only high MCH and MPV, rest is normal (from past year). UA's, however, are all screwed up: cloudy urine, alkaline, moderate proteinuria at 1 g/dl, chronic, intermittent hematuria (on/off for almost 5 years), and occult amorphous crystals.
I don't know what all of this means, but I do know that I AM sick, I just don't know what with. Can't get medicaid (we make $100 too much per month) and insurance doesn't kick in til January 1. So what should I do when I'm bleeding out my rectum and nose and am having severe abdominal pain? What would you ED nurses want me to do? Stay home, possibly worsen and die of infection, or come in, put up with the nurses' snide remarks, eye-rolling, paternalistism, and refusal to even give me toradol after the doctor specifically said that I was going to receive pain medication? I'm not looking for opioids, I'm looking for relief until I can get to a nephrologist! What would ya'll do?

I have thought about situations like this, especially being that I am a full time student (meaning when I begin work full time my insurance will not cover "preexisting conditions" in the US. If I were to develop cancer or the like now, all I would leave my family with would be bills and fond memories. I am not reccomending this, but I told myself if this did ever happen to me I would move to canada (hopefully with my family) so I could get free healthcare. You need treatment, and to be honest palliative care such as opiods will only make your kidneys worse in the long run. I am not trying to diagnose you or tell you what to do, I am just saying what I would do in a similar situation. My heart goes out to you, and I wish you the best.

Nurses who refuse to give pts meds because of thier own feelings should lose thier license to practice. Evidenced based practice, as well as common sense, tells us that the patient is the only one who knows thier own pain. Even the pain of withdrawl is pain that needs to be treated, albeit what we really need is stricter treatment programs for drug users.

[allaboutthefamily]

Originally Posted by ecnav

I'm thinking about 'evidence based medicine'. Why not employ polygraphs -lie detectors- in the pain assessment. Like bispectral analysis used in anesthesia, polygraph science might help identify factitious complaints. Like bispectral, it wouldn't be the sole determinant, just another source of information leading to more complete patient assessment.

A polygraph would not be the way to go IMO. They are not exceedingly accurate in controlled experiments (in some 25-50% inaccurate). Furthermore, a polygraph measures respirations, skin moisture, temp, etc. all things that are affected by acute or chronic pain. That is to say it would be hard to tell when someone was lying or just experiencing a bout of acute pain. I have heard of a technique to "trick" polygraph machines, by creating your own pain (i.e. digging nails into palms, putting a pin in your shoe) you can actually raise the measured parameters during baseline questions making subsequent lies appear as truth. I know I wasnt very clear in this post, I just have never subscribed to the accuracy of a lie detector and would defenitely not believe EBN based upon polygraph machines. I do think you are headed in the right direction though, perhaps imaging studies of the brain would be more in line with what you wish to accomplish.

Even this would not solve the problem, because we cannot very well image every patient complaining of pain, but it would give us a better idea as to the scope of the problem.

[nanacarol]

The patient who OD on cocaine really did not receive the appropriate treatment from his primary physician. Taking him off of his addictive medications without addressing the addiction failed the patient. It would have been great if you and the other nurses had had other resources to refer the patient to. Our responsibilities are far reaching. nanacarol

[nanacarol]

Why not take it a step further and really investigate the source of the pain, whether it is physiologic or physical, chronic or acute, whether it is emotional or spiritual. That would be the real appropriate strategy. But we don't usually have the time or training to do any of that. So we should be faced with merely taking the patient's assessment and report in lieu of any stand out explicit data that refutes the patient's complaint and medicating the patient. We are not the drug police, we are to minister to the patient not add to the patient's stress and feelings of being devalued. nanacarol

[sociostudent]

I have often thought of going to canada or mexico, even, to find out what's wrong with me. I live in Texas, and so Canada seems like a long way to go. But mexico is only 8 hours away.
The point I wanted to make with my original post, is that a person in chronic, unrelenting pain is eventually going to do whatever it takes to relieve their pain and suffering. If that means crossing a border or using a substance illegally even (smoking marijuana, etc.), they'll do it. And if doctors are unwilling to provide any pain relief (or nurses are unwilling to push them) to those who are truly in pain, that person is going to be nonfunctional in their daily life (unable to work or take care of their family) AND will suffer from mental health problems due to chronic, untreated, and unbelieved pain. The best-case scenario would be for the physician, nurse, and patient to all work together to treat the pain (multifocal modalities such as physical and emotional therapy, as well as pain medication) in a setting that is nonaccusatory or non-biased. If the patient is truly in pain, they will be more than willing to undergo the drug-testing, the mandatory therapies if it means that the pain will ease. However, outside of a cancer treatment setting, I have not seen this truly happen yet.

[I love my cat!]

Originally Posted by sociostudent

The point I wanted to make with my original post, is that a person in chronic, unrelenting pain is eventually going to do whatever it takes to relieve their pain and suffering. If that means crossing a border or using a substance illegally even (smoking marijuana, etc.), they'll do it. And if doctors are unwilling to provide any pain relief (or nurses are unwilling to push them) to those who are truly in pain, that person is going to be nonfunctional in their daily life (unable to work or take care of their family) AND will suffer from mental health problems due to chronic, untreated, and unbelieved pain. The best-case scenario would be for the physician, nurse, and patient to all work together to treat the pain (multifocal modalities such as physical and emotional therapy, as well as pain medication) in a setting that is nonaccusatory or non-biased. If the patient is truly in pain, they will be more than willing to undergo the drug-testing, the mandatory therapies if it means that the pain will ease. However, outside of a cancer treatment setting, I have not seen this truly happen yet.

Excellent points!
Then I read articles like this:
Nursing Homes Undertreat Dementia Patients' Pain

From article:
Researchers at the University of North Carolina Chapel Hill evaluated data for 551 residents of six nursing homes across the state and found that residents who were cognitively impaired were less likely to receive regular doses of pain medication or to receive pain drugs at all.
This was despite the fact that dementia patients and cognitively healthy patients had similar rates of often-painful conditions like cancer, osteoarthritis and degeneration in the spinal disks.