Difference of opinion with MDs

  1. Hi everyone,
    I just wanted to pose a question, since I ran into a situation at work the other nite. Well, we had a young woman on our floor who was about 38yrs old, chronic migraines who came in because she was suffering from numbness and tingling on her whole right side of her body. The pain was getting worse, nothing was really helping her pain. When I came on shift, she was in her room crying telling me how much she hurt. I gave her some Xanax but even that didn't help to calm her down. Tried getting some more history out of her. She's been under a lot of stress, I guess working a ton of hours, doesn't have much support, as she's single and both parents are deceased. She admitted to having asthma, and also fibromyalgia but this pain was different. The MD had come to see her and told her her tests were negative...MRI, MRA, etc. When I talked to the other nurses on the floor they said that this doc think's she needs a PSYCH consult---like she was faking her pain for attention! I was sooo mad! Why is it that alot of times when the docs can't find a substantiated cause for someone's pain they right away think it's in their heads? I've seen a lot of people in pain, and this lady genuinely seemed like she was. He had ordered her Neurontin for her and after I gave it to her she said it really helped. Then even some of the nurses on the floor were saying...OH, it's in her head, that stuff doesn't work that fast. Am I just too sensitive and naive or is it wrong to believe the patients when they say they are in pain????? I feel like, who am I to judge how bad this lady's pain is????
    Thanks for your input...
    Amy
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  2. 23 Comments

  3. by   dianah
    When a pt says she has pain, she has pain, regardless of where it comes from (head or otherwise). What a relief to know the MRI/A were negative (no tumor!). Give the Neurontin time, perhaps it really will help her pain.
    I agree, some people (e.g., some docs) find it hard to admit they don't know where pain is coming from - always try to "pin" it on some physical cause, and when none found, dunno what to do. Keep being pt's advocate! --- Diana
  4. by   whipping girl in 07
    As an off-and-on chronic pain sufferer, I was glad to read that SOMEONE believed that this lady truly was in pain. I have endometriosis, and I have gone through extended periods of excruciating pain, going to the dr ("I did the surgery and got it all, you shouldn't be in pain anymore, must be in your head...") and getting no relief no matter what I did. I have a good gyno now, although she is a little stingy with the pain pills ("Now, Konni, I don't want you to get addicted to these," as she writes a Rx for 10 Lortabs!!) Geez, maybe if I took them all at once! And came back for a refill tomorrow.

    Chronic pain has more to do with the nerve pathways being screwed up than with an actual physical cause. It's often best treated with antidepressants or even anticonvulsants such as Neurontin. And if the patient finally got to talk to someone who BELIEVED she was in pain, it probably actually eased the pain. I know, in my case, just knowing that my doctor does believe me and will write the Rx for me helps ease the pain when my endo flares up. Fortunately, I've finally (hopefully) stumbled upon the hormonal combination that keeps me pain free 95% of the time. I can live with that!

    I've always heard that ICU nurses tend to undertreat pain; I probably tend to overtreat it, but I know what it's like to be in pain. Even if someone comes into the hospital for surgery or after an accident with a physical dependence on a narcotic, it is NOT up to us to dry them out, for God's sake. If it takes 10 mg MSO4 qh to control their pain, so be it. I'll give it to them (and if the MD's orders are not adequate for pain control, I let him/her know). They can deal with their dependence or addiction later, as far as I'm concerned. Patients do not heal as quickly if they are in pain.

    You are not naive, you certainly did the right thing. It's the rare patient that complains of pain that needs a psych consult, IMO. Stress can make autoimmune disorders (such as fibromyalgia) flare up. It sounds to me like this is her problem, and the pain is her body's way of telling her she has to slow down. It's the same for anyone, but especially for those with autoimmune disorders. Some of them can't handle any kind of stress at all.

    You fulfilled nursing's most important role: pt. advocate. Keep up the good work!
  5. by   micro
    catch 22

    d. if you do and d. if you don't

    i tend to overtreat it also....but have learned that there is another side to the story.....scientifically that is.......

    a psych consult is not a bad thing at times......it truly is not.....as long as the patient and the physical is not ignored............because mind and body are truly one.........

    mind=brain

    mind can sometimes = more than physical.............and that is okay also.........
    we are only human.....we are not meant to understand everything............

    and as health care providers.....we are meant to provide holistic care

    the brain and the synaptic activity is an actual process.......scientifically proven.........

    and there is much more coming out all the time...........
    Last edit by micro on May 14, '02
  6. by   colleen10
    Amy,

    Your post really touched me because a few short years ago my mother and I went on a trip to Key Largo for a weeks long vacation, just the two of us, to celebrate my graduation from college. On the 4th day into our vacation my mother woke up in the middle of the night in severe abdominal pain and nauseated. Thinking it was just something she ate or a stomach flu she tried her best to weather it and get rest. During the day I went down to the beach while she stayed in the room trying to get over it.

    By noon she knew something was wrong because she had never been in so much pain in her life and she was not getting any better. She was wheeled to a cab and went to the nearest hospital available. (The last time my mother had set foot in a hospital was when she gave birth to me).

    After being examined by the ER doc. the doc. told me that my mother had a pancreatic condition due to over consumption of alcohol. The doctor took us for a bunch of rowdy vacationers who partied too hard and had hang overs. Unfortunately, my mother and I had only consumed about two glasses of wine between the two of us and the doctor was rather snooty when I told her this. At this point, despite IV fluids and pain killers (eventually a shot of demoral sp?)my mother's condition had worsened, pain increased and she had bouts of consciousness and in-coherency.

    After the first diagnosis the doctor changed the diagnosis on average about every 2 hours. The doc. told me at various points throughout the day that my mother had:

    problems with her gall bladder
    stomach virus
    food poisoning
    cancerous tumors which had spread throughout her abdomen
    uterine fibroids

    At midnight, when I finally left the hospital, they admitted my mother for "food poisoning" and put her on anti-biotics and said to come get her at 9AM the next morning.

    At 7AM the next morning I received a call that the surgeon had examined my mother and although he didn't want to he was taking her to the OR for what he believed was an appendectomy. Apparently, he thought that my mother was drug seeking or just a masachist that enjoyed having herself operated on. His words to my mother were "If I go in there and don't find anything........."

    Well, he did find that she needed an appendectomy. When the surgeon went in he said she only had a short time before it would have ruptured. She was needlessly in pain and mis diagnosed for over 24 hours for nothing.

    Later while my mom was recuperating one of the ER nurses stopped by and asked how she was doing. She also remarked that "yeah, I had a feeling that there was something REALLY wrong her".

    Yes, the attitude that the patient is faking is contagious.

    So, I guess the moral of the story is we can't judge another's pain and we probably shouldn't.

    When I think of what could have happened to my mother just because a doctor couldn't figure out what was wrong with her..............

    We are all human, even doctors, and we make mistakes, over look things. If someone can mis-diagnose appendicitis I'm sure that there are a slew of other things that are mis-diagnosed too.

    So, follow your instinct, your gut, because no one has to live with your conscious but you.
  7. by   mattsmom81
    Seems to me if Neurontin relieved her symptoms her pain is of the neuropathy type...and isn't that the case in FMS (fibromyalgia syndrome) and also disorders like RSD? (Reflex sympathetic dystrophy) along with neuropathies that diabetics can develop.

    I always give patients the benefit of the doubt with pain...and I'm glad we have gone to a more humane method of pain management . (At least most of us have...still some stuck in the dark ages)

    Ever notice docs take a man's complaint of pain more seriously than a woman?
  8. by   fedupnurse
    They told a colleague of mine her chest tightness and difficulty breathing were all in her head. Turns out she was an undx'd asthmatic and was on a beta blocker. She's the meak mild type and didn't say anything to her docs but I sure did. I said if this were a male patient you would have left no stone unturned-you would have done echo's, stress tests, caths the whole nine! Don't get me wrong, I don't hate men but I have seen firsthand over the past 10 years that men are treated more thoroughly and quickly than women. Now if a patient is calling out in pain and then is asleep in five minutes without intervention, sure call a psych consult. Other wise, continue to be a true patient advocate and err on the side that this patient is in pain.
    Keep up the good work!
  9. by   boobaby42
    Here here! Doctors and other healthcare people are TOO quick to call someone an addict, or drug seeking. My dad, with terminal CA, could only get loratab for his pain. With bone ca, brain ca, lung ca, and a malignant tumor on the adrenal gland, prostate, and kidney failure as well, the doc wouldn't call him anything stronger in. Finally, after my husband got very aggressive with the radiology doc, they rx morphine. Well, he died that night. Damn! If I go through that with any body else I love, I'll be looking for street drugs if I have to. My loved ones will not suffer like that again. : (
    Last edit by boobaby42 on May 14, '02
  10. by   mattsmom81
    Oh, Boobaby, that is criminal, IMO! I would definitely be reporting those docs to the board ...maybe see an attorney about negligence or intentional infliction of distress by witholding analgesia. (probly doesn't meet criteria but it's fun to think about suing the butts off those heartless excuses for docs)

    Ignoring cancer pain is the worst of the worst! Inhumane. I'm so sorry you had to watch such awful care for your Dad. I lost both my folks to cancer (one fast, one slow) It's so hard even under the best conditions (((HUGS)))
    Last edit by mattsmom81 on May 15, '02
  11. by   SICU Queen
    Lortab for terminal CA?? That's AWFUL!!

    I'm with you, I'd be looking for some street drugs next time... (but hopefully there won't be one of those...)
  12. by   P_RN
    Neurontin DOES work rather quickly, and it DOES help neuropathic pain.
    Also Amitriptyline in very small doses helps.

    The psych consult may validate the PATIENT'S statement of pain. Even if the tests are "negtive" she has pain because she SAYS she has pain!
  13. by   zudy
    that is interesting what you said about amitriptylline,P-RN, I had a pt recently tell me that she had been in severe pain for 2 yrs from fibromyalia, was started on amitripylline 12.5mg at HS. She st pain went from a 9-10 to a 2. Also had a pt with meningioma and intractable vomiting for months and amitriptylline stopped it. just FYI.
  14. by   JWRN
    Pain is so undertreated in this country...For so many reasons...Addiction to narcotics, its just psychosomatic, she's just crazy, their not in pain their heart rate is normal, etc....A large part of the problem comes from both the MD and staff..APS research shows that pain is often under assessed by staff nurses...One reason for the new JCAHO pain standards....Not to leave the MD out, many are afraid of over-medicating, or having the DEA check them out because of the number of narcotic scripts they write....I like Margo McCaffrey's definition of pain...Pain is whatever the patient says it is....(there is more but I can't remember it off the top of my head right now)....Even those drug seekers who are known that come in c/o of chest pain or abdominal pain must be taken seriously on the off chance that they really are having an MI or perforated bowel, etc.....Oh well just my two cents.........

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Difference of opinion with MDs