Sorry this is so long, just need to vent...
I work in a smaller teaching hospital. We have a group of residents/interns who rotate in and out from a larger teaching hospital- each group spends about a month with us at a time. We all know that residents/interns need some guidance now and then, and I am generally very patient and will help them whenever I can. However, this group, I hate to say it, is DANGEROUSLY STUPID. My frustration level is just through the roof, and I can't take it right now. The biggest problem? They all seem to have this MASSIVE fear of opiates, and my patients are suffering because of it.
Case #1-
Elderly woman with a very extensive cardiac and pulmonary history, chronic back pain, on home OxyContin with Vicodin for breakthrough pain, uses 1-2 PRN doses at home a day. Admitted in acute pain (chest pain) thought to be non-cardiac, related to a severe pneumonia. Ordered for her home dose of MS Contin, no PRN pain med (not even tylenol) ordered. During initial assessment, pt reports 8/10 L rib pain with cough. Intern on the floor, and approached for PRN order. Intern admits he hasn't seen this patient, didn't admit her, etc. Tells me he doesn't really feel comfortable giving her an opiate, because he doesn't want to compromise her resp. status. I tell him to discuss with his resident if he needs to, but the woman would really like her PRN vicodin ordered. He asks for a stat ABG. I tell him this is possible, but she's satting 98% on 2L, has some rhonchi at the left base, and her resps are 26-30... it will take me a little while to get an ABG (few respiratory therapists to draw at night) and could he maybe go down and assess the patient first? His reply? "These opiate addicts drive me nuts, she's not in pain, she's in withdrawal" A- didn't you just tell me you've never seen this woman? So how can you tell she's not in pain (nevermind that pain is what the patient says it is) B- How in the world is she in "withdrawal" if she got MSO4 in the ER earlier today AND her home dose of oxycontin tonight???? He reluctantly gives me a PRN oxycodone (would have been better to go with the Vicodin, since we know that works for her, but whatever) and tells me to use it sparingly, because we don't want to suppress her respirations too much (because that rate of 26-30 is too low????)
Case #2-
96 yo man with metastatic lung AND prostate CA, RA, chronic abd pain for years. S/P lap chole after which he went into respiratory failure, CHF, MI. Recently extubated and transferred to telemetry. Very confused, oriented to person only. At home, he was taking MS Contin 30mg 3x a day. I get in report that he's been telling the 3-11 nurse he's going to die tonight, but can't give anyone any specifics as to why he thinks that. (we all know to believe them when they say this, though) Intern (another one) on floor to see patient, currently writing orders (which he placed on the rack despite the lack of secretary, so I didn't see his STAT orders for hours), wife has been called and is on her way in to see patient.
Patient denies pain at first, but winces when his abdomen is gently touched. Definitely NOT answering questions appropriately. Wife tells me he's been asking for a sleeping pill for days, but the doctor said no. All he can tell me is that he's "miserable"-nothing specific. Morphine, a whole whopping 1mg, Q4H ordered for breakthough pain from Ultram. Given at 0000 with absolutely no results. Ultram given when due with absolutely no results. Intern paged- states his signout says to avoid opiates, benzos, and ambien. Tells me the patient denied pain when he asked him earlier. I tell him the patient also denies he's in a hospital, but that he won't stop moaning, grimaces with touch, is constantly restless in bed, has been on the call light every 2-5 minutes, and is now currently weeping and asking "why they let him suffer like this?". I also tell him the wife says he acts like this when he doesn't take his MS Contin, and that I think he's in opiate withdrawal. His response? Well, we could start him on an SSRI for the weeping, but that would take a while to take effect, so he'll address it with this patient's team in the morning. Long story short, despite repeated calls to the resident, intern, and nursing supervisor, I wasn't able to do a thing for this man all night except hold his hand and tell him he would be okay, and that killed me. I went home and didn't sleep for 24 hours wondering why I do what I do.
Case#3-
Young, relatively healthy woman in her 30's admitted with sudden-onset bilateral leg weakness, leg and back pain, headache.Tentative dx of Guillain-Barre. Not on any home pain meds. Given toradol, percocet, and morphine in the ER with some, but not much relief. Came up to the (telemetry) floor without any orders- something we just recently (and stupidly) started allowing. Despite the morphine given in the ER prior to transfer, I'm told in report she was in tears just transfering from stretcher to bed. Meanwhile, I'm told housestaff is calling from the ER to find out her code status. She's healthy 37 year old mom... what do you THINK her code status is????
I immediately check for orders (at 11:15) and don't see any. Initial assessment, she's got 1/5 strength in her right leg, 2/5 in her left, 7/10 back and leg pain. I find her orders, and strangely, NOTHING- not even tylenol ordered for pain. I call the (worst of the group) intern- who says, "She was just watching TV". Tell me, what does that have to do with anything???? She tells me her attending told her to manage the pain with Tylenol, given that GB can lead to respiratory failure. I very gently remind her that the morphine given in the ER barely touched the woman, and that she's had a dose of toradol, too. She tells me the patient has no history of GI bleed... but then asks me to put her on hold, and go CHECK with the patient about GI bleeds and reflux, which I do. So she begrudgingly gives me orders for tylenol and toradol, both of which I give ASAP (the toradol I had to wait for a supervisor override) By the time I get the patient medicated, see my other patients, and start entering her zillion labs for the morning, and then clarify the lovenox IV (did you maybe mean SQ, since we don't give it IV) order, I notice that this intern wrote (after the patient had been admitted to a TELE bed) "Admit to PCU". She didn't think to mention this to anyone in our three or four conversations??? So before calling the idiotern back to clarify, I reassess the patient's pain. Not surprisingly, she's now at a 10/10... and she looks 10/10 too. BP elevated, white as a ghost, tears running down her cheeks. I get the idiotern on the phone, tell her she can't just write for PCU after the patient's on tele without notifying someone, and she says to me, no joke "what IS PCU"? We don't even have a PCU bed available. She still refuses to order anything else for pain, and tells me to talk to the resident. I get the resident on the phone, who admits she's never seen this patient and doesn't really know what's going on... but she's in the middle of an ICU admit, and it'll be at least an hour before she can come up. I tell her an hour is unacceptable, and someone needs to do something about this woman's pain. She says they'll discuss it and call me back. So I'm running in and out of the room, trying massage and positioning, heat, emotional support, everything I can do for this poor woman. 20 minutes later I still haven't heard back, so I page them again. Finally, with 10 more reminders about respiratory failure (we do stock Narcan, you know!) she gives me an order for a whopping 1mg morphine q3h and says maybe if it's psychological, that will help. Um, I thought we stopped giving placebos a long time ago? And if this woman's so sick we have to admit her to PCU, and we're so worried about her respiratory status, what makes her think the pain is all in her head? Did I mention her MRI showed disc compression in the lumbar spine? But, sure, it's all in her head! Between the toradol, tylenol, morphine, and non-pharmalogical interventions, I did manage to get this lady's pain down to a 3-4, which was in her tolerable range, but I should NOT have had to fight like that to do so. Again, I had another patient in tears asking me why the doctors would want her to suffer.
I did manage to get all her labs entered eventually, but I did let them know I skipped the pregnancy test, considering the woman is S\P TAH with bilateral oopherectomy. Their response? Then why is she on oral contraceptives???? Um.... doc? Last time I checked, Premarin was HRT... or did you not look THAT one up before you ordered it?
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