Why don't docs send these pt's HOME!?

[zofran]

I have been frustrated at work lately when dealing with a few pts.

First guy, admited with pancreatitis, so hes NPO and receiving iv pain medication Q2h. A CNA saw him down in the cafeteria eating a cheesburger, and staff from the other side of the hall saw him take a large cookie off a dying pts berevement(sp?) cart that is sitting in the hall for the pt family! Of course I confronted him and he denies it. I document, tell the md, but nothing is done. Same thing the next day, a cna saw him in the cafeteria eating bacon and eggs. I call the md...nothing.

Second guy, has had chrons for a long time. Has been on narcotics at home. He comes in for a bowel resection. All is well until he begins passing gas, gets his diet advanced, and the IV narcs get d/c. Even though the surgon put him back on his reg po narcs from home plus po narcs for breakthrough pain the pt says "its too painful to eat" So the pt begins to refuse food and refuse to ambulate. He ends up on TPN....still refusing food, still refusing to ambulate, refusing to do anything unless he gets more pain meds....This goes on for over a week...ct's and abd series show nothing.....hes just sittng there, taking up a hospital bed, doing nothing but taking po pain meds...FINALLY surgon gets a consult for an hospital doc to deal with this. The hospital doc tells pt he will be d/c to a nursing home if he continues to refuse to eat and walk. Still took the docs 5 more days to get him out.

Third guy, in with sickle cell crisis..due to some lab work, pts hx of leaving AMA, and the fact he has been banned from the hospital down the street, docs don't really believe hes in a true crisis. But they are treating him as it really cant be proven he is lying. So on eve shift he disapears for 3 1/2 hours. Is just no where to be found..They have security looking all over...Doc is notified, documentation is good etc. He comes back and said he "fell asleep" in the lobby. The next day on my shift pt appears to be high on something. Hes so figety, cant sit still, wont stop moving, talking fast, grinding the teeth...not acting the same at all from the previous day. I confront the pt, get the doc up there and again....Nothing is done.

I guess I just don't understand.....If a pt will not comply with treatment or sabotage there own treatment as in these above examples..why cant the docs just d/c them. I would think, if the documentation was excellent, that there would be no reason why not. Do you guys have any thoughts?

[sissiesmama, ASN, RN]

Oh, yeah! We have always and still do get these patients on our unit too. A sickle cell pt (and I'm not saying he wasn't in pain) brought his alarm clock and set it to wake him up about 10 min before time for the q 2 hours prn Demerol/Phenergan. He asked us to not dilute it and he would have his IV tubing in his hand and pinch it off while I was pushing it.

Like we aren't going to notice things like that??!!

Anne, RNC

[southernbeegirl, BSN, RN]

i hate it when i read vent threads and people respond in a nonventing way, lol. that said...can i just say one thing?

my husband had porphyria. although completely unrelated, porphyra exacerbations and sickle cell exacerbatios are treated almost identically clinically (nothing to be done but iv fluids and iv pain meds mostly).

i saw nurse after nurse judge my husband. he had long hair, tatts and slept between pain shots.

he could be in complete agony but looking at him you would never know.

a patient that lives with pain day in and day out like he did don't offen show s/s pain that we'd normally see. yes, they can sleep thru the pain too. they live with it 24/7 so their body learns to cope. and sleeping is often times the only time they get relief at all.

my husband, too, would set his alarm to let him know when he could have the next injection if he had a nurse that hadnt taken care of him a lot. the nurses that knew him always just brought the med when it was time. he was in the hospital for months at a time.

i learned a lot about sickle cell from his hematologist because of the way both are treated similarly. i met a lot of patients with SS and they presented just like my husband often times.

that being said (and thanks for letting me get that off my chest)...

i wouldnt push a med fast either just so they can get that "rush".

[shiccy]

Oh by all means for the sickle cell crisis patients, I have all the empathy in the world for what they go through. It's the med abuse that I have a problem with.

I have no idea what it is like to have the condition, obviously. I do know that those with full blown sickle cell disease have a very short life expectancy. That being said, however, the problem that I had with my sickle cell pt wasn't the fact that I had to give her Benedryl IVP or that she had a huge tolerance for her pain meds, but the fact that she wanted me to push a 10ml flush right after for the rush.

I have no problem with taking care of pain control issues, but the "I want the med because it gives me a high" thing bothers me to the core.

[traumarns]

.And with the floor leavers -- call the doc and request an order for a dose of narcan after any "unexplained absence" from the floor. You give them narcan, and tell them they'll get it anytime they leave the floor, and presto, they are ready to go home.

narcan aint gonna help if hes tweeken from meth or crack. if hes high from opiates you are absolutely correct, he is not gonna be a happy camper.

i would get a utox and have security search him and his belongings each and every time. if drugs found in his possession , call the po po.

dude aint gonna like the pretty shiny bracelets they put on his wrists and legs.. plus he wont get to call his mama for help, or get visitors to bring him his "stuff." he will want out pretty quickly

i bet your hospital has a policy re elopements- ours is if they leave campus and then reappear, they are no longer pts on the floor. they get a trip to the er. if the er docs cant find anything to admit for, they get to go BUH BYE!

[shiccy]

I would almost think Narcan'ing a pt for a reason that wasn't medically necessary would be almost illegal. I say this because you can't just give medications if a patient refuses them, and is of sound mind and body. In fact, it may fall under the "doing harm" and "causing undo discomfort" ... Long story short: I'm sure that's illegal, but you could always *TELL* them that this is what will happen...

[zofran]

I wish our hospital would make these floor leavers readmit to the ED. That is a great idea! I am going to ask the docs about this. I also like the different colored gowns for flight risks..the narcan thing is good too.....

[netglow, ASN, RN]

Also, those scores, those satisfaction scores! It's these folks who end up complaining about inadequate pain control/unattentive staff/bad food, etc. You would think that the quicker they got booted the better for all. As soon as they know, that you know, that they know, they are seekers (LOL couldn't resist) they fill their time finding ways to irritate you because they're ****** and that's how you get a poor rating it's pure revenge.

This is such a no brainer! Why can't facilities figure this one out? :angthts:

[sissiesmama, ASN, RN]

i hate it when i read vent threads and people respond in a nonventing way, lol. that said...can i just say one thing?

my husband had porphyria. although completely unrelated, porphyra exacerbations and sickle cell exacerbatios are treated almost identically clinically (nothing to be done but iv fluids and iv pain meds mostly).

i saw nurse after nurse judge my husband. he had long hair, tatts and slept between pain shots.

he could be in complete agony but looking at him you would never know.

a patient that lives with pain day in and day out like he did don't offen show s/s pain that we'd normally see. yes, they can sleep thru the pain too. they live with it 24/7 so their body learns to cope. and sleeping is often times the only time they get relief at all.

my husband, too, would set his alarm to let him know when he could have the next injection if he had a nurse that hadnt taken care of him a lot. the nurses that knew him always just brought the med when it was time. he was in the hospital for months at a time.

i learned a lot about sickle cell from his hematologist because of the way both are treated similarly. i met a lot of patients with SS and they presented just like my husband often times.

that being said (and thanks for letting me get that off my chest)...

i wouldnt push a med fast either just so they can get that "rush".

Southernbeegirl = Please accept my apology if I sounded offensive or rude. That is not the way I meant it. During my 19 years as a nurse, I have taken care of many many SSC patients, and I do understand their disease and their tremendous amount of pain. I would not wish that disease on ANYONE. I have seen them curled up in a ball, crying and moaning, and beg you not to even touch that area of their body. I have such empathy for them - they are in such pain, and it is just miserable. I would never deny my patients their pain meds, even if there is a question about their pain status. That is not not my job. My job, like everyones else is to either decrease or at least lessen their pain level. I have never withold pain meds becacause it is my job to treat their pain at their pain level that they give me.

The thing that bothers me at times is when they go outside to smoke or pinch off their tubing and ask the nurse to push the narcotic fast. The ones that "doctor hop" when their PCP catches on. I am an er nurse, and when they call before arriving to see if it is a "friendly doc" working . If the friendly doc is there, they arrive "post haste". If they aren't working, they don't show up at our ER, they pick another .

Like I said, I hope I didn't offend you, it's just after 19 years, and you see some of those possibly "seekers", it just works on your nerves. Just my 2 cents. Please accept my appology.

Anne, RNC

[canoehead, BSN, RN]

We never tell callers what doc is working, for just that reason. If you have an emergency you take the doc you get.

[sissiesmama, ASN, RN]

We never tell callers what doc is working, for just that reason. If you have an emergency you take the doc you get.

That is standard practice in our area also. For a while, I worked nights in a small rural hospital. This area is also high in drugs, ect. Apparently, the night clerk was "the clue" as to who was the ER doc that shift. After she got caught, she was fired, but then was caught cruising the parking lot to see which ER doc's car was in the lot. We live in north Louisiana and we have a lot of the "good old boy justice", if you know what I mean, and nothing was ever done about it. Most of the patients used the ER (which was only 3 beds anyway!) as their PCP, for colds, that type of thing, and could get most of the ER docs to prescribe narcotics out the wazoo. It was as long as they paid their bills, their wish was the doc's command.

Needless to say, I didn't stay there long. It was an hour drive one way and I was in the middle of a nasty divorce, and I packed my things and headed back "home". Thankfully, the larger hospital where the staff followed the rules, the the "we don't tell you who's on", ect.

I was SO glad to get back to civilation and to my parents. The only person I knew in the rural town was my now ex husband. I actually was written up by one of the other night nurses for not giving out the small town ER docs name.

Anne, RNC