What do you use for pain control

[alyca]

Just browsing around and seeing mention of some of the things used in your facilities for pain control. I work on a trauma/ortho unit (we don't do elderly total hips, knee replacements, etc--we do 'car crushed my leg' or 'bus rolled over with my arm underneath it and degloved it'.

We use generally MSPCA or dilaudid PCA's postop or upon admit to floor from ER, but I have issues with these, since people bolus themselves until they fall asleep, then wake up with horrible pain and have to be bolused by the RN until they can catch up again. Standard settings start at 1mg MSO4 Q8 minutes, increase to 1.5mg/6min if there are problems. DIlaudid at 0.2mg/8min, increase to 0.3/6min. We usually start MSContin BID as well, and transition them over to 15-20mg oxycodone Q3 hours a day or so postop, unless they are going down for more OR. If oxycodone doesn't work , or there are allergies, we will use PO dilaudid 2-4mg or more Q 3 hours.

We use vicodin or percocet only if it is a pt who we think has only a small amount of pain, never even mentioned for most of our patients.

We also have a pain relief service who is consulted for pts with persistent pain issues. They are fond of methadone for long term relief, and a variety of meds including fentanyl pops or PCA's, demerol PCA (generally a last resort), high concentration MSPCA's, etc. And, almost always, they add RTC tylenol. Ligament knee or elbow issues, or HO excision pts with CPM's get PNC's with bupivicaine to encourage compliance with 23 hours a day in their CPM's.

Just curious--what do you use??

[alyca]

Let me just reply that most of our patients have really fairly good pain control. We are not having people lying in agony not being treated, and there is not, in my opinion a huge problem at Harborview. We consider a 2-3 on a 0-10 pain scale, with 0 being no pain and 10 being the most pain possible, to be an acceptable level. Generally, the patients meet this. Not all the time, such as when doing activity, or post-op, etc. We give -contins or methadone or some other form of long acting pain medication for that overnight with the PCA. Pt's who have issues with PCA's do not stay on them long. They tend to get flagged as pain issue people and have their needs quickly addressed either by their primary team or the pain team.

Patients at Harborview are getting very good care, both of their injuries and their pain. They are unique in the severity of their injuries and the complexity of their medical issues, and would not receive the high level of care they need anywhere else. We had a patient flown in from Chile a few weeks ago just to our hospital because we could fix her severe injuries, and there was no other doc or hospital on the western US who could treat her. She had massive degloving and fractures requiring, among other things, a tricky free flap. But she is okay. She is home, her pain was monitored, and after a few weeks with us both she and her family were in tears thanking us as they left.

[alyca]

And, the pain relief service is not a clinic. They are on call, available to us 24 hours a day every day. We don't let pain slide. The first thing I ask each patient each morning when I arrive is 'how was your night--how is your pain doing'. I assess pain before I check on any vital signs, and it is the #1 issue for all our patients. Pain meds are by far the most common thing we give. More patients are on pain meds than are on multivitamins. I have seen patients with 120mg TID of MSContin, along with 90mg of MSIR Q2-3 hours, or 8mg PO dilaudid Q2 hours, 30mg oxycodone Q2-3 hours, etc. If I or any of my family members were seriously injured in a trauma sort of way, I would hope they were admitted to Harborview, because I know that is where they will be fixed properly and have the most positive experience. You would not belive the number of cards, thank you notes, fruit baskets, even gift certificates for massages and ski tickets our patients send us. People often leave in tears--not because they are in horrible pain, but because they are so grateful for the wonderful care they have received. They come visit us when they return for clinic appointments, some even now volunteer in the hospital. We give great care! (including pain control!)

[P_RN, ADN, RN]

That is a wonderful testimony to your hospital. We have had several international patients. Most seem very grateful for the help. But some, particularly the Eastern European and Russians seem to have issues with our medicine. Has anyone else found that? My mother is Slovak and she's reserved but not nearly so much as some of our patients.

[alyca]

International/non-english speaking pts are one of our target populations, so we get a wide variety of different cultures. Different cultures express pain differently. Some are stoic and try to keep things in, and you really have to ask them quite specifically about their pain and offer pain meds to them frequently. My big speech to these types of patients is that this is not pain that you can 'wait out'. A headache may go away on its own, and may not be needed to be medicated, but fracture/trauma pain is not just going to go away--there is not need to suffer with it.

Other cultures let it all out and you know absolutely everything about what they are feeling. Some have very high expectations--ie. having a pain level of 0 at all times, or wanting to be 'knocked out' by pain meds until they are healed. It takes a lot of pt teaching to get these guys on the same page as the medical staff as far as pain goals go. Pain levels and goals actually show up on our Q shift documentation.

[kind_angel]

We use Morphine Pcas...in recovery room they give a loading dose of 5to10 mg of morphine and thereafter the patient can use the pca button and dose themselves at 1mg per 5 minutes.We also give paracetamol with pcas.Generally we take down the Pca's second day post op and get them on oral analgesia.Usually its tramadol 50 to 100mg or/and cocodamol30/500 1m.In elective surgery you will find some patients prefer to stick to whatever analgesia they were on before surgery.It just depends on how mush pain they are in really.

By the way we also use Epidurals at mostly 5-10mls/hr however most patients prefer pcas to epidurals.