Pain is NOT subjective

To begin with only the complaint of pain is subjective. There are however very objective signs of pain that can be observed. If your telling me your pain is 8/10 (being 10 is the worse pain you've ever had in your life) and your sitting calmly reading a magazine, text messaging, laughing...etc. Well you either have no prior experience with pain other than a splinter, you are exaggerating or you are lying. END OF STORY. By the way I work in the Emergency room and I would say the exaggeration of pain is the rule not the exception. In addition, providing narcotics and controlled substances to those that are seeking them for other than appropriate means is not a harmless process. People that have addiction and substance abuse issues are DIRECTLY HARMED by allowing them to successfully manipulate for these medications. (First rule is do no harm...remember) If you think that a lawsuit is able to be won by nonsense like improper pain management (I'd like to actually see the circumstances around that one). wait until you see the lawsuit by the substance abuser that goes home and dies of an overdose of controlled substances that they were given by an ED Physician to manage their "pain". Yup especially when they have a documented history of substance abuse and are known to the hospital. This happened at the hospital I just left. A 21 year old male died following an overdose of medications that he was provided in the ED for a complaint of "dental pain". Well guess what. That hospital, physician and every nurse involved in that case is being sued by the family, and they will and should win. Providing that patient with those medications was unethical. But Physicians and nurses go right down that road because they are forced to by hospital administrators bullied by regulatory agencies that no longer survey and evaluate but dictate to the cries of political correctness. I certainly believe that true pain should be addressed but what other area of medicine do we treat people based on purely subjective information. When a patient comes in and complains of chest pain we evaluate the pain parameters and than take into account the OBJECTIVE data such as EKG results, diaphoresis, etc prior to calling the cath lab don't we. Pain is no different. If the patient is lying there reading a magazine, lying on a stretcher, legs crossed in front, no guarding, full range of motion in all extremities, relaxed facial expression, non-pressured speech, no psychomotor agitation, no diaphoresis, no increase in pulse or blood pressure, (lets see how many more objective signs can I name). Well you get the point. This is frequently the patient telling me they are having 9/10 abdominal pain, and usually for many days. Sorry I'm not buying it! Tylenol. If we are going to just medicate a patient based on their subjective comlaint then just put a dispenser in the ED lobby and stop wasting everyones time. i will continue to appropriately assess both my patient's objective signs and certainly document them as such. As for some of the other comments the Drug companies are horrible and the Physicians are complicit to give people whatever they ask for. Then you have made up things like fibromyalgia. Give me a break. Everyone can send their flaming messages towards me but I've yet to see someone with that diagnosis that isn't on a dozen psychiatric medications. Not stating that this is the case with everyone, but in the 5 years I've worked in the ED I've yet to see the exception.

Ok, this pressed so many of my hot buttons.
First of all, I have Fibromyalgia. It's not a "made up thing". It has taken years away from my life. I have struggled to work, and have struggled with the pain. I am a chronic pain patient. I believe in what ever you can think of as adjunct medication and alternate pain management treatments for controlling pain. The issue of pain control is when you can no longer take neurontin, ibuprofen, naproxyn, TENS, massage, acupunture, aquatherapy, etc...because you don't get a good outcome anymore. I can't take muscle relaxers because of all the side effects. So I am left with opiods and valium. Yes, I take anti-depressants, I exercise, I try to eat right, and I try to be a productive member of society.
Three years ago, a 250 lb patient fell on me and I got HURT. With FM, that just make it hurt more. The Workman's Comp Doc(#$%#$%@quack) liked doing acupuncture with electrostim- after I told him I couldn't tolerate electrical therapy after having used a TENS for 10 years. He did it anyway. That was about all he had to offer. W/C says that because pain is subjective, despite the pain that this back injury left me with, I can't get a disability rating; and yet, working full time is extremely difficult for me. Right now I'm working three 8's a week, and that's about as much as I can do without becoming overly exhausted and calling in sick.
I have had mutliple surgeries and I know what pain med works best for me. You'd think that when I go to the ER with a paralytic ileus and tell them that A) it's an ileus and B) please start and IV and give me Dilaudid cos it works best for the pain, someone might listen. Instead I get treated like I'm a drug seeker. Then I get "the look" and "the attitude" from the ER nurse until I start projectile vomiting with an abdomen that is rock hard, the tears are streaming down my face...for some reason, it's the vomiting that convinces them that I really am in trouble.

However. As far as my patients are concerned; some have high pain tolerance, some not so great. I've seen appendectomy pts refuse any pain meds at all. I've seen others huddled on their gurneys, diaphorectic, squirming, crying, or whatever folks in pain do, and tried to get them something for their pain, only to meet with "I'll get there when I get there"(as an OR nurse, I don't have access to the narcotics- anesthesia does). If the person administering pain medication has never been dramatically ill, they have NO understanding of how long a minute without pain relief can be. I am a strong believer in being a patient advocate because of how I've been treated as a patient; not "just" as one with FM, but as a potential surgical patient, as a surgical patient and as noted before, someone with a paralytic ileus.

I wish that pain could be quantified better, so that the bosses, nurses, doctors, med students and residents would be able to really understand how a patient who is an 8/10 feels. I have days of 1/10, but most of my days start out at about a 4 or 5, just waking up. As the day goes by, sometimes I'm just fine and don't need anything to help out. I love those days. Not taking meds at all is a dear hope for my future. And other times, I'll awaken in the middle of the night with 8/10 from nowhere.

Opiod therapy may not be the best treatment for various patients, but on the other hand, if you have someone who comes to your ED, who was in a car wreck, has a bad back that was just re-injured, leg and head lacerations, etc, but who has a 20 year history of being clean and sober- would you deny that person pain medication for an acute situation? I have a friend like that, and he was given a very limited quantity of pain meds to help him through the situation. Would any of you consider him "drug seeking"?

BTW, low dose methadone, like low dose oxycontin or the fentanyl patch, is prescribed to keep the FM'er's level of discomfort under control as long as 8-12 hours at a time, rather than popping pills every four hours. The lowest level possible is given as a way to control the ever present pain with usually other adjuncts given as well, and possibly vicodin or percocet from break through pain. Most of the FM patients I have met/chronic pain patients as well, are mostly interested in sleeping well enough to function the next day at work. With chronic pain, sleep is disrupted and the rest of homeostasis is reduced to a shambles.

I do agree that there are drug seekers out there- seen some. THEY are the ones who make the true honest to God chronic pain patients suffer. We just want to have as normal a day as possible; they want the highs, etc of the drugs themselves. Most(agreed, a certain number do become junkies)pain patients are not drug seekers. They are simply looking for a way to have QUALITY of LIFE. Remember that from nursing school?

Very often, only people who know me well enough can tell if I am in a lot of pain. The look on my face is pretty sutble. My actions are more likely to give me away; I become crabby and abrupt and sometimes, agitated. :scrm:Suddenly, I'll realize I'm in pain and will take something. I do not deny that I have developed a mild physical tolerance over the years, but, as I pointed out, there are good days when I take nothing at all. Sometimes, when I'm lying still and trying to relax, as that patient mentions previously with the lack of pain affect, I'll be fine, til I try to get up or move. Sudeenly, there is a crescendo of sensation- as my clean and sober freind says- pain is God's way of letting you know you're alive, and baby, WE'RE REALLY ALIVE!!!


So, yes, your boss is an ass. Pain is a very subjective issue, unfortunately, and aside from the clear drug seekers, should be accepted at "face value".

I knew someone would respond with the fibromyalgia. Sorry but still not buying it. I have aches and pains every day myself. I'll bet if I went to enough doctors someone would tell me that I have fibromyalgia. I have seen people with very minor injuries carry on crying and screaming. I know they are exaggerating their pain. Drug seekers also don't just seek drugs for the high. They frequently seek the drugs and dramatize the pain for the secondary gain of attention. In addition I can also point out that I have yet to meet a man diagnosed with fibromyalgia. Come to think of it most of the patients that present in the ED, around 75% are women with some type of unaccountable pain with no objective findings. Sorry but its the fact but you can all flame me about it. half of the people in the ED I work in now refer to the ED as the womens clinic. And having traveled for over 2 years I've never seen an exception to this anywhere. I'm not saying that these people don't have pain. But remember pain is subjective. I can say that the pain I have every day is a 1/10 and someone else can say the same level of pain is 8/10. Regardless I can tell you the pain I have is barely worth tylenol. Just because someone describes the same level of pain as 8/10 doesn't mean they should be medicated with anything other than tylenol. I'm also sorry to disagree with you but nothing should be taken at face value. Objective data should always be part of any assessment.

I find it very interesting that after my lap-chole/R carpel tunnel release double surgery that the PAR nurse wanted desperately to medicate me for pain because my vital signs indicated that I was in pain even though I was not. I did not allow her to medicate me. When I arrived on the unit they were going to hook me up to a Morphine PCA and I refused because I did not feel pain so I requested Tylenol. See, I am narcotic naieve so won't take anything unless I need it. After my abd hyst they over medicated me in PAR because they felt I needed it and hooked me up to a PCA on the floor which I did not use even though I was in pain because the dose was too high for me and no one would call the doc to get the dose lowered, so I suffered all night until the pain went away the next morning. Just because I choose not to take meds, mainly because I am allergic to soooo many, does not mean that I don't believe in them for my patients. I work in Hospice and Palliative Care and so many times have been called to see patients that have just been diagnosed with Stage IV cancer when they came through the ER two days ago with pain. So there will be times that someone may be hypotensive but be in pain because they are dying of cancer, so the vital signs may not always support a picture of pain. Usually agitation, restlessness, tachypnea may be there, but if you don't believe people in a coma can be in pain, they can. Uncontrolled pain can lead to a myriad of problems later and may even cause a person to appear to be a seeker because he/she does not trust that the pain will be relieved, that someone will care enough to help. The emotional toll that pain takes on a person is very real and may add to the physical pain, thereby increasing the intensity and anxiety. We are all made so differently so please have compassion for people in pain, whether physical or emotional or spiritual. God bless you and I hope those in pain find relief and help.

While I will not flame you; I think that if you think really hard about it that the numbers for the increased ratio of women in the ER are not as dramatically different as you state. I have several years in the ER and I must say that sometimes it is dependent on the time of year, the area of the country and many other factors. I find that women in the ER will report their pain a lot quicker than most of the men. I do think that we will find that their will be a "physical" finding to go along with fibrom. eventually. I remember when the syndrome "chronic fatigue" was the catch phrase in the late 80's and it was associated with wealthy female patients. Strange how some of those cases were later linked to Epstein Barr Virus. (an actual real little bug). I am just saying we shouldn't disallow something as real until it is known for sure, and even then to the person in pain...it is real.

I do think in an acute pain situation that there are going to be VS changes, diaphoresis, palor even...kidney stone pt. comes to mind. I do not agree that there will necessarily be these changes with chronic pain. Some people are very stoic and some are great big whiners....but they both hurt. I have taken care of a lot of native americans and you would be hard pressed to tell if ANY of them are in pain, even acutely. I also think that in the US the guys are "weak" if they "whine" about something, in other words, we train you guys to suck it up. Bottom line is that we should treat people's pain. No not everyone should get a mega dose of fentanyl, nor should everyone get tylenol. My drugs of choice are.............shocker........Toradol and zofran...when I get a migraine the benadryl, reglan and toradol combo kick butt. This is just what works for me, is nonnarcotic, and I can work when taking it.