Two Big Questions For Pain Experts

Specialties Pain

Published

If it's assumed that the patient's pain is ALWAYS what they say it there are two major questions that arise. The questions arise because they are real-life situations.

1. A patient has had surgery that isn't expected to be painful. The patient has had 4mg of Dilaudid for pain that is reported as 10. The patient has a goofy grin and says: "I'm going to say that my pain is a 10 because I like pain medicine." (This actually happened)

Do you continue to administer Dilaudid in this situation? Do you take his report of pain at face value? I was advised by my co-workers to send the fellow home and I did so.....He left smiling......Did we do the wrong thing?

2. A patient is close to being in a Dilaudid coma after receiving 10mg of Dilaudid. The patient appears very comfortable and, when awakened, rates his pain at 10. (This actually happened)

Do we have a pain emergency here? (I've seen many situations that are clearly pain emergencies but this one doesn't seem to be a pain emergency.) Can you in good conscience send the patient to the floor with a pain of 10 under these circumstances?

O.k.....I asked more than two questions but the other questions are tied to the main ones.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
No....Nobody has told me how to manage the patients. Should they have received more medication(s) or not?

In the case of #2 administration of more opioids would likely have necessitated reversal with Narcan. Given that is it O.K. to discharge him despite a pain rating of 10?

I have given you my definitive answer....that my answer would be based on patient assessment and on an individual basis. I cannot get any more definitive than that.

YOu also have not answered why you are so insistent on these answers. Which is begining to make me uncomfortable.

I bow out gracefully

Specializes in Emergency & Trauma/Adult ICU.

I'm going to go WAAAY out on a limb here and try and expound on the OP's points. But as I'm just "reading between the lines" and applying my own experience, it's entirely possible I've got the OP all wrong and am barking up the WAY wrong tree. It wouldn't be the first time. :writing:

My random thoughts:

There has been a decade or so of push toward "pain is what the patient says it is" mentality in American medicine. Do we think it has served us (patients and clinicians) well?

It has fueled an astronomical increase in the number of opioid prescriptions, and created a cultural expectation that pain relief = the effects produced by opioids which are not only the relief of pain but also the accompanying psychotropic effects.

The accompanying push to attempt to quantitatively measure the inherently *qualitative* experience of patient satisfaction with care has also reinforced to patients that "pain control as soon as you want it" is an expectation. Especially in the acute care setting (which includes the OP in PACU), the nurse who attempts to introduce adjuncts to opioid analgesia (ambulation/ROM therapy, relaxation, distraction, positioning, etc.) is understandably met with frustration/negativity by many patients, who have been conditioned to believe that pain control = the relief/euphoria/sedation produced by opioids. The fact injury and other surgical interventions *ARE GONNA HURT* for a limited period of time ... seems to have been lost almost entirely. (I'm thinking of a recent patient who presented to the ER 3 hours post discharge from the endoscopy lab after a routine screening colonoscopy with cramping abdominal pain. Umm ... you've spent a day doing what we euphemistically refer to as bowel prep, followed by a scope ... is it not reasonable to expect some temporary discomfort??)

I'm not understanding the reflexive, vitriolic response to the OP's questioning of ... not whether or not an individual patient requires opioid pain control ... but whether or not the system is broken, setting us all up for failure.

Specializes in PACU.
In the real world I always look at my patients past record for input on my decisions.

I did that......It didn't give me any information that helped with the situations.

Did I do the wrong thing with the patients or not?

Specializes in PACU.
YOu also have not answered why you are so insistent on these answers.

I have answered that several times. I want to know what the experts say on how the patients should have been managed. Depending on their answers I might do things differently in the future.

Specializes in PACU.
It has fueled an astronomical increase in the number of opioid prescriptions, and created a cultural expectation that pain relief = the effects produced by opioids which are not only the relief of pain but also the accompanying psychotropic effects.

Thank you for your insightful and thoughtful response.

It's past time to bring reality into how we treat pain........The theoretical models have nothing to do with the reality of pain control in some situations (they work really well in many situations).

Specializes in Hospice.
I have given you my definitive answer....that my answer would be based on patient assessment and on an individual basis. I cannot get any more definitive than that.

YOu also have not answered why you are so insistent on these answers. Which is begining to make me uncomfortable.

I bow out gracefully

Indeed, Esme. I believe the OP is only interested in manipulating us into giving him the knee-jerk answer he wants in order to prove the point he tried to make in his locked thread - that it's all the "experts" fault.

I'm with you ... we're re-inventing the wheel here.

Specializes in PACU.
I believe the OP is only interested in manipulating us into giving him the knee-jerk answer he wants in order to prove the point he tried to make in his locked thread - that it's all the "experts" fault.

No.....I want to know what the experts advocate in the two examples I mentioned.

I'm not talking about "knee jerk answers". I'm talking about situations that had to me managed and I want to know how to manage them properly.

Why can't anybody tell me how to manage them properly? The problems had nothing to do with the patients being under-assessed.

If anyone claims to understand how to manage pain patients they should be able to give me some ideas on how to manage the two examples. If you can't tell me what to do why not have the courtesy/integrity to admit that there are no easy answers?

Specializes in PACU.

There seems to be an underlying assumption in most of the responses to my questions that I want there to be problems with the pain scale.

I don't want there to be problems. If it worked the way it should my job would be a whole lot easier and many patients would be in a whole lot less pain......Of course I want that!

The thing is that there are problems with using the pain scale. They are widely acknowledged problems. Just about everyone I know (which is a lot of Nurses and Dr's) have noted problems with the pain scale.

We're talking about problems that involve harm to patients. Many of the responses I've gotten tied to make the problems about me.....The problems have to do with whether patients are properly cared for not my feelings about this stuff.

Can anybody take a patient-centered approach instead of attacking me? (Altra's post is the exception of course).

Specializes in Emergency & Trauma/Adult ICU.

The OP is clearly upset. But seriously ... no one else has ever been faced with the *ahem* "COGNITIVE DISSONANCE" produced by documenting a patient's self report of 10/10 pain and other assessment parameters to the contrary? No one else has ever been called on the carpet by a patient who called the unit director to complain at great length about poor care ... because clinicians declined to write scripts for Opana for an ankle sprain?

We're professionals, and we generally take this stuff in stride. But we're still stuck in the farce of a system which sets up these scenarios ... and once in a while frustration bubbles over. I suspect that's where the OP is, on this particular weekend.

OP ... wishing you a better shift the next time you work.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
No.....I want to know what the experts advocate in the two examples I mentioned.

I'm not talking about "knee jerk answers". I'm talking about situations that had to me managed and I want to know how to manage them properly.

Why can't anybody tell me how to manage them properly? The problems had nothing to do with the patients being under-assessed.

If anyone claims to understand how to manage pain patients they should be able to give me some ideas on how to manage the two examples. If you can't tell me what to do why not have the courtesy/integrity to admit that there are no easy answers?

I believe that telling you that it depends on the patient and on an individual basis....it clearly stating the is not an easy answer.

Therefore, I have already answered with integrity.

Specializes in PACU.
wishing you a better shift the next time you work.

Thanks.....You too! My frustration has to do with, as a percentage, a whole lot more patients with people habits who are extremely difficult to manage.

It's been widely reported that overprescription of opioids has reached epidemic proportions.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The OP is clearly upset. But seriously ... no one else has ever been faced with the *ahem* "COGNITIVE DISSONANCE" produced by documenting a patient's self report of 10/10 pain and other assessment parameters to the contrary? No one else has ever been called on the carpet by a patient who called the unit director to complain at great length about poor care ... because clinicians declined to write scripts for Opana for an ankle sprain?

We're professionals, and we generally take this stuff in stride. But we're still stuck in the farce of a system which sets up these scenarios ... and once in a while frustration bubbles over. I suspect that's where the OP is, on this particular weekend.

OP ... wishing you a better shift the next time you work.

good point!!
+ Add a Comment