Are we adequately treating pain?

[ag01medic]

I just watched an episode of Trauma Life in the ER and Code Blue on Discovery health and observed two different cases.

#1 Was a young boy (prob 6 or so) with an almost full amputation of his left arm, midline humerous area due to a boating accident. It was pretty heart wrenching hearing this boy cry and tell his dad that its hurts so bad. He was given 2 of morphine pre-hospital and additional on arrival.

#2 Was a ~35 y/o female involved in an MVA with a femur fracture of her left leg. This lady was in some extreme pain and was very voval about it. The Chief Surgical Resident was pretty pompass in my opinion and finally ordered 2 mg of morphine, just prior to them putting her into a traction splint. Needless to say, she screemed the entire time. Why?

Now, I understand the argument of of masking pain, but how can we let our patients writhe pain??? Research has shown that we under treat pain. Does anyone else have any experiences or thoughts to share?

[alwayskatiek]

and what about those patients who suffer from SICKLE CELL CRISIS???? In the hospital where I work at, we do see a lot of these patients suffering from sickle cell crisis and are frequent flyers. They come in almost lethargic due to unbearable pain, joints swelling, hypoapneic and showing signs of dehydration. I have seen a lot of nurses and even Docs just shrug their shoulders because they think these patients only comes to the hospital "to get their drugs" and even heard a comment saying "these people knows how to work the system in order to get free drugs". I don't exactly know how these patients feels when they're on crisis but I can't imagine the pain they're going through ( just by reading literature about sickle cell). I, personally don't judge these people right away...I look at the whole picture, their symptoms and labs. I know that majority of the point of care of these patients needs to begin from them. They need to be EDUCATED. I don't deny my patients their pain meds when they tell me that they're in pain....of course the only time I "hold off" is I see that they look too sedated and if their blood pressure calls for their meds to be held off. I mean we can see amongst them who's faking or who's sincere. Docs needs to be notified and sometimes educated as well...as we NURSES are the primary care taker of these patients and we spend a whole lot of time with them to know if something needs attention....WE ALL NEED TO THINK OUTSIDE THE BOX and not to judge too quick!

At one point in time I worked the hem/onc floor, and they were very good about pain control for all of their patients. I was eventually written up, and ultimately left because I asked a sickle cell pt, in with pneumonia, to walk just outside her door (she had not been out of bed in 4 days) before I gave her the 3mg of IV Ativan, which was in my hand. I think that there is treating pain and OVER treating pain, as we have a responsiblity to help these patients get better and go home. But my question is, where do we draw the line?

PS forgot to mention that the patient was rating her pain at a "0" when I asked her to walk, and had been rating 0 every day of the admission.

[deeDawntee, RN]

What a great thread!! This issue makes me SOOOOO mad!!

I know 2 things for certain:

1) We under treat pain.

2) We need new treatments for pain. Pain medications that actually provide comfort and don't contribute to addiction and dependence. It is the nature of the human body to grow tolerant to narcotics. There has to be a better way.

Where is the committed concentrated research into new treatments for pain?? Narcotics are such an awful answer. Does anyone know of any?

[rgroyer1RNBSN, BSN, RN]

Yes, we are undertreating pain. We have one notorious hospitalist who is similiar to the one talked about here. I swear he the most he will order for pain is 5 MG Toradol IV or 10 MG IM, and 1GM Tylenol. And he says that as long as they have that little bit he cant get into trouble for no pain management, which is ridiculous. No I hate going above peoples heads since Im a house sup. and this has happened to me, but sometime you gotta do what you gotta do no matter who you **** off. Last week he learned his lesson though! I had a patient with an obstructed kidney stone, who he ordered his regimen for, now mind you Ive had chronic kidney stones, And toradol does help them but not as small amount as he ordered. He ordered this poor man 7.5 MG of Toradol IV, 5 MG Reglan IV, 1 GM of Tylenol PO, 300 MG Motrin PO, I thought you seriousely have to be kidding. Well he was outside this mans door 2 hrs later when I was in the room assesing this patient, well he overheard this patient tell me that if he didnt get some relief he was gonna have his teenage sons beat this doc's you know what if they caught him out in public, well anyways I finally called the chief of Urology who was supposed to come for a consult anyways, well I love our urologist there very effective at pain control, anyway the chief ordered the guy 50-75 MG Demerol IV Q 4-6 h, 30 More of toradol IV q6h, 25 of Phenergan q 6h, then he went down and ripped this hospitalist a new one which I admit was wrong of him to do in public, but he did it right at the desk and there were nurses clapping, literally.

[RedSox33RN]

I, too, am absolutely disgusted with how we treat pain, even in our ED. There is one particular doc that I really don't think will order anything stronger than ibuprofen 800. We had one come guy come in, really nice guy, with severely dislocated R arm/shoulder. His scapula was literally right near his spine, arm twisted all the way around his back. I've obviously never seen anything like it, but some of the 30+ year RN's hadn't either. Guy was in obvious severe pain. Shoulder had been repaired with surgery and hardware before, but xrays showed something came loose (not the technical term, but it escapes me now) and hence this.

This poor guy sat there on the gurney for over 90 minutes(!!!) with no pain meds. I think doc was also thinking the guy was a drug user (biker-type guy, all tats and piercings, but no track marks) and was extremely rude to the guy. I was not the primary on his case, but observing as part of my orientation. The guy was BEGGING me for pain meds. I felt so badly, and kept saying something to the primary RN, who stated he was also waiting for doc to order something. Dr. came in twice, and said rudely "I can't examine you if you won't bring your arm around to the front of you." The guy couldn't!! He was screaming when Doc tried, so doc got huffy and left.

Finally they sedated with propofol so they could reduce it, and the guy got 2 of morphine. But seriously, we may as well have given the guy regular strength Tylenol for all the good it did him. The only relief he said he got was with the propofol knocking him out, and the relief of shoulder being reduced.

And if he or his wife had asked, one RN would have told them that they should file a complaint with the medical board in our state. That was the grossest case of undertreatment I've ever seen, and many nurses said the same. Even if by chance the guy WAS a drug addict, he was still in pain, and we would KNOW that if he's a drug addict, 2mg of morphine is not going to do anything. We have to take into account his tolerance for opiates at that point - am I correct? He denied any drug use, however, though said he'd done plenty in his 20's and 30's (so over 10 years).

Oh yeah, and he got a script for 4 (yes four!) 5mg vicodin when he was d/c.

I'm sure we all have stories like this, but in my "young" career in the ED, this has been mine, so far.

So, to answer the OP's question, no, I don't think many docs do adequately treat for pain.

[rgroyer1RNBSN, BSN, RN]

Oh yeah red, you should have gotten the one I had last night that I had, He had a dislocated shoulder, well he was screaming in pain, well he just happen to get one of our older docs whos notorius for undertreating pain, you know what he had me do- he had me start a liter of ns, and I got to give him wow a whole wopping wow 10 MG Nubain IV, and 12.5 Phenergan IV, then he was going to reduce it, he didnt even offer this poor man a local, and personally if I was this guy I would have kicked his you know what on the spot.

[vamedic4, EMT-P]

No, we're absolutely not treating pain effectively.

The saddest thing about this, ladies and gentlemen, is that some doctors are afraid of what the government will do to them, so they don't adequately treat pain. The doctors aren't in charge of it all anymore- the government is. The FDA, as my wife's physician says, is practically riding the backs of physicians from general practitioners to pain specialists to cut down on the amount of pain medication they give patients. That, and requiring extensive documentation as to exactly why Patient A is on a particular medicine regimen. This is particularly tru in the case of chronic pain.

For some reason the government thinks it knows better than the physicians about how exactly to treat pain.

vamedic4

[Simplepleasures]

I also am one with chronic back pain, which can become acute at a drop of the hat, incredibly mind boggling screaming kind of pain that puts the whole leg into a continuous spasm that sometimes will not release. My current doctor is great and does prescribe Flexeril which does help. I can describe this kind of pain as being similar to a uterine contraction in childbirth, and continues sometimes for hours, in the entire leg from hip to toe . The chronic pain is like a toothache in the leg with no accompanying spasm. Many back pain sufferers have been treated like drug seekers in the ED.I had an experience with this once and have now told my doctor that if he ever sends me to the ER again I will NOT go.

[ER JUNKIE]

Wow...what I'm reading here is shocking...In our ED I think that we are very generous with our narcotic pain meds. We usually start w/ either 4-10mg Morphine or 1mg Dilaudid IVP along w/ 30mg of Toradol and usually 4mg of Zofran and see how they do. If a pt is sitll in pain, we reassess the pt and go from there. Even if it is a frequent flyer, we will medicate them quite generously and refer them to pain clinic. The only time I have seen a doctor deny narcotic pain meds is when we do a check and find out that our frequent flyer has been to 5 hospitals in 1 week and filled numerous Rx's for tons of narc's. At that time we will tell them that we can no longer give them anymore narcotics for _____ problem and that they must go to pain clinic for their chronic pain. I would hate to be the pt with the Fx (or whatever) and get offered tylenol for pain. I think that pain is very subjective and all of us need to be empathetic to each individuals pain and as nurses, be advocates for our pt's if they are truly in pain and it is not being controlled.

[VivaLasViejas, ASN, RN]

In my area, the ER won't even look at you if you have a DNR order that specifies "comfort measures only", even if you're otherwise healthy as a horse and not in the process of dying.

Will someone please explain to me what constitutes comfort measures if a) you are in acute DIScomfort, b) your primary care provider is unavailable or is unresponsive to your needs, c) EMS can't treat you on scene, and d) the ER won't treat you?

Treatment of pain in this country is a joke..........only nobody's laughing.

[rgroyer1RNBSN, BSN, RN]

I think its a given for alot of nurses and aides to have back pain, I also have back pain quite a bit, my doctor on the other hand treats it very effectively with norflex, and vicodin or ultram, of course he says he has alot of nurses with back pain as pts., I told him I said yeah well you try lifting these heavy a@$ pts. all day, seriousely these pts. are not getting any lighter no offense to any one Im heavy myself, but it becomes a problem when someone becomes 400lbs. and is a total lift.

[Altra, BSN, RN]

In my area, the ER won't even look at you if you have a DNR order that specifies "comfort measures only", even if you're otherwise healthy as a horse and not in the process of dying.

Will someone please explain to me what constitutes comfort measures if a) you are in acute DIScomfort, b) your primary care provider is unavailable or is unresponsive to your needs, c) EMS can't treat you on scene, and d) the ER won't treat you?

If this is the same situation that you detailed in your post in the the General Nursing forum ...

The hospital in question is either in flagrant violation of EMTALA or there has been some huge misunderstanding. An ER must provide a medical screening exam to all who present at its doors.

EMS provides emergency stablilizing treatment only.

In my experience, the "comfort measures only" portion of a DNR/POLST/ whatever term is used in your neck of the woods comes into play when there is agreement between the PCP, patient, and family/POA that care will now be limited to nutrition, hydration, pain control and other comfort care. No more treating cardiac arrhythmias or hyperlipidemia, for example.

The situation with the "unavailable" PCP needs to be addressed. I hope this patient & family hound this butthole until he/she sees the light.

[KaroSnowQueen, RN]

This past Saturday night my middle daughter said she couldn't take it any more, she had a headache for five days solid and she couldn't deal with it any more. She couldn't get off work to get to the doc during working hours.

So I take her to the hospital closest to us, 3 blocks away, notorious for being a band aid station. Figure they can at least give her some Toradol. Nope, the doc said, basically, you've got a headache because you're fat. He said, she has a small throat, therefore because she is overweight, therefore she can't breathe well and that causes her headache. Said to take Tylenol, that's what helps him. This is after we had said she was taking Advil, tylenol Sinus, even gave her one of my Imitrex with no relief.

We got up and left, went to the next ER 45 minutes away. She was seen almost immediately, given a NS bolus, IV Morphine and Phenergan, a rainbow of labs drawn and sent for a cat scan. On release, given 15 Lortab 10mg.

What a difference in the spectrum of pain relief!!!!!!!!