I am a psychiatric nurse who has been working in the field for about a year now. Today, I had a patient who complained of severe abdominal pain and had a history of endometriosis which had gotten so bad to the point where they recommended she have a hysterectomy. She was currently being medicated on Ibuprofen and Tylenol which had no effect. I knew that these would not even touch her.
Come on Tylenol and Ibuprofen for endometriotic pain?
I then contacted the psychiatrist to see if I could get an order for breakthrough pain to which she declined. Narcotics are typically not prescribed in the psychiatric setting due to how common opioid addiction is within this population. The only patient I have even had who was on opioids was my patient who was post op ORIF after having jumped off a two story building.
There is a common misconception in the psychiatric field that many patients are "faking it." I believe that pain is subjective and try to give my patients the benefit of the doubt. That being said, as a psych nurse I am not oblivious to the fact that some patients are "medication seeking."
I typically am a good judge of character, but this was not one of those moments. She was wrenching in pain to the point of tears. If she was "faking it" she was doing a really good job at it.
At this point, I decided to advocate for my patient and escalate the situation. I asked again and she [psychiatrist] continued to refuse. I then relayed this to my charge nurse and she recommended getting an order from the hospitalist because all medical issues are under the jurisdiction of the medical doctor.
The hospitalist agreed to order a one time breakthrough pain med. I told the psychiatrist what I had done and then she proceeded to berate me over the phone spurting profanities, saying I was insubordinate and said "I was being played by [my] patient."
I then escalated the issue to my nurse manager who recommended I follow the psychiatrist orders and let it go. When I asked if I did the right thing, he praised my efforts in advocating for my patient, but believed at the end of the day, the doctor's orders should be respected and followed.
I followed his advise and after all was said and done, the patient had to bear through the pain and eventually it subsided. Nursing community, did I do the right thing? Should I have done more?
Specializes in Community Health, Med/Surg, ICU Stepdown.
I agree a medical doctor or OB should have assessed this pt in person. Our psych unit has a psychiatrist on duty a well as a medical doctor who works only on the psych unit and is accustomed to treating psych patients for medical complaints. He actually checks in with each pt every day, and more thoroughly with those who have medical needs. It's nice because he's not afraid of psych pts, and he and the psychiatrist can make treatment plans together.
All I’m going to say as someone who suffered for many years from endo, ibuprofen and Tylenol are not effective. At all. I had 6 surgeries for it, and it caused my ovaries to twist and attach themselves to my bladder. It’s much more than inflammation.
I would get horrible migraines and vomit from the pain. Percocet was the only thing that came close to alleviating the pain. The pain was awful for 2 weeks a month. My first pregnancy was what finally made it go away. But my entire twenties were miserable.
We cannot dismiss women’s pain and say ibuprofen should take care of it. I’m not saying everyone needs high dose pain medicine, but some of these responses are why many women don’t seek help when they should. They fear being told here’s some Tylenol go home and put a heating pad on it.
Sorry you had such a terrible time but perhaps each case is different? Glad you finally got improvement.
I think at this point it is not important to question whether you did the “right” thing but rather focus on the outcome which was less than satisfactory for everyone involved and find out why something as simple as getting a patient’s pain properly evaluated and treated in a inpatient hospital setting got so convoluted. Clearly there was a deficiency here in some area, and most likely in more than one area. So the only question that needs to be asked is what needs to be done so this doesn’t happen again. Is there a clearly written policy outlining the procedure to request a medical consult? Have the nurses received the proper training regarding the process? Do the nurses and doctors do regular case meetings to facilitate communication and to coordinate care? I've been a nurse 35 years, sometimes things go wrong and the professional thing to do Is to determine why and implement a plan to correct it. Determining right or wrong is irrelevant bc provider focused and not patient focused. You can use this experience as a way to make positive changes in patient care.
The provider is the one who is going to get fired if she messes up like this again. Focus is properly on the nurse asking for help here.
To the OP: I have learned that doctors generally look at things through the lens of their particular specialty. Psychiatrists see life through the DSM. Surgeons surge. Etc.
Not sure why you called Psych about physical pain. I think you should have called Medical, as you eventually did.
Is there any Hx about endometriosis in the pt's chart? Did she have an admitting PE that might have helped you? Gyn consult? If nothing like this was available, I would have given her the benefit of the doubt, as you did. But I would have called the Medical doc, not the Psychiatrist.
The Psych was understandably upset with you but should not have "tantrummed".
You are lucky that your Charge was so mellow about it. Better luck in the future.
As a midwife, hysterectomies are rarely "recommended" for endometriosis anymore. In fact, it's a lazy providers way of dismissing the patient. A hysterectomy doesn't necessarily solve the problem as endometriosis is an inflammatory condition that can impact other organs than just the uterus. The pain can be so bad I have seen patients vomit. The treatment is to shut the cycles down. Stop the cycling = stopping the pain.
The problem is there wasn't an appropriate discipline available to help this woman nor was an ovarian cyst (that can lead to ovarian torsion) ruled out.
Had this been a man with a swollen member or scrotum, a urologist would have been consulted, but this is another example of providers dismissing a gynecological complaint because it was a female.
Misogyny? Perhaps. Or just plain ignorance? And/or bias secondary to the physicians' specialties?
On 10/29/2020 at 12:16 PM, Stillcrazyafteralltheseyears said:
There is a patient advocate number that is supposed to be posted on the unit. Not sure how you can give the patient the info without you being in trouble for disobeying the primary. But if acute pain is present it needs to be assessed by the physician.
LibraNurse27, BSN, RN
972 Posts
I agree a medical doctor or OB should have assessed this pt in person. Our psych unit has a psychiatrist on duty a well as a medical doctor who works only on the psych unit and is accustomed to treating psych patients for medical complaints. He actually checks in with each pt every day, and more thoroughly with those who have medical needs. It's nice because he's not afraid of psych pts, and he and the psychiatrist can make treatment plans together.