ER Nurse to Lunch Break Before Medicating Patient for Pain

[wondern, ASN]

While out of town on vacation this summer my husband was doing some exercising, sit ups to be specific. One day while doing these sit ups he said he felt as if he pulled something but was able to carry on with normal daily activities except now avoided doing more sit ups as it hurt too badly.

We continued riding bikes and swimming for a couple days after this but as time went on he seemed to get more sore.

Then later on the second night after he'd felt the initial muscle pull he woke up in the early am hours in pretty severe pain with some minor palpable swelling in his left lower quadrant. The pain was much worse than when he had the initial pull. He actually said he hadn't slept much at all which is highly unusual for him.

He has a history of diverticulitis and DVTs and is on coumadin therapy. We both thought maybe it could be a diverticulitis flare but most likely the muscle but just weren't sure. Who really wants to go to the ER at all though especially in the middle of the night?

He went ahead and took some ibuprofen even though he is really not supposed to due to being on coumadin but was hurting enough that he took three 200mg caplets and was able to sleep for a couple hours but woke up still in pain. I then decided to drive my husband to the ER that morning after he had slept a few hours as he was still having pretty severe left lower quadrant pain and now his color looked a little pale.

To try and make a long story short he was diagnosed after a CT scan with a torn abdominis rectus muscle or abdominal sheath with a subsequent 4 cm blood clot within the tear due to his history of being on coumadin therapy.

The ER physician said anyone else would have torn the muscle and be sore for a while but since he was on coumadin there was bleeding along with the tear which created the 4 cm blood clot from which he could see no signs of further active bleeding.

Upon assessment during the ER admission process via triage he told the nurse when asked his pain level was at 7-8 on a scale of 10, and had been in pain throughout the night before coming to the ER.

The ER physician came right in and ordered a pain med and a CT scan. Meanwhile the nurse started his IV, drew some blood and we thought gave him some pain medicine as he did some kind of flush with a clear solution in a syringe before my husband was taken for a CT scan of his abdomen where he was asked to scoot from stretcher to table, and of course back again.

When he arrived back from radiology department my husband said to me, "This pain medicine is not working...I'm still really hurting." I called the nurses station and asked for more pain medicine. I could see the physician at the desk from our room with a look on his face like, Really? He hasn't got his pain med yet? which I understood more clearly shortly thereafter.

I thought it might just be some breakthrough pain from going to radiology and from scooting back and forth from stretcher to table.

When the nurse finally came back in the room he states, " He hasn't had any pain medicine yet. I had to go on lunch break or I wouldn't have got any break at all."

Being a nurse myself I certainly understand the concept of missing a break. No it's not healthy. No it's not fun. No management doesn't like it sometimes regardless of what's going on. Sometimes however it is necessary in order to provide the proper and compassionate care needed for our patients.

At this point we'd been there in the ER patient room for at least over 30 minutes now and as noted above he even went to CT without any pain med. Maybe you could ask another nurse to give it in your absence?

As an ER nurse or any nurse for that matter, don't you think it would be a priority or should be a priority to medicate your patient for pain before going to lunch given the above scenario or any similar such situation?

Just wondering what other nurse's opinions are on this matter. What would you do? Would you make sure your patient got their ordered pain med before they went to radiology in pain or would you go on to lunch and give pain med that has already been ordered after you get back for fear that you'd get no break?

[Rose_Queen, BSN, MSN, RN]

Sounds like something you should be addressing with the patient relations department at the facility.

[jodispamodi]

For me I guess it comes down to how the orders were written, was the pain ordered at the same time as the labs, IV? AND did the pharmacy acknowledge and verify before the nurse went on break? (basically were they available to pull) If they were then then for me I would have administered before going on break, if they werent I might have gone on break figuring they'd be available when I got back. At my facility we cant pull meds on any new admission until pharm has verified all meds.

[wondern, ASN]

I'd think pain meds would be readily available and a first line treatment in an ER!

[JKL33]

Wow, they got a lot done in 30 minutes.

I hope your DH has healed and recovered.

Here's what I do. When CT is ready for the patient super fast (like it sounds was the case), I ask my patient if they would like to take a quick trip to CT first, or if the pain is such that they'd rather get it under better control before going to CT. Sometimes it's very obvious which thing needs to happen first. Whenever possible I let the patient help decide. If your husband was uncomfortable and wanted pain meds for CT, I would've done it myself or asked whether a co-worker had a moment to help (though they're not just standing around, either).

Here are a couple of matters that you may have misjudged:

- The physician looked indignant and shocked because he has no clue that the orders that took him only 20 seconds to enter, represent about 20-30 minutes of nursing tasks. They can waltz back out to the desk and with a couple of "clicks" order an entire care set of multiple orders. Then they look shocked that it takes more than a few seconds/minutes to get it all done. So the physician's incredulity here is irrelevant.

- The nurse flushed the new saline lock with saline, as is done with all saline lock insertions. Otherwise it would've clotted off. I'm pretty sure there was no intent to deceive.

- Here's a scenario that may be very likely (well, it would be very likely if I was looking at your DH, a patient on blood thinners with an abdominal trauma and now swollen abdomen): I would know that a CT itself is quick, but CT results take time. I would be concerned about what could be a critical or surgical situation, and I would want those results as fast as possible. I would love it if the patient could tolerate the quick trip to CT and back, and then I could work hard on comfort and getting settled in when pt returns from CT. I wouldn't be one bit surprised if that was the goal. Then he realized he might actually be able to grab a bite to eat while your DH was out of the department.

- Unless I'm misunderstanding, within 30+/- minutes, your DH was triaged, was evaluated by a physician, got a saline lock inserted and labs drawn and sent to lab, and he went to CT and came back, with results already pending. In almost any ED I've ever heard about in this country, that means the care of this abdominal pain case is moving right along at a faster than usual pace. Just the facts. Sounds like they decided to get to the bottom of this right quick.

I would request that you extend grace. People are trying, they really are, I promise you. I don't know what to say except that we can't be everything to everyone all the time. It saddens me to think that no matter what choices we make, there's no guarantee that someone won't come along to say it was the wrong choice. Pain control is crucial and I would never pretend it isn't. Just the same, not everything can be done "at once."

[MilliePieRN]

Sometimes it takes a few min for the Med to get ordered in the computer system. Sounds like you heard the verbal order before the doc sat down to actually put in the computer order? Iv, labs, then sent to radiology? If that's the case, I can see where she would go eat while he went to have a scan rather than waiting for him to get back from the radiology if the order had not shown up prior to him leaving for the scan. I don't know the whole story, so I'm unable to say what I'd do in this specific case. I will say I'd give the pain med as soon as I could, but I would not delay a ct scan. I wouldn't have said the part about taking a lunch or not getting one at all. 30 min doesn't sound too unreasonable, especially if during this time he got an iv and had a ct scan.

[MunoRN, RN]

I'd think pain meds would be readily available and a first line treatment in an ER!

It's important not to minimize the importance of pain control in patients with acute conditions or injuries, but opiates are definitely not a "first line" treatment of anything except of acute opiate withdrawal, they do not serve the basic purpose of preventing death or other harm.

Keep in mind that depending on the ER, there can be a significant amount of time between when an opiate is ordered and when it can be given. Requirements for pharmacy review vary in different EDs that I've worked in, but most frequently non-emergent medications such as this can only be given after pharmacy has reviewed the order, there are obviously exceptions for procedural sedation and analgesia as well as clearly time sensitive medications. So whether the nurse went on break or not it could be half-an-hour before they can get the med.

[YumCookies, BSN, RN]

Depends. I try to medicate and meet the other needs of my patients before leaving the floor. However, there are certain situations where I may not necessarily do that (i.e needing to eat something ASAP because I am dizzy, seeing black spots, and not willing to have a syncopal event in front of my patient) - in those situations you need to put yourself first. Instead I would ask another RN to give the med for me.

[wondern, ASN]

I actually did extend the nurse grace at the time and said to him I certainly understand that feeling when he said he was afraid he'd not get a break if he didn't go. Just wanted to see what other professionals would do. That's what this sounding board is for. Right?

I think I'd at least ask another nurse to give it before I left the floor or give the patient a choice like suggested but please don't be saddened by my posing the question JKL33. It's only a question. I wasn't trying to judge too harshly or I guess I would've said something to someone by now like patient relations as was mentioned.

I do appreciate the care we got that day. Yes it was good he got to CT scan quickly and also great that he got his IV and labs drawn within that amount of time. Actually the results of the CT were quick in this case too. I was very grateful and thanked everyone.

I just found it kind of odd that it took that long to get some pain relief in an ER and that he went to lunch first. I thought the meds would be in the computerized drawer readily available in an ER. It would've been exceptional if he'd had his pain treated as quickly as everything else. That's all. Thanks for everyone's input. Now I know some of you have to wait for 20-30 minutes at times to get pain meds. Wow!

Maybe my DH did too good a job of not showing his pain too. It's not like he as wailing or anything.

Also about the opiates, they make both of us sick so if we had a choice of something else we'd certainly pass on them. He switched to tylenol asap after he healed a few days. Pain control was what I was referring to as a possible first line treatment in an ER not feeding an opiate addict with opiates! Most people needing pain relief in an ER are really in pain not opiate addicts, though I realize this is a horrific problem in our society today.

No he was not going to die from hurting an extra half hour or so at 7-8/10 and scooting from stretcher to table etc. it was the only part of the experience that truly sucked, and to us at the time made no good sense. Awww, so is life. I do appreciate y'all helping to try and solve the mystery of it all for me Thanks for all your replies.

[RNKPCE]

The pain medications are likely right in the computerized draw. However when an order is entered, pharmacy usually has to authorize the order. They check for patient allergies, duplicate orders, interactions and other contraindications. Once the "stop sign" in epic is lifted the nurse can pull and administer the medication. This authorization process can vary in length of time depending how many other orders are in the queue for the pharmacist to verify, how many pharmacists are working etc. I've seen meds authorized as quickly as less than 5 minutes to up to 45 minutes. Once authorized an icon disappears on the e -record saying the medication is free to be given and the drug dispenser allows us to pull the med. In rare instances a medication can be overridden and pulled before authorization but this is usually in emergent situations such as needing to pull ativan on a patient who having a seizure. Even then sometimes the medication dispenser will not allow a medication to be overridden.

[chacha82, ADN, BSN]

Although uncomfortable, I also would definitely not delay the patient getting to CT in order to medicate. Once your person is in the que and ready to be moved, you move them or risk losing the spot. It's not ideal, but there's usually a delay for the meds to be pulled in the AccuDose even after we click the order. Docs don't always know that. It also depends on what other tasks this nurse had to do in addition to getting your husband to CT.

[Wuzzie]

I called the nurses station and asked for more pain medicine. I could see the physician at the desk from our room with a look on his face like, Really? He hasn't got his pain med yet? which I understood more clearly shortly thereafter.

Yeah, I've seen that look before. Right when the doc realizes he forgot to actually order the pain medicine and he's trying to cover it up by throwing the nurse under the bus.

Not saying that's what happened in your case but I've seen it on more than one occasion in my three decades of nursing.