Frustrated with Interns who can't (or won't) treat pain!

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Sorry this is so long, just need to vent...

I work in a smaller teaching hospital. We have a group of residents/interns who rotate in and out from a larger teaching hospital- each group spends about a month with us at a time. We all know that residents/interns need some guidance now and then, and I am generally very patient and will help them whenever I can. However, this group, I hate to say it, is DANGEROUSLY STUPID. My frustration level is just through the roof, and I can't take it right now. The biggest problem? They all seem to have this MASSIVE fear of opiates, and my patients are suffering because of it.

Case #1-

Elderly woman with a very extensive cardiac and pulmonary history, chronic back pain, on home OxyContin with Vicodin for breakthrough pain, uses 1-2 PRN doses at home a day. Admitted in acute pain (chest pain) thought to be non-cardiac, related to a severe pneumonia. Ordered for her home dose of MS Contin, no PRN pain med (not even tylenol) ordered. During initial assessment, pt reports 8/10 L rib pain with cough. Intern on the floor, and approached for PRN order. Intern admits he hasn't seen this patient, didn't admit her, etc. Tells me he doesn't really feel comfortable giving her an opiate, because he doesn't want to compromise her resp. status. I tell him to discuss with his resident if he needs to, but the woman would really like her PRN vicodin ordered. He asks for a stat ABG. I tell him this is possible, but she's satting 98% on 2L, has some rhonchi at the left base, and her resps are 26-30... it will take me a little while to get an ABG (few respiratory therapists to draw at night) and could he maybe go down and assess the patient first? His reply? "These opiate addicts drive me nuts, she's not in pain, she's in withdrawal" A- didn't you just tell me you've never seen this woman? So how can you tell she's not in pain (nevermind that pain is what the patient says it is) B- How in the world is she in "withdrawal" if she got MSO4 in the ER earlier today AND her home dose of oxycontin tonight???? He reluctantly gives me a PRN oxycodone (would have been better to go with the Vicodin, since we know that works for her, but whatever) and tells me to use it sparingly, because we don't want to suppress her respirations too much (because that rate of 26-30 is too low????)

Case #2-

96 yo man with metastatic lung AND prostate CA, RA, chronic abd pain for years. S/P lap chole after which he went into respiratory failure, CHF, MI. Recently extubated and transferred to telemetry. Very confused, oriented to person only. At home, he was taking MS Contin 30mg 3x a day. I get in report that he's been telling the 3-11 nurse he's going to die tonight, but can't give anyone any specifics as to why he thinks that. (we all know to believe them when they say this, though) Intern (another one) on floor to see patient, currently writing orders (which he placed on the rack despite the lack of secretary, so I didn't see his STAT orders for hours), wife has been called and is on her way in to see patient.

Patient denies pain at first, but winces when his abdomen is gently touched. Definitely NOT answering questions appropriately. Wife tells me he's been asking for a sleeping pill for days, but the doctor said no. All he can tell me is that he's "miserable"-nothing specific. Morphine, a whole whopping 1mg, Q4H ordered for breakthough pain from Ultram. Given at 0000 with absolutely no results. Ultram given when due with absolutely no results. Intern paged- states his signout says to avoid opiates, benzos, and ambien. Tells me the patient denied pain when he asked him earlier. I tell him the patient also denies he's in a hospital, but that he won't stop moaning, grimaces with touch, is constantly restless in bed, has been on the call light every 2-5 minutes, and is now currently weeping and asking "why they let him suffer like this?". I also tell him the wife says he acts like this when he doesn't take his MS Contin, and that I think he's in opiate withdrawal. His response? Well, we could start him on an SSRI for the weeping, but that would take a while to take effect, so he'll address it with this patient's team in the morning. Long story short, despite repeated calls to the resident, intern, and nursing supervisor, I wasn't able to do a thing for this man all night except hold his hand and tell him he would be okay, and that killed me. I went home and didn't sleep for 24 hours wondering why I do what I do.

Case#3-

Young, relatively healthy woman in her 30's admitted with sudden-onset bilateral leg weakness, leg and back pain, headache.Tentative dx of Guillain-Barre. Not on any home pain meds. Given toradol, percocet, and morphine in the ER with some, but not much relief. Came up to the (telemetry) floor without any orders- something we just recently (and stupidly) started allowing. Despite the morphine given in the ER prior to transfer, I'm told in report she was in tears just transfering from stretcher to bed. Meanwhile, I'm told housestaff is calling from the ER to find out her code status. She's healthy 37 year old mom... what do you THINK her code status is????

I immediately check for orders (at 11:15) and don't see any. Initial assessment, she's got 1/5 strength in her right leg, 2/5 in her left, 7/10 back and leg pain. I find her orders, and strangely, NOTHING- not even tylenol ordered for pain. I call the (worst of the group) intern- who says, "She was just watching TV". Tell me, what does that have to do with anything???? She tells me her attending told her to manage the pain with Tylenol, given that GB can lead to respiratory failure. I very gently remind her that the morphine given in the ER barely touched the woman, and that she's had a dose of toradol, too. She tells me the patient has no history of GI bleed... but then asks me to put her on hold, and go CHECK with the patient about GI bleeds and reflux, which I do. So she begrudgingly gives me orders for tylenol and toradol, both of which I give ASAP (the toradol I had to wait for a supervisor override) By the time I get the patient medicated, see my other patients, and start entering her zillion labs for the morning, and then clarify the lovenox IV (did you maybe mean SQ, since we don't give it IV) order, I notice that this intern wrote (after the patient had been admitted to a TELE bed) "Admit to PCU". She didn't think to mention this to anyone in our three or four conversations??? So before calling the idiotern back to clarify, I reassess the patient's pain. Not surprisingly, she's now at a 10/10... and she looks 10/10 too. BP elevated, white as a ghost, tears running down her cheeks. I get the idiotern on the phone, tell her she can't just write for PCU after the patient's on tele without notifying someone, and she says to me, no joke "what IS PCU"? We don't even have a PCU bed available. She still refuses to order anything else for pain, and tells me to talk to the resident. I get the resident on the phone, who admits she's never seen this patient and doesn't really know what's going on... but she's in the middle of an ICU admit, and it'll be at least an hour before she can come up. I tell her an hour is unacceptable, and someone needs to do something about this woman's pain. She says they'll discuss it and call me back. So I'm running in and out of the room, trying massage and positioning, heat, emotional support, everything I can do for this poor woman. 20 minutes later I still haven't heard back, so I page them again. Finally, with 10 more reminders about respiratory failure (we do stock Narcan, you know!) she gives me an order for a whopping 1mg morphine q3h and says maybe if it's psychological, that will help. Um, I thought we stopped giving placebos a long time ago? And if this woman's so sick we have to admit her to PCU, and we're so worried about her respiratory status, what makes her think the pain is all in her head? Did I mention her MRI showed disc compression in the lumbar spine? But, sure, it's all in her head! Between the toradol, tylenol, morphine, and non-pharmalogical interventions, I did manage to get this lady's pain down to a 3-4, which was in her tolerable range, but I should NOT have had to fight like that to do so. Again, I had another patient in tears asking me why the doctors would want her to suffer.

I did manage to get all her labs entered eventually, but I did let them know I skipped the pregnancy test, considering the woman is S\P TAH with bilateral oopherectomy. Their response? Then why is she on oral contraceptives???? Um.... doc? Last time I checked, Premarin was HRT... or did you not look THAT one up before you ordered it?

:banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead:

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Wow. I'm only a GN, so I don't know how common this is, but wow. Why do they beat us over the head with "PAIN IS WHAT THE PATIENT SAYS IT IS!!!" in nursing school if medical school is teaching the opposite? Can't you call whoever's above the resident if he/she isn't properly treating his/her pt? This sounds like a really serious problem that the whole service needs to address. What did your supervisor say? Did she recommend any further action, or was she willing to talk to the attending for you? Unfortunately, someone taught these interns to have a massive fear of opiates, and that's the problem that really needs to be addressed.

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You're so devoted, don't ever lose that - you can be my nurse anyday :D

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Specializes in Neuro ICU and Med Surg.

I would have involved the house supervisor and went all the way to the attending. These idiots need to be kept away from patients. How would they like to be in pain and not be medicated. Wow I am so sorry you had to deal with them.

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I did involve the supervisor. We're discouraged from calling the attendings when the patient has housestaff, and my experience is that they're not very willing to do much when woken up in the middle of the night on a patient with house staff coverage... they asked for house staff because they DON'T want to be bothered. In the second case, the supervisor that night told me NOT to call the attending. You'd better believe I would have called the attending on the 10/10 pain if I hadn't gotten it to a "tolerable" level, part of me was tempted to call anyway, but I was being told by the housestaff anyway that HE was the one who said no narcs for that patient (makes me wonder if they really told him how much pain she was in)

I DID (in all three cases) leave a lengthy note for the attending... the third case was last night, but I know in the other two, the issues were resolved when I came back in. In the third case, I even documented her blood pressure changes with pain, etc.

It frustrates me to no end to feel as though I did everything I could for these patients, but it wasn't good enough. The very, very nice 37 year old gave me a very heartfelt thank you as I left this morning... and I didn't feel I deserved it... but I'm glad I was able to bring her some comfort.

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You're so devoted, don't ever lose that - you can be my nurse anyday :D

Thank you- I needed to hear that today

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Specializes in NA, Stepdown, L&D, Trauma ICU, ER.
The very, very nice 37 year old gave me a very heartfelt thank you as I left this morning... and I didn't feel I deserved it... but I'm glad I was able to bring her some comfort.

You absolutely DID deserve it! You worked your butt off helping this woman and did every possible thing you could

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Specializes in Med/Surg, Home Health.

Dang! Those people need to be reported! They sound dangerous. Kudos to you for being such a great and caring nurse. Its a shame those "docs" have the ability to make your job 10 times harder and more stressful than it has to be...not to mention the misery they are putting the patients through. I had a doc like that once who I called approximately 20 times one night trying to get help for my patient...who died the next morning. He FINALLY came up to see patient right at the time he coded. Doc freaks out and slithers out of the room scared to death. The situation was left up to me until the RRT showed up. I was morified and traumatized, had to call in sick the next night. The doc was written up twice for that and another incident on another floor. Nurses and patients need to be able to depend on the docs.

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Specializes in Rehab, Infection, LTC.

wow. if i ever get sick, will you please take care of me? you are awesome!

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Specializes in Emergency.

This needs to be addressed so it doesn't happen again. Are these residents not aware of "double effect" with opiates in end-of-life care? I'm specifically refering to the elderly metastatic CA patient:

"The principle of double effect is used to justify the administration of medication to relieve pain even though it may lead to the unintended, although foreseen, consequence of hastening death by causing respiratory depression. Although a review of the medical literature reveals that the risk of respiratory depression from opioid analgesic is more myth than fact and that there is little evidence that the use of medication to control pain hastens death, the belief in the double effect of pain medication remains widespread. Applying the principle of double effect to end-of-life issues perpetuates this myth and results in the undertreatment of physical suffering at the end of life..." (http://www.hospicecare.com/Ethics/fohrdoc.htm)

Is there a pain committee at your hospital that can address this issue?

Tell them that if they're afraid of resp depression, then they should put orders in for narcan if needed.

Advocate for PCA pumps.

Chart "Dr. Smith (resident) aware of pain, no orders received". Make sure to tell them to their face that you are charting that they've been notified of the pt's c/o pain and that they (the resident) are not writing orders. Also state that JCAHO is big on pain control and they need to catch up to current practice.

I'm also so sorry for having to deal with this. I recently switched from another hospital where I was used to giving Morphine 2mg IVP in the ED; rarely would I see morphine 4mg IV; maybe once a month I'd get an order for dilaudid 0.5mg IVP. In the ED at the facility I'm at now, pretty much everyone gets dilaudid 1mg IVP PRN; its very nice to have your pt's pain under control (and quite honestly, most patients don't need more than one dose of dilaudid because it works so well for their pain). Dilaudid also works faster and wears off sooner than morphine. I almost always premedicate with zofran 4mg IVP to prevent nausea/vomiting; yeah, zofran is expensive but its now available as a generic med which helps to bite the cost. Screw reglan, compazine, and phenergan; zofran is the way to go IMHO!

Go ahead, print off what I've said and give it to the resident. I'll battle them for adequate pain control ANY DAY!

Personally speaking, I know how difficult it is to try to heal when you're in pain; I injured my back very badly and I wouldn't let my husband take me to the ED because I didn't want to be seen as "a seeker" (I also didn't want my coworkers to assess me); after seeing my PCP the next day I was only offered ibuprofen for my pain (BTW, last time I took any narcs was when I had major sinus surgery in 1997...). For close to a week couldn't get up on my own and my husband had to literally carry me around the house. I was miserable for nearly 8 weeks - so there are times when pain control is warranted and if someone is suffering, then what's the harm of giving some pain meds?! Isn't that why they have pain meds in the first place?!?

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Specializes in Stepdown progressive care.

wow, and I thought only our interns were scared to death to order any pain meds. I've encountered this many times before. They must drill into their head that any pain meds cause resp. depression because they refuse to order anything for pain or even ativan when pts are agitated and crawling out of bed. We even had a pt on bipap once and they didn't even want to give them anything because it might depress their respirations. They're on a bipap for goodness sakes.

I remember once I had a pt with a chest tube and they refused to give the pt anything for pain even though he was having a lot of it. WE finally just ended up calling the attending and told him the whole story and said your interns are too afraid to order anything. The attending was the one who finally gave us an order for something.

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I gave dilaudid to an older lady with a broken hip. Came back 15 minutes later to assess her pain relief, and she was nearly dead. Nonresponsive with few, shallow breaths. O2 sats were like 30%. Called a rapid response and had to transfer her out. She was perfectly fine before the opiate. I felt so guilty!

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