"I'm NOT going to support his habit...." LONG

[tencat]

I've had two patients who are well-known drug addicts (UA's done and they tested positive for every drug on the panel) who had large abscesses drained from their arms. Abscesses were due to IV drug use. Both patients required QID wet to dry dressing changes. I've done QID changes on 'non-addicts' and always in the orders I've had PRN morphine to give prior to the change. But not with the addicts. Both addicts only had 1 PRN 7.5 mg Lortab ordered q 3-4 hours for pain. Now, I'm really new to nursing (I've only been one since September), so maybe I am not fully understanding what's happening. But I do know those wet to dry changes are PAINFUL, even with the morphine. It seems to me that it's downright cruel to expect a heroin addict to deal with these dressing changes with only one lortab q 3-4 hours. Am I wrong? I suppose the rationale could be that it's impossible to give them enough morphine to ease the pain without killing them with an overdose. But when I talked to my nurse manager about the latest patient, she said that she would not, under any circumstances, support his drug habit by ordering morphine for dressing changes. The physician feels the same way. I guess I need some validation that I'm not wrong, or at least some advice on how to emotionally deal with these dressing changes. I'm really distressed by the pleas I get from them for something to help with the pain, and me being powerless to do anything other than pre-medicate with one lortab. Any words of wisdom? Thanks!

[wildmountainchild]

UKRNinUSA,

I am so utterly appalled at your post I can barely type. Who are you to judge? Who are you to hand out karmic revenge? You have an obligation as a professional to be compassionate, caring, and non-freaking-judgemental!

Since you are now in the good 'ol US of A there is a greater than 60% chance that you are overweight. If you are diagnosed with CAD secondary to excessive lipidemia should I withhold vital meds from you because you are reaping the seeds sown from years of eating poorly and little exercise? Because you deserve to suffer!!!!!!!!!!

If you were being an idiot and jumping your dirt bike off ramps in the parking lot and fractured your femur should I deny you care because you're stupid? If we based the level of care we gave our patients on thier life choices we would be denying care to just about everyone.......and this likely includes you. Are you PERFECT? Have you never make a single mistake?

For some addicts thier mistake was trying something ONE time at a party w/ some friends. Many addicts were once lawyers, nurses, CEO's, mothers, sisters, and fathers. People make mistakes, but it is not for us to condemn them to hell on earth (inadequate pain management) because of our own bigotry and prejudice. And that is exactly what you are displaying .......bigotry and prejudice.

Please educate yourself on addiction and pain management for the sake of your patients. MUCH has been learned about those subjects in recent years, I'm sure you could benfit from some CE on the subject.

Good luck.

Whoever taught you nursing theory, and basic pain med administration should be fired. They obviously didn't get the point across.

[tencat]

wildmountainchild, did you read the second post that UKRNinUSA posted? It was further explained in that post. Obviously you have strong feelings about the issue. Fair enough, but please le't not turn this into a bashing session. I've gotten so much good advice from everyone (UKRNinUSA included).

Augigi, I forgot to mention that the H2O2 is mixed in with normal saline. Does that make a difference? I didn't know that H2O2 caused fatal embolisms....makes me a bit nervous.

[leslie :-D]

the only thing i knew about hydrogen peroxide is that it is cytotoxic and therefore, contraindicated in wound care.

i think i'll mosey over to medscape.com and see what i can find.

as for your gentlemen pt., the surgeon has no right playing God, re: his judgemental attitude.

the primary focus should be on healing the abscess w/as little pain as possible.

furthermore, there are other interventions that can be used to control the drainage.

the wound vac will only cause more discomfort.

i would somehow get a wound consult, as well as a pain consult.

and take good notes!

perhaps it wouldn't hurt the surgeon to know that pt's poorly-controlled pain is being well-documented.

leslie

[wildmountainchild]

Yep, I did read the second post. And it in no way mitigated the damage of the first.

I will always speak my mind (and my heart) where patient care is concerned. It makes me sick to think of those patients suffering, and if we as colleages condone bad behavior by not calling our co-workers on it when we see it (or read it), it makes us just as guilty as it makes them.

My main objective was to get UKRNinUSA to seriously think about what she said and what that means for her patients. I believe she wrote form the gut, w/out time to package her thoughts for public consumption, and therefore her comments are likely to be more honest because of it.

By the same token, I believe you have an obligation to raise the issue w/ your head nurse and the docs until it's solved. Your liscense could be on the line. But more importantly, patient care is on the line.

I won't apologize for writing what I did, I will apologize if I hurt someone's feelings though, it wasn't intentionally done. I obviously DO feel strongly on this issue. However, you asked the questions......you should be willing to listen to all the answers.

I wish you the best in your moral dilemma.

[UKRNinUSA, RN]

Such venom wildmountainchild, but I am pleased to get such a passionate response. I agree that I may have sounded callous and judgemental but that was not my intention. I am in no way advocating withholding pain meds from people to punish them for their opiate addiction. As other posters have noted opiate addicts do require more pain meds than those without this problem - I am totally in agreement with this.

I chose to view the situation from a different angle. Tencat wrote that she is a new nurse and she is up against her nurse manager and the physician. She feels powerless, she needs help to cope with the emotional distress she feels when she is doing these dressing changes.

Now as far as the pain meds go, who do you think is going to win this one - the new nurse with two months experience or the doc. Hmmm, lets see..... my bet goes to .......the doc, especially if the nurse manager is backing him up. So basically adjusting the pain meds is off the table. Its not going to happen -my guess is that if she pushes the issue she will end up looking for a new job and these patients will still be suffering. And so now there will be three people suffering.

So how then can we help these patients with their pain and help empower tencat - by changing the dressing to something more appropriate that will reduce the pain, reduce the frequency of the dressing changes and help the abscesses heal a lot faster. Once upon a time, way after I finished nursing school, I admitted a new patient to physical rehab for poor mobility associated with donor site pain (both thighs -approx 5% body surface area each thigh) for at least a week's inpatient stay. The poor guy could hardly walk and hadn't slept well since his surgery. Nothing was touching his pain, he was miserable. I did my assessment and looked at the dressings he had on his wounds -the wound bed was all dried out and bits of xeroform gauze and 4x4's were stuck in the tissue that was attempting to granulate and re-epithelialize. (Donor sites are particularly painful because you slice right thru the cutaneous nerve endings.) The rehab docs pretty much gave me carte blanche with wound care so I carefully removed the dressings (after some serious soaking) and applied a more appropriate dressing - a large transparent film (starts with a T) that covered up those protesting nerve endings and supplied a moist wound environment to quicken the healing, reduce the chance of infection and lessen scarring. I finished my paperwork and went home. The next time I went to work the doc told me that the patient had slept all night without any meds, got up by himself, was able to walk without any pain at all and discharged himself home. He didn't need physical rehab he just needed the right dressing.

Tencat requested words of wisdom and help to deal with her emotional distress. Having seen a lot of tragedy during my 22+ year career I tried to share the coping mechanisms that have allowed me to continue nursing. Philosophy has always helped me to deal - I just loved it in nursing school.

Addicts DO need to feel the consequences of their addiction before they get on the road to recovery -if everything was always rosy in the garden why would they feel the need to stop their destructive behaviour. I am not for punishing them, but in order for tencat to emotionally cope with this situation, I wanted her to realise that this physical pain (altho I don't approve of the doc's treatment) maybe necessary (in God's [not mine] Grand Scheme of Things) for them to realise the consequences of their addictions.

As far as being bigoted against addicts -not true. I have had and still have friends, relatives even lovers with addiction problems. I have had and still have addiction problems myself. I went through counselling for 2 years for bulimia/codependency. I still cannot kick the nicotine habit despite trying to quit every year for the last 10 years. And how did you know I was fat? Are you psychic? But I have lost 27 pounds since last March, when the DJD kicked my butt and I finally realised that all the motrin and yoga in the world wouldn't help my pain unless I shifted my center of gravity back to where it was supposed to be (another instance of adverse consequences prompting me to address my addiction to refined carbs).

And whoever wrote about treating the abscess and not the addiction - EXCUSE ME - what nursing model are you following? Sounds like a medical model to me. I was taught to nurse the WHOLE (physical, spiritual, emotional, intellectual, social) patient and not the disease - its something I learned 25 years ago and that I still base my practice on today.

My mistake was that I tried to lend a hand to a colleague when I was pressed for time and ended up being misinterpreted. I tried to rectify that with the second post. No worries, it'll probably happen again.

[tencat]

Thanks for all your support and suggestions. I've found it very helpful and encouraging. I brought this issue here because I knew I'd get what I needed, and I did! The discussion here has mirrored what I've encountered at work. There are several people who agree with me, but they are ok with "I'm just following orders." I'm just one of those annoying people who are not ok with that. :) There are those with whom I work who think it's ok to punish someone for their 'misdeeds'. As UKRNinUSA said, if I go against the issue and fight it, it won't matter. It will still be business as usual and I'll be out a job. I think it's possible to bring some other ideas to these people in charge, though, and 'wheedle' out a compromise that they will agree to. I'm just trying to figure out what those ideas could be. For my own license, however, I am going to use minute amounts of H2O2 and large amounts of only Normal Saline. I'm also going to try ice to help 'numb' it up. (Great idea, by the way!) And I'm going to continue to tell these patients that they need to stand up and make their voices heard.

[MS._Jen_RN, ASN, RN]

I didn't have a chance to read all the replys, so sorry if I repeat. You are not wrong in being upset. Where I work if this presents we often consult an addicitve disease specialist for pain management. Often the answer likes in using non-opioid meds such as Buspar, Methadone, Torodol, ATC Motrin. Also, the pain threshold can be raised with a long acting med that wouldn't aid in "getting the rush" such as Oxycontin or Ext Rel Morphiene. For the sake of your patients in this situation I think that I would consider an anonymous report to the ethics committee.

~Jen

[MS._Jen_RN, ASN, RN]

I Just picked up on the fact that you are using H2O2. That's a HUGE no-no in the area of wound care. Others have posted about the emboli, it is cytotoxic-immediatly- and doesn't discriminate between the pts cells and bacteria. As for pain with dressing changes, I've found wound vac changes to be more painful than standard w/d. Qid w/d is not appropiate as others have said. We would probably do it BID at most, or better yet, use something like Aquacel (calcium alginate) and do it QD or BID if very "wet".

Let us know what happens, what you do. At least send a letter of concern in general terms about tx of pts with h/o IVDA.

~Jen

[sheilagh]

As a former active addict and as a nurse I fully understand your dilema. My thought also while reading your post was are they active users? if so, is the PMD doing anything to eleviate the withdrawal? Your skin is 20X more sensitive during withdrawal.How about the local idea? I had a confused geriatric pt with severe wounds and we used a lidocaine type liquid for her changes because she couldn;'t tolerate opiods. We have a pain mgnt nurse consultant, if your facility does have one she may be able to intercede with the Dr for you.

Good luck, let us know what happens

[sheilagh]

Scariest thing I ever saw....I was a newbie nurse on med-surg and 1 of my pt's was a 22 yoa female with an abcess lateral to left knee.She was receiving 1 percocet q3-4hrs prn.Orythopedic surgeon arrives for consult for possible surgical I&D. He comes out of the room and says he can do bedside, and rattles off what he needs.Yikes! I gather supplies, but when he asks me to give morphine I have to tell him he has to because I am an LPN and am not allowed to do IVP. He is not happy, and he begins to give pt 2mg IVP at a time until she doesn't wince when he touches leg. At 6mg total given with no relief voiced, he asks her what other meds she takes, she answers 2-3 percocets a day."oh well that explains it," he states and tells me to hold her while he cuts. She actually rose 3 feet off the bed and howled with incision and he yells "hold her down damnit". As he finished up she was holding onto me for dear life, her face buried in my chest sobbing with occasional new cries of pain.And blood? Everywhere, on the floor, walls,all over the pt and the bed was covered.He walks out of the room like nothing and leaves orders at the desk for dressing changes. How can it get worse? 2 mins later the pt's family is there to visit. I keep them outside, clean up room and pt quickly and run to get her as much pain meds as she has ordered. Everytime I see that doc I shudder and go the other way. I refuse to EVER assist again at bedside with him and I reported the incident to DON...but nothing happened.

[leslie :-D]

i too have witnessed many bedside procedures, where the pt was severely undermedicated....or not medicated at all!

the surgeon would state "oh this shouldn't hurt"...

one time i had to get a doctor to cath a male pt with metastatic prostate ca.

pt's bladder was highly distended, no uo, and had masses blocking the bladder outlet.

i told the doctor pt needed a suprapubic cath.

doctor waved me off and proceeded to ram the catheter-RAM IT!

pt screaming, blood everywhere, and still, w/o success.

ended up being transferred from inpt hospice to er.

but even before md started, i reminded him pt would need premed for procedure.

again, totally ignored.

while the pt was being transferred, i quietly reminded md that he too, would someday be 75 yo w/either bph or prostate ca.

still sickens me to think of the torture inflicted on my helpless, helpless pt.

i still hear the screams....

leslie

[tencat]

Lidocaine is another thought. I'll keep you all posted.

How does a newbie nurse tactfully point out that all this no medication, H2O2 for dressing changes is really not best practice???? Would anyone even listen to me, anyway? We don't have the luxury of a wound care specialist or pain specialist because we are a very small rural hospital.