Patients with drug issues vs. the doctor playing dumb about it!

[nursey07]

I recently had a patient who "fired" me (haha) because I refused to push his dilaudid when he had fluids running. Aside from the fact that he was getting it every hour on top of Fentanyl patch, Phenergan, Zofran, Ativan, Valium......you get the jist. The doctor absolutely refused to use a PCA pump and would not discuss addiction issues with said patient and or staff. He just decided to go with what the patient wanted! I calmy suggested to the patient that he ask the doctor himself for the PCA pump if he felt the doses we were giving him were not taking away the pain sufficiently because the pca can give him MORE! I also said at one point that I hoped the Fentanyl patch would help his pain more so he didn't have to use the Dilaudid as much! He took this as a direct attack from me and went to my charge nurse saying I made him feel like I was judging him for asking for pain meds. In my experience, I know this is his own guilt of knowing what he is doing and was happy when he decided I wasn't the nurse for him!

What ****** me off is this makes me look bad to charge, management and administration where I felt I was advocating for the patient!

The doctor won't listen and when a solution (pca pump) was suggested he would get mad about it! Number one: who has the time to make sure one out of 8 patients is properly doped every hour? On top of more frequent trips for his other PRNS?

Number two: If the doctor wants to put him on an hourly dosing, COME UP AND DO IT YOURSELF!!!!!!!!!!

This doctor is such a wuss to come up and look at the guy and say, "You're an addict and we're lowering your doses?" I'm also sick of the other nurses who "just go with it". How does this help the guy and why are we powerless over this?

Ughhhhhhh sorry for the rant, but it just ****** me off!!!!!!!!

[meandragonbrett]

I refused to push his dilaudid when he had fluids running.

As opposed to no IVF running? Why?

[CoffeeRTC, BSN, RN]

As opposed to no IVF running? Why?

yeah...that.

I'm curious..what's his Dx?

[wooh, BSN, RN]

I took it as the guy was used to accepting nurses not just pushing it with an INT, but with fluids running, a lot of nurses (including myself) will normally just push it slow through a distal port. And she wouldn't do that just because the fluids were running.

[nursey07]

NO I have no opposition to pushing meds via distal port or even port to which fluids are running, but when his is running over 100ccs an hour, I see no reason to push it any faster! 100ccs is already pushing it faster than the recommended 1 minute. Thats what Im getting at. He wanted it pushed, but pushed fast so he could get the rush.

He had a lami two weeks ago, and went home and fell. He came back and all xrays/mris/ctscans have shown no damage from his fall. If anything they have showed improvement. So he is technically two weeks post op with 2mg dilaudid being pushed every two hours or 1mg/hour. I see this as innopropriate and neglectful per the doctor!

If he is looking for pain relief, he shouldn't be opposed to proper implementation of said medications! I don't mean to get on a soapbox here, but it just ****** me off that the doctor won't do anything about his meds!

He finally agreed to a pain consult, so hopefully that will do something. I have not been back since that has been put in place so I don't know what is going on.

[RN1982]

What is going on with the patient that requires him to have to take so much pain medication? I wouldn't rush to judge whether a patient has an addiction or not. Some patients tolerate higher doses of pain meds. Perhaps the pain patch was not helping his pain?

[leslie :-D]

What is going on with the patient that requires him to have to take so much pain medication?

s/p lami 2 wks ago.

pt fell at home after discharge.

all diagnostics negative for injury...

rather, showing improvement/healing.

leslie

[nursey07]

Well, again, we have asked the doctor to put him on a PCA pump because the patient says the meds (and how they are given) are not suffice to him. The pump would allow him to get up to a max of 6mg/hour. But again, the physician refuses to budge and the patient takes it personally everytime I suggest other motifs to counter pain (toradol, valium, comfort measures, etc)......If the doctor wants him to have more meds, so be it, but policy won't let us push any more meds and everytime the guy wants it pushed at a certain rate to get his high. He doesn't understand that if you push it fast, it wears off to fast and can cause slowed breathing, hypotension, etc.......He wants it pushed fast which makes me wonder if hes really having the pain he says he is? If he IS, then the doctor should be taking heavier measures via pump, because we are at our max as to what we can give him at this point!

Again, hopefully pain management will have a solution.

[leslie :-D]

and the patient takes it personally everytime I suggest other motifs to counter pain (toradol, valium, comfort measures, etc)......

comfort measures s/p lami?:eek:

i'd take it personally too.:rotfl:

lordy.

leslie

[nursey07]

Ok, so whats the solution? Let him stay on Dilaudid for prolonged period of time? And if so not give him enough per patient? I understand comfort measures might sound ridiculous, but what else is there then? Push his meds extra fast as he wants them?

Maybe its just me, but if after two weeks from a lami that had no complications, should he be needing all of this? Ok, theres tolerance and needing of higher doses, BUT AGAIN, the doctor won't agree to it, so what else is there to do?

[nursey07]

Comfort measures? ok sounds like I'm putting him to sleep. I meant, repositioning, distraction, measures of that nature

[Indy, LPN, LVN]

I have had experience with trying alternative methods post knee replacement, post hip replacement as well. I had one lady who developed 3rd degree heart block on demerol, on the spinal during surgery, and slid in and out of 2nd degree a little with mild morphine dosing. She had one on one care though, ice to her joint nonstop, heat to her back which hurt as well, and frequent massaging of related muscle groups to help her relax. She said it was the longest night of her life but she got through it.

I do believe it's possible that ice/heat/massage can help but only if the patient is willing to accept such. I do that for the LOL's who don't know they've had surgery as well, it often seems to help the pain meds last a little longer.