Pain Management in the ER

I work in an inner city ED in a very low income/low education area where we see A LOT of drug seekers. I know every ED has drug seekers, but I mean, we have A LOT!

I do think our biases affect our ability to see pain as truly subjective. I know pain is what the patient says it is, but the girl in the corner nodding off and a known methadone patient? I'm not so sure medicating her is a good idea. Believe it or not, we actually had a patient sue our hospital for getting her addicted to dilaudid! However, the pancreatitis pt? You better believe I'm advocating and hounding the provider to medicate that pt properly.

The problem here is that it's a very fine line and not so extreme cases most times, right? It's definitely a toughie. I work with providers who give whatever the pt wants just to get them out ASAP and free up the bed. I also work with providers who are very stingy with controlled substances. I guess it depends on your clinical experience more often than some would like to admit.

Honestly, sometimes I look in the chart to see how many visits they have and what their past visits consisted of. If I see patterns, I'll notify the provider. Other times I'll straight out ask in a concerned voice "do you have any problems with narcotics?" just to sort of let the pt know I'm cognizant of it.

I think we over treat it.

Benadryl and phenegran are not used to treat pain. The literature shows that pain is very often under treated and certain ethnic back ground wait much longer than others to receive anything for their pain. Lots of room to improve.

I tend to ask them what they already took at home, and how effective it was.

And also, if they have had the pain before, then what they took last time.

And check BP

My theory is that if the pain is genuine, they will work with me, tell me what they took and whether it helped, and be co-operative with the BP reading.

If they just roll their eyes and give me the "the last nurse just gave me norco" line, then they can wait.

Its not foolproof, just somewhere to start.

I feel like our doctors always order something for pain relief but that doesn't always work for the patient. You don't always need narcs to treat pain but that's what a lot of patients want.

I find that patients also want to be 100% pain-free... doesn't everybody? But we need to be realistic with them and tell them that we may not be able to take their pain away completely but at least get it to an acceptable level... and then find out what that acceptable level is.

A couple of our docs use a pretty standards "cocktail" for headache/migraine patients that includes fluids, Benadryl, Toradol, and Phenergan. It really works well on many of my patients. They still gotta have a ride home due to the effects of the Benadryl and Phenergan, but they don't end up with the post-narc rebound headaches.

Some of our docs use that cocktail too. I think we have seen much great decrease in headache pain with that than with other narcs.

I think in some cases we significantly under medicate our patients that are in "real" pain; i.e.: long bone fx or hot appies, or lacs.

There are many people that I think we give into just to keep them quiet while they are in the ED. It is very frustrating but a sad reality of most EDs.

meredith

A couple of our docs use a pretty standards "cocktail" for headache/migraine patients that includes fluids, Benadryl, Toradol, and Phenergan. It really works well on many of my patients. They still gotta have a ride home due to the effects of the Benadryl and Phenergan, but they don't end up with the post-narc rebound headaches.

Our doctors use those cocktails for migraine/HA patients, too...though some prefer Compazine or Zofran. And some like to use mag. It seems to work pretty well for patients as opposed to the use of narcs.

One, in particular, over-treats. Now and them some under-treat. I, obviously, want to treat people's pain. OTOH, someone with a "fresh" sprained ankle will probably not get total pain relief unless you use IV narcs. However, this would be silly. So, it's kinda a delicate balance….I want to relieve pain, but not everyone needs narcs so that we can eliminate every trace of pain.

Do people actually believe the "he says he has pain, so he must have pain" bogus theory we learn in nursing school? This only applies in perfect world where people do not lie and addictive, drug-seeking behaviors are non-existent. Of course, I say pain mgt is important if manager or interviewer asks, but really, after seeing multiple drug seekers and pain med addicts who say their pain is 10/10 with perfectly straight face and while talking on the phone with the "girl friends", I am more convinced to look for objective signs of pain. For example, I had a pt who was literally twisting and writhing in pain, and he never asked for pain med before, so I knew his pain was real. A frequent CP flyer who comes in for morphine and demands it to be given straight push without diluting it with saline and has the nerve to roll the eyes backwards when giving it like he's feeling ecstasy? I know his is NOT real. Get real, addictive behaviors are real deal, and although I never have taken even a norco in my life, I guess morphine and dilaudid are hell of a drug. I'm staying away from that crap.

Do people actually believe the "he says he has pain, so he must have pain" bogus theory we learn in nursing school? This only applies in perfect world where people do not lie and addictive, drug-seeking behaviors are non-existent. Of course, I say pain mgt is important if manager or interviewer asks, but really, after seeing multiple drug seekers and pain med addicts who say their pain is 10/10 with perfectly straight face and while talking on the phone with the "girl friends", I am more convinced to look for objective signs of pain. For example, I had a pt who was literally twisting and writhing in pain, and he never asked for pain med before, so I knew his pain was real. A frequent CP flyer who comes in for morphine and demands it to be given straight push without diluting it with saline and has the nerve to roll the eyes backwards when giving it like he's feeling ecstasy? I know his is NOT real. Get real, addictive behaviors are real deal, and although I never have taken even a norco in my life, I guess morphine and dilaudid are hell of a drug. I'm staying away from that crap.

Oh, that is all sooooo true!

And I wish I had a answer, but until then we are all stuck with the "what the patients says" theory.

I don't rush their assessments, I wait until they finish their phone calls, then ask for specific details of their pain, and slowly go through the PQRST assessment with them.

And stop each time they take another call.

Always a touchy subject. This caught my eye because the last place I worked one doctor's answer to ANY c/o pain was benadryl and zofran. Then if that didn't work, he would order Haldol!! The benadryl/phenergan/toradol thing works great for many of the migraine patients. I don't get the Haldol though...I read one study about it being effective for a small percentage of migraine patients BUT NOT for anything else. I think it may have been more to knock people out but I think it's unethical.

It's really a shame that we DON'T have any way to tell and it's a shame that so many people have abused the system that people in true need are undertreated. I have this perspective as both an ER nurse and as a patient. I had gone to the ER with pains like an intestinal obstruction (have had in the past). It was my second visit in two days because it was not going away. The ER doctor stated "I don't have time to treat chronic pain patients"...my response "have you seen the CT?"..."Um...yes...but I'll have the radiologist go over it again" In other words, no she hadn't looked and just assumed. Lo and behold I was obstructed in TWO different places!!

But, I get it totally.

I'm wondering if there is some other sort of assessment scale that could be developed. For example, psychologically people have different associations with color. The trick would be to keep the results of the scale secret so no one can "beat" it. Wishful thinking but no worse than answers of "20" on a 1-10 scale!! The person who can come up with the solution to this will be a millionaire no doubt!