Pain Management: How aggressive are your ED docs?

[kmoonshine, RN]

Ok, so I recently started working at a new ED (I have prior ED experience). I was told by many coworkers that the docs are really aggressive for pain control and order IV pain meds for pretty much everyone complaining of pain.

Its my second day in the ED (I'm on orientation), and I'm really bored! So I say "give me the next patient". I get a 50 year old pt c/o low back pain for one week no paresthesia, no weakness - nothing to suggest other complications. Anyways, for a c/o back pain at my old ED the docs would have pretty much only ordered Toradol and Flexeril IM; maybe po vicodin with a script to go home.

At my new job today, the doc ordered this back pain patient morphine 4mg IVP, valium 5mg IVP, toradol 30mg IVP, and IV 0.9%NS TKO (pt drove herself to the ED; ambulated with moderate pain). They sent her for an xray too (which never would have happened at my old job unless fx was suspected).

So anyways, I totally snowed her! And I'm thinking "great, my first IV start in 2 mos and I knock her out!" I monitored her BP and pulse ox; she would dip down to the low 90's but it would bring itself back up when I would wake her. She was arousable to voice, states "I'm just so tired, I have no pain now and haven't slept well over the past few days because of my back." She remained A/O x3 throughout her stay. She was obese, which maybe contributed to her pulse ox dip when sleeping. Her resp. rate was WNL. I sat her upright to see if it improved her sleeping oxygen sats, but she continued to dip. I put her on 2 liters of oxygen, and she maintained 99% SpO2.

Within 30 minutes she had her eyes wide open and was ready to call for a ride.

I've given high doses of pain meds before (dilaudid 8mg IVP for a sickle cell pt, given in one dose), I've given fentanyl, and a slew of other meds. However, I'm just not used to morphine 4mg IVP + valium 5mg IVP for standard pain management. I'm all for pain management, but I definately need to take it slower until I am more comfortable! Perhaps it was the luck of the draw and she was just very opiate naive and morphine 2mg IVP would have snowed her.

So, how aggressive are other ED docs? Is it standard to start everyone on morphine 4mg IVP for pain?

[Dixielee, BSN, RN]

Most ED's I have worked in are aggressive about controlling acute pain related to injuries, MI's, burns etc., but pretty stingey with narcotics. Usually we will give Toredol and an Rx for vicocin and FU with ortho, pain mgt. etc. Most ER docs I have worked with will not give a lot for chronic pain without complications.

We have a couple who do the migraine cocktail for someone with migraines though and it seems to work well...benadryl 50 mg IV, toradol 30 IV, reglan 10 mg IV.

[MassED, BSN, RN]

where I work, it really depends on the docs. I had a low back pain patient - 250 lb guy with chronic back pain, herniated discs... yada yada. You know that kind of patient - with the way they are yelling, crying, writhing in pain, as though they are the sickest of the sick on the ER. So I proceeded to give this guy... let me think, cause it was so much. Morphine 2mg (to start) IV, Toradol 30 mg, Valium 5 mg IV, and PO Valium.... so after repeated Morphine 2mg (I think 10 mg total) the guy was SNOWED and saying "I can't move, I can't get up, I can't go home like this." So I told him he wouldn't be admitted for chronic back pain and he had to try to get out of bed. So much drama to sit at the side of the bed - I'm sure my poker face didn't hold. GIVE ME A BREAK with the drama. I'm sure that he hurt, but this was overkill. A few IM shots and a script - C ya... CHRONIC is the key word here - no reinjury... so go see your PCP after you fill your script!!!! I don't know why some docs are so on that kick of all that IV pain med for a nonemergent person.... Press Gainey, perhaps?

[I love my cat!]

I worked in the ED for a very short time, but I have to say, most of the MDs did NOT treat the patient's c/o pain very well at all.

Their decision not to medicate appropriately made my job a lot more difficult.

I had to deal with a patient who was in pain, frustrated, scared and angry....not them

I don't know. I guess I feel that if a person is going to take the time and energy to get to the Hospital, then wait anywhere from 2-8 hours on the waiting room, they do deserve to be listened to and medicated for their pain.