Pain management

[Matt8700, RN, EMT-B]

How do you maybe a provider that is either unwilling to treat a patients pain or is under treating a patients pain.

Example: patient waits 8 hours in the lobby to be seen. Provider orders Motrin for the patients chronic hip pain. I know the condition is chronic but the patient appears to be very uncomfortable. Provider is approached and is unwilling to listen to or collaborate with nurse. Patient leaves unhappy.

Example: patient c/o headache. Given toradol and is ineffective. Discharge. Again provider unwilling to listen to nurse.

Example: patient fell, negative xr of knee. Given Motrin after waiting 10 hours to be seen. Patient appears uncomfortable but provider not willing to discuss pain management plan.

These instances are all involving the same provider. But how do you all speak to a provider when they don't want your input. This particular person hates when nurses approach and will not listen. At times the nurse is made to look bad because the provider is not willing to listen to our assessment of the patient. How do you all handle?

[PeakRN]

What would you have preferred for pain management? We have an opioid crisis because we overprescribed narcotics and turned people into addicts. Did you give an ice pack, splint/apply an ace wrap, position for comfort, or distract the patient? Did you request a lidocaine patch, reglan, benadryl, tylenol, et cetera or did you just tell the provider that they are in pain? Unless I truly don't know what to do I try to approach providers with a solution, not just a problem.

Does the provider not listen to concerns about pain management or any patient concerns including safety? Have you addressed your concerns about the provider not listening with the provider, talked to your charge nurse, the nursing director, or the medical director?

[Matt8700, RN, EMT-B]

This particular provider is of the mindset that their orders stand and that they should not be questioned. I am not suggesting narcotics at all, but the other medications that you mention could be very helpful and satisfying to the patient. I guess my bigger question here is how do you approach a provider that is not interested in your concerns as the patients nurse. Many times the answer that we get is "they get what I ordered or they can leave." And of course sometimes, especially after an 8 hour wait, we have to provide a form of customer service as well. Even if it is just a lidocaine patch I think the patient would be happier than a Motrin. I think the issue is more with the provider not wanting the input of the nurse and being unwilling to help a patient in need. Doesn't have to be narcotics, but it should be something. And btw, these instances were patients in their 50s and 60s, not a 20 year old that had nothing better to do than generate an er visit. These were reputable people that sort of just got passed off and somewhat ignored.

[akulahawkRN, ADN, RN, EMT-P]

First off, remember that documentation is key. If the patient states they're in pain and would like medication, ask the physician. Do whatever non-pharm stuff you can for the patient. In both cases, document the request and response. If the physician declines to order pain medication, then make a note of it. Document the patient's response to your interventions. If the patient is dissatisfied with the physician's plan, document it verbatim. The patient can always also complain to the hospital about said physician... Hopefully other nurses will also do the same thing and with sufficient complaints about the physician to the hospital, the hospital and physician may have a discussion, after which things hopefully will change.

When someone wants to complain about something, I'm happy to provide phone numbers and whatever else I can (and I document that info was provided) so that even if I can't stop my hair from being blown back by Mr. or Ms. Unhappy, at least they can't say I didn't try to give them the means to file complaints. I learned a long time ago that I'm not going to please everybody so for those folks, here's how and where to complain.

[Lev, MSN, RN, NP]

These people shouldnt be in the ER to begin with. I have little pity for people who don't use their primary physicians or go to the drugstore.

[DayDreamin ER CRNP]

How do you maybe a provider that is either unwilling to treat a patients pain or is under treating a patients pain.

Example: patient waits 8 hours in the lobby to be seen. Provider orders Motrin for the patients chronic hip pain. I know the condition is chronic but the patient appears to be very uncomfortable. Provider is approached and is unwilling to listen to or collaborate with nurse. Patient leaves unhappy.

Example: patient c/o headache. Given toradol and is ineffective. Discharge. Again provider unwilling to listen to nurse.

Example: patient fell, negative xr of knee. Given Motrin after waiting 10 hours to be seen. Patient appears uncomfortable but provider not willing to discuss pain management plan.

These instances are all involving the same provider. But how do you all speak to a provider when they don't want your input. This particular person hates when nurses approach and will not listen. At times the nurse is made to look bad because the provider is not willing to listen to our assessment of the patient. How do you all handle?

#1: The AMA recommendation is to treat chronic pain with NSAIDs not narcotics. As a provider myself, there is nothing that I can justify prescribing for the patient's chronic pain that he/she doesn't already take at home. And if they take it at home, they can take it at home. If the patient is in continued pain, he should see the MD that prescribes the medication. That is the contract patients sign when they are in pain management. As a provider, I'm also looking at the state-wide pharmacy database to see what the patient has already had filled. I'm not necessarily going to share that info with other staff member either.

#2: Again, narcotics / opioids are not indicated for a headache. Period. If I prescribe morphine or dilaudid, I'm almost guaranteeing a rebound headache.

#3: I'd give motrin or maybe even an Ultram and send this pt home with a script for naproxen and a referral to ortho.

I think we have created a society that feels like we should always be 100% pain free and providers should throw whatever medications at patients to facilitate that. This is partially why we have such an opioid crisis.

As a provider, I don't have to justify my orders to anyone but the patient and my boss. I realize that sounds very anti-nurse. While I do appreciate what nurses bring to the patient care equation, I would get very tired of being questioned about every little thing I order. Don't be that nurse.

If you are having an issue with that one provider, I'd talk to him or her about how to best communicate patient needs and your concerns. I would also encourage you to chart and document objectively. Keep it to the facts and your patient's response. You can always chart, "MD made aware of patient's pain assessment. Awaiting further orders."

[Oldmahubbard]

Maybe it isn't fair to expect that an ER provider will look at the big picture. For the hip, although it is chronic, something has happened that has made it enough worse today, that the person is willing to sit in the ER for many hours to get help. This is an unpleasant experience, to say the least.

X rays were taken, or whatever else is needed, to rule our acute pathology. The state narcotic website has also been checked, and the nurse may not know the results.

This is an unfortunate situation because upstanding citizens, pillars of the community, can also game the system for narcotics.

The patient has already taken what is available at the drugstore. If the state website is clear, I would err on the side of compassion, and order a few tablets of a weak narcotic.

So sad, that many people seem to think that fentanyl and oxycontin are the only narcotics out there, when there are several much milder and safer choices.

Narcotics are almost never the solution for headaches. Such patients need a referral, or they can just wait to turn 40, after which headaches usually resolve. OK, a little sarcasm, I was a headache patient.

The nurse in this scenario bears none of the responsibility. Aside from sharing any concerns with his or her supervisor.

Lack of power is the essence of nursing. Probably why I had to get out of it.

[Matt8700, RN, EMT-B]

KeeperMom, I understand your point. And again, I was not suggesting a narcoticnfor these patients. What I would suggest would be things such as toradol, ultram, etc. Non narcotic medications, buttoned that will offer some relief. I feel bad when you say that you don't have to justify your decisions to the nurse, after all, we are part of the tram too, and often the ones that spend the most time with the patient. I feel that patient care is a team approach and to work with a provider that does not feel as though my input is valued means that I cannot properly care for our patient.....And yes, I said our patient. Nursing is not meant to be a simple process of completing tasks (you order and I do). There is supposed to be more to it than that. I am not saying I should be able to tell you what to order, butbi am saying that if I have spent a sufficient amount of time with a patient, I feel that my opinion should count. Remember a big part of nursing is advocacy.

[Oldmahubbard]

Ok, but Ultram was made a narcotic in my state, after being on the market for 25 years as a non-narcotic.

Someone figured out a way to abuse it.

It makes me sad that people lump it in with fentanyl, which is ridicoulous, but there you have it.

[DayDreamin ER CRNP]

@Matt8700 Please don't misinterpret my response. While a provider doesn't have to justify his/her order, *I* personally am open to the information gathered from the nurse and I'm very open to discussing the patient and the course of treatment. I was an ER nurse for over 9 years and truly appreciate the patient/nurse connection. What I don't appreciate is a nurse that constantly questions my judgement or my orders. I'm also not saying this is the situation at all. Just offering a different side of the coin in terms of pain management, meds ordered and overall treatment.

While I am a big fan of toradol, I am very cautious when prescribing that med. Ultram can also be an excellent option but it has limitations and some significant drug interactions I have to be mindful of when prescribing. I am definitely sympathetic to a patient's pain and condition and I will adjust my orders accordingly. I do have to start small and increase as we need to based on results. Of course, if the patient has an obvious injury or a verified kidney stone, I make adjustments.

Noting about pain management in the ER is simple. We've all seen the seekers and tweakers that ruin it for everyone.

[JKL33]

This particular provider is of the mindset that their orders stand and that they should not be questioned. I am not suggesting narcotics at all, but the other medications that you mention could be very helpful and satisfying to the patient. I guess my bigger question here is how do you approach a provider that is not interested in your concerns as the patients nurse. Many times the answer that we get is "they get what I ordered or they can leave." And of course sometimes, especially after an 8 hour wait, we have to provide a form of customer service as well. Even if it is just a lidocaine patch I think the patient would be happier than a Motrin. I think the issue is more with the provider not wanting the input of the nurse and being unwilling to help a patient in need. Doesn't have to be narcotics, but it should be something. And btw, these instances were patients in their 50s and 60s, not a 20 year old that had nothing better to do than generate an er visit. These were reputable people that sort of just got passed off and somewhat ignored.

It does sound like communication could be more smooth. I have come up against a couple of docs like this and it was easy enough to finesse by simply acknowledging that the situation wasn't ideal and taking a little care with my tone and mannerisms so that it doesn't come off as if I think something has been done wrong. There are nurses who approach providers on behalf of even patients who are clearly messing around, yet when they approach the provider it's with a tone that is something just short of snotty and demanding to say, "Umm, Bed 40 needs something else for pain, he got no relief at all." In cases like that, I would fully expect the provider to feel a little like, "Oh, really? Well, no." KWIM? Yes, we are first and foremost patient advocates, but that includes advocating properly, and for the right things. You mention further down in the thread that you are a team member and want to be treated like one. I agree with you, I just sense that you should take care to portray that you acknowledge the provider is also your team member - not just someone who needs to make your patient happy come what may.

Secondly - - with regard to the quote above. It seems like you're right on the verge of basically saying your patient deserves some door prizes. While I agree with you wholeheartedly about not turning a blind and uncaring eye to those suffering, you must understand that the things you want to hand out in order that your patient has something to show for the 8 hour wait are all things that are prescribed under someone else's license, and someone else is ultimately accountable for them, not you. I get what you're saying but you can't forget that fact.

And of course sometimes, especially after an 8 hour wait, we have to provide a form of customer service as well. Even if it is just a lidocaine patch I think the patient would be happier than a Motrin.

IF it will help the patient, sure, okay. But no - in the sense you're talking here, this is what I mean when I say you are right on the verge of being flat out wrong. People don't get something more than what they need as a reward or a "service recovery" or anything else. The type of customer service you perform is to sit down for a couple of minutes and talk to your patient, make good eye contact, hear their problems, and do some encouraging, teaching and explaining.

[Matt8700, RN, EMT-B]

KeeperMom, thank you for your response. I appreciate your input.

I have my ever worked in one ER and I hear from our travel nurses that the nurse/provider relationship in the er I work in is very one sided. There is never any discussion of the patients plan of care with the nurse, no input, none at all. They see the patient, walk right by the nurse and go to their desk and enter orders. I can't tell youbjow many times we could have ever them from putting in orders were can't complete if they had only asked us first.

These were just a few different examples, but my real question is how do do you go about negotiating with a provider when you feel that you need to advocate for a patient, particularly one that does not like to be asked about their orders?