Earlier this week I had a patient that apparently comes into the ED frequently always with abd pain, they can never find anything wrong with him. He must have thought I was an easy target because I have never seen him before. (I only started on the unit in August) Chief complaint? Constipation x 2 days. Takes multiple narcotics, hx of abuse, ect. He is complaining that he has 10/10 pain, as he is sitting up calmly, and is asking for pain meds. I went to the doc and was like, this guy claims 10/10 pain, but look at him. So he goes and does the abd exam with no tenderness on palpation. I had 9 patients that night (some of them really sick) and his wife was harrassing me every minute for something, I was like (in front of the patient too) I have a lot of patients, many sicker than him, that I need to attend to right now, I cant get a pill/give him dilaudid/get him another blanket. The nice lady in bed 2 is about to be intubated and she needs my attention right now. Give me a minute please. He starts saying to me that he is very sick and dying and that I need to focus my attention to him mainly. Than he tells me that I need to order Klonopin for him NOW because he takes it at home and he missed his dose and if he doesnt take now it its "very dangerous". (The doc was getting the d/c papers as we were speaking). He than becomes mad when he finds out he was being d/c'd, he "demanded" to be admitted. Sorry, but a clear CT and x-ray is not going to buy you a day or two free drug stay!
Thank you all for listening to my vent!! I love this site, I can vent about this and you all have been there done that and understand!
Someone metioned earlier in this thread that they have to use the 1/10 scale for Quality Assurance purposes. The problem with a lot of these measurements are that they are great for quality improvement statistics, but lousy at actually rating a pt's pain.
If a chronic pain pt comes in with 10/10 pain and leaves with 10/10 over 9/10 pain does that mean we did a lousy job at helping them? Some of these people are on 80 of oxycontin tid. Unless we happen to a chunk of raw opium for them to suck on they are not going to get much better. Even regular pain might not be well documented by
the scale. If a pt comes in with fx finger with pain of 4/10 and refuses pain meds and leaves with same number on the scale is that a bad ED job?
When I was a street medic we were not required to utilize any scale for pain. I documented pain and it's relief in the pt's own words.
"32 y.o male c/o pain to R index finger post experiencing crush injury to that finger while changing tire. Pt states "my hand feels like it's on fire". Vitals as noted. IV 1000nss up KVO. 2mg NS04 given per protocol IVP. Pt now states hand no longer feels like it's on fire. Some residual pain, pt says it is tolerable at this time. Refused anymore morphine." No one reading that would misunderstand the pt's perception of pain and relief.
The problem is the tool. Statistics, math, they are finite subjects. Pain is nebulous. Medicine is not an exact science, logic would dictate that using an exact science to measure an inexact one would result in numerous errors. It's time to stop hammering square pegs into round holes for the sake of making Quality Assurance Data interpretation easier.
having been a ER nurse for 15 years, I also thought one would have to be writhing in pain to rate the 10/10 scale.. That is until I blew 3 discs that took a year to get fixed. What use to be intolerable pain at 5/10 became the norm...when I was a 10/10 it was what originally was a 5...I could still function calmly, but needed more help to get back to where I could function at a "normal" capacity. All patients need to be treated one on one...and sometimes even"frequent flyers" come in with serious situations that are overlooked because the staff is "annoyed" with them....better to be safe than sorry..
one clue whether a patient is "seeking" as we put it in our ED, is when they are "allergic" to every pain med except oxycontin or morphine, and when they know that "ketorolac" is Toradol and that "it ain't a narcotic"....hmmmmm someone doing their homework before they come in..there are different types of 10/10 pain also..ie) disc pain was oh my God this is not stopping, I want to get back to life pain, just give me something to take the edge off...and kidney stone pain was OH MY GOD....EITHER GIVE ME SOMETHING FOR PAIN OR I WILL CUT MY OWN KIDNEYS OUT WITH A DULL BUTTER KNIFE pain (imagine Ren and Stympy eyes, sweating, tongue hanging out pain)
both rated as a 10/10 and managed totally different.
Specializes in LTC, CPR instructor, First aid instructor..
1....disc pain was oh my God this is not stopping, I want to get back to life pain, just give me something to take the edge off...and kidney stone pain was OH MY GOD....EITHER GIVE ME SOMETHING FOR PAIN OR I WILL CUT MY OWN KIDNEYS OUT WITH A DULL BUTTER KNIFE pain (imagine Ren and Stympy eyes, sweating, tongue hanging out pain)
2....b"32 y.o male c/o pain to R index finger post experiencing crush injury to that finger while changing tire. Pt states "my hand feels like it's on fire". Vitals as noted. IV 1000nss up KVO. 2mg NS04 given per protocol IVP. Pt now states hand no longer feels like it's on fire. Some residual pain, pt says it is tolerable at this time. Refused anymore morphine." No one reading that would misunderstand the pt's perception of pain and relief.
oth rated as a 10/10 and managed totally different.
3.... don't like the 0-10 pain scale, either. When I had to have an emergency appy, and the nurse asked me to rate my pain, I told her I couldn't THINK about a stupid number, but it freakin' hurt! I used the FACES scale instead. I like it, it works for me, and many kids and not-so-bright adults can use it, too.
....I shall begin describing my different forms of pain. 1...MY BONES...They feel like a toothache... 2...THE PINCHED NERVE IN MY GROIN...It feels like a bunch of bees stinging me all at the same time. 3....MY POST EMBOLOTIC PAIN (The one I dread the most) It feels like I'm being thrust through my chest and into my back with a hot sword. It also makes me feel like my throat is being squeezed shut, and it radiates up both jaws and into my head. Now, Here's the kicker. So far my body is only able to tolerate Dilaudid 2mg which was administered in April 2001, and I still continue to use when my pain becomes intolerable, in order to avoid becoming addicted to it. Many times I have to take 800mg NSAIDS with it. Fentanyl duragesic gave pneumonia, Morphine gives me projectile vomiting accompanied by pruritis, Oxycontin, Percocet, & Methadone, & Vicodin give me pruritis,Tylenol with Codeine is like taking asprin, it does nothing to releive the pain, and Demerol increases my pain, and epidurals do nothing, same thing as Tylenol with Codeine. So what do I do? I have been to two pain specialists, both of who told me they couldn't help me, and my PCP told me he would refer me to a pain specialist at a well known medical center about two hours away, which I asked him how I would be able to go there since I'm on 4 litres of oxygen 24/7 and am in an electric wheelchair. He didn't have an answer to that one. Oh yeah. I forgot one that's another baddie. It severe DDD in the cervical spine with total collapse of c-5-7, and deterioration in T-1 accompanied by severe spurring on the left side, and spinal nerve impingment. The MRI was taken in 1999. Nothing is done anymore, because as I was told by the two pain specialists, "You are not a good candidate for any surgery involved with general anesthesia, because you have COPD, and have a history of respiratory failure twice. Solution...I keep on keeping on, and I focus on others with cheer, because there isn't a blasted thing left that I'm aware of to treat it.
Someone metioned earlier in this thread that they have to use the 1/10 scale for Quality Assurance purposes. The problem with a lot of these measurements are that they are great for quality improvement statistics, but lousy at actually rating a pt's pain.
If a chronic pain pt comes in with 10/10 pain and leaves with 10/10 over 9/10 pain does that mean we did a lousy job at helping them? Some of these people are on 80 of oxycontin tid. Unless we happen to a chunk of raw opium for them to suck on they are not going to get much better. Even regular pain might not be well documented by
the scale. If a pt comes in with fx finger with pain of 4/10 and refuses pain meds and leaves with same number on the scale is that a bad ED job?
When I was a street medic we were not required to utilize any scale for pain. I documented pain and it's relief in the pt's own words.
"32 y.o male c/o pain to R index finger post experiencing crush injury to that finger while changing tire. Pt states "my hand feels like it's on fire". Vitals as noted. IV 1000nss up KVO. 2mg NS04 given per protocol IVP. Pt now states hand no longer feels like it's on fire. Some residual pain, pt says it is tolerable at this time. Refused anymore morphine." No one reading that would misunderstand the pt's perception of pain and relief.
The problem is the tool. Statistics, math, they are finite subjects. Pain is nebulous. Medicine is not an exact science, logic would dictate that using an exact science to measure an inexact one would result in numerous errors. It's time to stop hammering square pegs into round holes for the sake of making Quality Assurance Data interpretation easier.
(climbs down off soapbox)
A thoughtful post and one I cannot disagree with. Try assessing Cardiac pain - "but I don't have pain I have pressure!!!" There has to be a better way. So many many times I have heard - "I can't give you a number - I just know it hurts!!"
Pain memory fades as well so asking to compare pain now with the "worst you have ever experienced" is giving them a scale without a referrence. even asking "the worst you can imagine" - depends on the level of imagination and imagining pain and experiencing pain are two different things - again we are giving a scale without a refence. I at present, do not see a way out of this. Maybe hit each person on the toe with a hammer - now that pain is 6/10 where is yours in relation to that??? - just kidding! just kidding!
one clue whether a patient is "seeking" as we put it in our ED, is when they are "allergic" to every pain med except oxycontin or morphine, and when they know that "ketorolac" is Toradol and that "it ain't a narcotic"....hmmmmm someone doing their homework before they come in..there are different types of 10/10 pain also..ie) disc pain was oh my God this is not stopping, I want to get back to life pain, just give me something to take the edge off...and kidney stone pain was OH MY GOD....EITHER GIVE ME SOMETHING FOR PAIN OR I WILL CUT MY OWN KIDNEYS OUT WITH A DULL BUTTER KNIFE pain (imagine Ren and Stympy eyes, sweating, tongue hanging out pain)
both rated as a 10/10 and managed totally different.
Why is it that whenever a pt knows the names of meds that work and the names of those that don't , you all get suspicious? What if that person has been treated for a specific problem and has therefore been exposed to more drugs than a typical healthy person? Wouldn't they then have a higher ratio of allergies? And a broader knowlege of drugs? I feel you would have to be complete moron to not pick up some lingo, the dose of drug that works for you and maybe a couple generic names for it as well. Nes't pas?
I still say crucify whoever it was that invented the pain scale, Its just a pain to use and educate pts on.
They either hurts or theys dont hurts
much simpler
Too cute Teeitup! It's French but I wrote it wrong. It's spelt N'est pas and means "don't you think?" As for the pain scale, well can't wait to go back to the ER for migraine. NOT! I'm a little easier now since my visits to ER have gone from 7 a month to 3 a year. I don't feel like I'm getting as many looks. THank goodness for Propranalol is all I can say. :)
didn't mean to sound insensitive, of course those with a chronic situation have a intolerance to many meds that would set a horse on their behind, and have breakthrough pain....and any good ED nurse knows the details of that particular patient if they continue to come back to the same ED...but there are many other signs when it comes to "seekers", the stories don't mesh, alot of backtracking....patients that truly need help are very honest and up front about the history and the present problem
teeituptom, BSN, RN
4,283 Posts
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