"I'm NOT going to support his habit...." LONG

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I've had two patients who are well-known drug addicts (UA's done and they tested positive for every drug on the panel) who had large abscesses drained from their arms. Abscesses were due to IV drug use. Both patients required QID wet to dry dressing changes. I've done QID changes on 'non-addicts' and always in the orders I've had PRN morphine to give prior to the change. But not with the addicts. Both addicts only had 1 PRN 7.5 mg Lortab ordered q 3-4 hours for pain. Now, I'm really new to nursing (I've only been one since September), so maybe I am not fully understanding what's happening. But I do know those wet to dry changes are PAINFUL, even with the morphine. It seems to me that it's downright cruel to expect a heroin addict to deal with these dressing changes with only one lortab q 3-4 hours. Am I wrong? I suppose the rationale could be that it's impossible to give them enough morphine to ease the pain without killing them with an overdose. But when I talked to my nurse manager about the latest patient, she said that she would not, under any circumstances, support his drug habit by ordering morphine for dressing changes. The physician feels the same way. I guess I need some validation that I'm not wrong, or at least some advice on how to emotionally deal with these dressing changes. I'm really distressed by the pleas I get from them for something to help with the pain, and me being powerless to do anything other than pre-medicate with one lortab. Any words of wisdom? Thanks!

Specializes in burn, geriatric, rehab, wound care, ER.

There's no faking when someone is poking around in your gaping open wound with peroxide. What kind of Karma do I bring on myself by inflicting unnecessary excessive pain on another?

I did think that wet-to-dry changes 4 times daily was not best practice. It is usually a temporary measure for us until a wound vac is secured, but it still lasts a few days. The wound vac changes are also painful.

Peroxide -another big no-no -it can cause air-embolism - I think it could become a legal issue if it actually happened especially since evidence based clinical practice guidelines (i.e. standard practice) are being violated; it also delays wound healing, it also hurts like hell. Normal saline is your best option. Dressings that optimize wound healing can actually reduce the pain. Maybe your wound vac rep can gather together some literature that can persuade the doc to change his practice -there is a mountain of research out there. You could also check out the wound care forum.

I did not mean to be glib about the Karma thing, its just that pondering philosophy has always helped me to see the bigger picture. I have suffered from abscesses myself and I know how painful they can be. I had a disagreement recently with one of our docs because I did not think he was addressing the patient's pain sufficiently as he was I&D-ing an abscess for the second time in 2 days. Eventually after IV morphine had no effect he agreed to do a nerve block and the patient managed to get thru the procedure -but just get thru it -she still had pain. Anyway I was glad to have been able to help out the patient but was still mad at the doc and muttered under my breath "I hope you get an abscess, so you can see how painful it is." Five minutes later he mislanded on a step and broke his foot. Coincidence? Karma? Who knows, but it was pretty freaky.

BTW, I wouldn't let your doc within a 100ft radius of an abscess of mine.

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Specializes in Looking for a career in NICU.
You have a legal obligation to question and refuse to carry out inappropriate medical orders. To do a painful dressing change without sufficient pain medication is indeed an inappropriate order. Let your charge nurse know that you will NOT participate in carrying out this order. She can address it to the physician and/or do it herself.

I agree. By law, drug addicts are considered disabled individuals and to deny them pain relief for bona fide medical reasons (not the frequent flyers that come into the ER for migraine meds when a migraine doesn't exist), I think is extremely unethical and cruel.

If the doctor has a personal ethical issue with properly treating drug addicts, then he should excuse himself from the case so another doctor can properly care for them.

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If the doctor has a personal ethical issue with properly treating drug addicts, then he should excuse himself from the case so another doctor can properly care for them.

The pt also has a right to request another physician, if he feels he is being neglected/mistreated because of his addiction.

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It is not the hospital staffs job to rid this man of his addiction, or make him face the consequences of his addiction. This man deserves pain medication in amounts that will bring his pain down to a tolerable level without causing serious adverse effects just like everyone else. Pain is a vital sign. If it isn't being treated then this is neglect pure and simple. I'm appalled at the doctor.

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Specializes in Cardiac Thoracic Surgery, Emergency Med.

That is totally unethical! I wouldn't work for a person that had a mindset like he does. I would refuse to do the dressing change without proper pain control. It is cruel.

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Pain is now considered a vital sign ...

Thanks for the reminder, Triage.

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Bless you all! You guys are giving wonderful advice. You know, Tazzi, I've asked myself that question.....if I really want to work somewhere that condones this behavior. But I live in a small town, and I really feel connected to the people I treat since I am able to follow up on them and see them everywhere, not just in the hospital......95% of the time the good outweighs the bad. I don't think it's a job I will do for 20 years, however.

UKRNinUSA, do you have any references that you could send my way regarding use of peroxide and wet-to-dry dressing changes? If I had some research to back me up it might make a difference. Thanks for your help!

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Specializes in Looking for a career in NICU.
The pt also has a right to request another physician, if he feels he is being neglected/mistreated because of his addiction.

The problem is, it didn't sound like he knew pain relief was purposely being withheld from him because he was a drug addict and that the doctor and nurse manager "were not going to support his habit."

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I did tell him that he needed to demand to know why he wasn't getting adequate pain meds, and not to be intimidated by the physician since it's the physician's job to take care of him and give him the best medical care possible. Unfortunately, we're a one horse town. No other surgeons are avialable within a 50 mile radius.

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Specializes in Critical Care, Cardiothoracics, VADs.

Re emboli related to peroxide wound irrigations:

Jones PM. Segal SH. Gelb AW. Venous oxygen embolism produced by injection of hydrogen peroxide into an enterocutaneous fistula. Anesthesia & Analgesia. 99(6):1861-3, table of contents, 2004 Dec.

Sun WZ. Lin CS. Lee AA. Chan WH. The absence of arterial oxygen desaturation during massive oxygen embolism after hydrogen peroxide irrigation. Anesthesia & Analgesia. 99(3):687-8, table of contents, 2004 Sep

Henley N. Carlson DA. Kaehr DM. Clements B. Air embolism associated with irrigation of external fixator pin sites with hydrogen peroxide. A report of two cases. Journal of Bone & Joint Surgery - American Volume. 86-A(4):821-2, 2004 Apr.

Schwab C. Dilworth K. Gas embolism produced by hydrogen peroxide abscess irrigation in an infant. Anaesthesia & Intensive Care. 27(4):418-20, 1999 Aug.

Haller G. Faltin-Traub E. Faltin D. Kern C. Oxygen embolism after hydrogen peroxide irrigation of a vulvar abscess. British Journal of Anaesthesia. 88(4):597-9, 2002 Apr.

Konrad C. Schupfer G. Wietlisbach M. Gerber H. Pulmonary embolism and hydrogen peroxide. Canadian Journal of Anaesthesia. 44(3):338-9, 1997 Mar.

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Specializes in Critical Care, Cardiothoracics, VADs.

Re advanced wound products versus "wet to dry" dressing effectiveness:

Kim YC. Shin JC. Park CI. Oh SH. Choi SM. Kim YS. Efficacy of hydrocolloid occlusive dressing technique in decubitus ulcer treatment: a comparative study. Yonsei Medical Journal. 37(3):181-5, 1996 Jun

Lindholm C. Leg ulcer treatment in hospital and primary care in Sweden: cost-effective care and quality of life. Advances in Wound Care. 8(5):48, 50, 52, 1995 Sep-Oct.

Mulder GD. Cost-effective managed care: gel versus wet-to-dry for debridement. Ostomy Wound Management. 41(2):68-70, 72, 74 passim, 1995 Mar.

Blackman JD. Senseng D. Quinn L. Mazzone T. Clinical evaluation of a semipermeable polymeric membrane dressing for the treatment of chronic diabetic foot ulcers. Diabetes Care. 17(4):322-5, 1994 Apr.

Gates JL. Holloway GA. A comparison of wound environments. Ostomy Wound Management. 38(8):34-7, 1992 Oct.

Overall, it seems wet to dry dressing usually do an equivalent job, but it takes longer, is less cost-effective, and causes more pain for patients.

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Specializes in ER.

My :twocents: ...

Unless the patient has specifically requested no opioids, and is trying to detox, he/she should be getting pain meds, regardless of addiction. You are there to treat the abcess/injury, not the addiction. I don't withold food from the obese, even though I might think that they eat too much. I don't withold formula from a new mother because I think she should breastfeed...

Good luck!

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