The chest pain vent.

[enigmaticorange]

I work nights on a cardiac floor that of course includes lots of admits for chest pain. I often get this scenario:

Patient admitted at 1am from ED, chest pain was 10/10 on admit to ED, recieved MONA, etc, pain relieved by the time patient is admitted. So, around 3am patient experiences chest pain and what orders do we have? Tylenol. Xanax. wow. really? No nitro, no morphine, nothing?? Then I have to call the doc and get one of two scenarios:

1. Call Doc, Doc doesnt call back unless we page 3 times because they are asleep. I would be too if i were them. They proceed to order the morpine/nitro/whatever we need or ask for, no problem.

2. Call doc, doc proceeds to yell about the fact that of course he knew the patient is having chest pain, he/she admitted them and sent them up with Tylenol because it isnt cardiac pain and/or they are drug seeking.

Ugh. so here is my wish list to docs:

1. If a patient is admitted for chest pain; address it. Send a note or a message if you are unwilling to give anything for pain.

2. If you are willing to give pain meds and you have a patient admitted with pain, ORDER PAIN MEDS!!! You took the effort to order basic PRN's like tylenol, just add one more on. You know people dont come to the ER for "pain" if tylenol is going to do the trick.

3. I realize that the patient is most likely not experiencing true "chest pain" after enzymes are negative and they have a clear cath. This does not mean the patient does not have pain that needs to be addressed. No, this pain wont kill them, but you dont have to ignore it, either.

4. I can spot a drug seeking patient also. I see them all the time, and the generally arent shy about what they want. ("Give me Phenergan at the same time, and fast!!")

ok, rant over.

[FancypantsRN]

Yep - I know how that goes. I went through that almost nightly, with a stack of "chest pain protocol" forms sitting in the file cabinet unused. It would make it a lot easier if either the protocol was ordered, or the nurse taking the patient was informed why it is not being ordered.

[Ayeloflo]

I like your post. I must say that the manner in which pain is addressed (if it does get addressed at all) really does irritate me. Nurses are left to deal with a patient who is suffering. Patients automatically direct their anger to the nurses, and I don't blame them.

Oh yes, I would page that doctor and ruin his/her sleep!!!

If pain is not cardiac in nature, does it not require attention? Does the doctor only care about "vitals" ?

Let's keep in mind that patients are not usually expert at ranking their pain on a pain scale.

A patients pain 10/10 may only be the worst pain he/she ever had. There are so many things that could cause pain in the chest area.

On point #4, You really want to avoid making assumptions that have no evidence to back it. The "drug-seeking" patient could go bad the next minute. Patients sometimes see several different doctors before they get the correct diagnoses. It happens all the time! Many doctors assume, assume, assume!!!

Phenergan? Why does the patient want it. What does it do to the patient? Has the patient taken it before?

As a nurse, I'm familiar with an amount of medical knowledge, including pharmacology. I tend to "guide" my doctor when I'm a patient because I know what could go wrong if I let the smart-aleck take total control

Do you know that the number of young men having a stroke is on the rise?

Do you know that the number of young people diagnosed with cancer is on the rise? The doctor prescribed antibiotics!

Guess how many doctors the patients saw before having the correct diagnosis.

So, yeah. If patient is in pain and call light is on. I check the orders, and I page for what is missing. Also, remember to document it each complaint of pain, and document each time you call.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Good rant! Rants are probably the most underused mental health helper for nurses.

[CaLLaCoDe, BSN, RN]

After reading the OP's rant, I think I'd like the Phenergan Dilauded combo;and...don't forget to push it fast!

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

LOL. Dilaudid straight up for me!

[GM2RN]

Why are you not addressing this when you get report from the ED?

Where I work, nurses taking report will often ask what the patient has ordered for pain. I try to remember to look at my orders before giving report and address this with the ED docs ahead of time, but sometimes I'm busy and forget, so this gives me an opportunity to get it taken care of before the pt leaves the ED.

Sometimes the reason no pain meds are ordered is because it was just overlooked by the ED doc. He is busy too, so all I need to do is ask and it's done. Or, if there is a reason that the doc doesn't want to order anything stronger than tylenol that I don't already know about, this is an opportunity to find out before the pt goes to the floor.

There might be a number of reasons why you don't have orders for pain meds, but the answer to your problem could be as simple as finding out in report.

[rkitty198, BSN, RN]

I wondered the same thing! I asked our Cardiologist why they do that, one told me...

That they gave orders for a patient to recieve morphine for chest pain. All indicators were that this patient was having pain unrelated to cardiac issues, but they kept him overnight for monitoring, due to the patients history.

The patient complained of chest pain and the nurse adminstered the Morphine. Overnight the patient was recieving the morphine and the vitals began to decompensate. Since the patient felt better and there was the PRN medication ordered the night nurse didnt think the vital change was enough to call the MD. Patient was more comfortable. When the day shift came on, the pain was increasing+changes in vitals+changes on the tracings.

This patient was having an active MI.

His thought was that he wanted to know if the patient was having chest pain that was so bad that warrented meds, he would want to know about it and be called to give pain meds dose by dose. He thought that if he gave us PRN meds then we would try to "fix" the problem and not notify him of changes.

Now this was a young pretenious MD who didnt trust the nurses for anything.

[Orange Tree]

Why are you not addressing this when you get report from the ED?

Where I work, nurses taking report will often ask what the patient has ordered for pain. I try to remember to look at my orders before giving report and address this with the ED docs ahead of time, but sometimes I'm busy and forget, so this gives me an opportunity to get it taken care of before the pt leaves the ED.

Sometimes the reason no pain meds are ordered is because it was just overlooked by the ED doc. He is busy too, so all I need to do is ask and it's done. Or, if there is a reason that the doc doesn't want to order anything stronger than tylenol that I don't already know about, this is an opportunity to find out before the pt goes to the floor.

There might be a number of reasons why you don't have orders for pain meds, but the answer to your problem could be as simple as finding out in report.

Haha...I try to do that all the time and they never know. Our floor orders come from telephone calls (to/from the "admitting" MD) instead of the ED doctor, and if there are any orders crazy/unclear/missing/inappropriate, they're handed off for the floor nurse to take care of.

[Do-over, ASN, RN]

We call the primary for admission orders when we got someone from the ER. OUr cardiac-type order sets allow us to admin NTG, morphine and order labs and ekg for chest pain. Usually not a problem to get the doc to order the sets.

[canoehead, BSN, RN]

When I worked the floor I'd usually have a list of questions and order requests by the time I went through the admission and orders. I'd definitely be calling about getting the chest pain protocol orders, or more information about what they want if the patient has pain.

[FancypantsRN]

GM2RN - some hospitals, ER doesn't have to give verbal report. That's where I ran into it. ER would fax report, the ER US would call to see if we got the fax (time allowing) - and medics would just bring the patient up. No chance to even speak to the ER nurse.

Otherwise, yes just easier to get it in report before the pt gets to the floor.