The Emergency Department: Where pain isn't what the patient says it is.

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Hey Everyone,

I am a new grad working in the emergency department and find I am really bothered by something. I notice that the staff seems really jaded when it comes to treating pain in the ED. There was a patient today who was in a motorcycle accident and I was told they were a drug seeker so they under-medicated the patient. After vomiting up all of their meds, the nurse tells me she can't give the patient anymore because they vomited them up on purpose. I was there and it didn't seem like that to me. Regardless, I thought pain is what the patient says it is. Do we really care if they have a drug problem? Is it our responsibility to make sure they don't get a fix? I thought it was our patients right to be pain free. It seems like these nurses may be running a little low on compassion. I know I am a just a new grad so will someone please tell me what is going on here?

"Pain is what the patient says it is."

Says who?

That is often said, quoted, repeated, as though it has some meaning. It is ridiculous and overly simplistic.

Take out the word "pain", and substitute it with, "diet", "alcohol use", "activity level", "medication compliance", etc.. In all other instances, we take what the pt says as one factor, but look at any number of other factors.

We know that patients lie about all sorts of things.

We also know that addicts will lie and steal from those they love the most to meet their needs. Why on earth would they not lie to us?

And, of course, as Zmansc as stated nicely, a good nurse looks at all the factors. Would you really leave an elderly person in pain simply because they rated their pain as a 2, despite elevated vitals, facial grimace, and pressured speech. "Well, she looks like she is in pain, and I know that a lot of elderly associate morphine with dying, but pain is what the patient says it is...."

With every drug we give, we way the potential risks vs benefits. Narcotics are no different.

Gotta be some reason very few experienced, competent ER nurse go around saying "pain is what the patient says it is."

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Specializes in Education.

Can you really blame us for becoming jaded when you have a patient come in several nights in a row, with vague complaints, and says that they weren't able to fill the prescription for narcotics that they were given the night before - when the MD can see that they really did fill it? When they say that they have 10/10 pain, but a full workup shows nothing out of the ordinary?

Really, I'm more likely to believe the person who comes to my department maybe once or twice a year than the person who comes in once or twice a day, refuses admission, and when you try to discharge them comes up with another complaint. There's knowing how to work the system, and then there's knowing how to play the system.

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Specializes in Critical Care, Emergency, Education, Informatics.

The Bezold-Jarisch reflex revisited: Clinical implications of inhibitory reflexes originating in the heart

The PDF is available for download at the site.

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Specializes in Oncology/Haemetology/HIV.

Incidentally, anyone using Tylenol IV to reduce/eliminate the need for narcotics in certain cases? If your ED isn't using it, it seems to be very good in alot of situations and if the provider is reluctant to give more opioids to a patient or to even give any opioids, then it's something you can advocate for your patient.

Good luck with that in my hospital. IV Tylenol here stateside is extremely expensive, and takes practically an act of Congress to order. If the pt can take po, it will not get supplied.

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Specializes in Emergency.
Good luck with that in my hospital. IV Tylenol here stateside is extremely expensive, and takes practically an act of Congress to order. If the pt can take po, it will not get supplied.

Well, last I checked NM was still stateside, and no act of congress is required here. Maybe we have a more progressive administration.... I predict it will get more use as opioid use in EDs continues to become a bigger and bigger issue. You just can't compare PO to IV in this case, the effects are not even close to the same.

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Specializes in Nasty sammiches and Dilaudid.
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Specializes in ED, Informatics, Clinical Analyst.

Our providers go the DEA website and print them a list of all the prescriptions for controlled substances they have had filled. :cheeky:

There are other clues too, like what I call the triple T allergy...

When the patient is allergic to Tylenol, Tordol, and Tramadol it kind of makes you wonder...

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Specializes in Nasty sammiches and Dilaudid.

We've had quite a few folks lately suffering from the terrible affects of hypodilaudism...

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I'm allergic to NSAIDs, Tylenol, and morphine, I'm in 10/10 pain, hold on I have a phone call....

BSN GCU 2014. ED Residency ;)

Sent from my iPhone using allnurses

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Incidentally, anyone using Tylenol IV to reduce/eliminate the need for narcotics in certain cases? If your ED isn't using it, it seems to be very good in alot of situations and if the provider is reluctant to give more opioids to a patient or to even give any opioids, then it's something you can advocate for your patient.

It is apparently a bit more effective than PO Tylenol, which can be used for mild to moderate pain, if that is what you are treating.

It will not treat a desire or need for narcotics.

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Specializes in Emergency.
It is apparently a bit more effective than PO Tylenol, which can be used for mild to moderate pain, if that is what you are treating.

It will not treat a desire or need for narcotics.

No it absolutely won't treat a desire or need for narcotics, I didn't mean to imply that. Sorry if I gave that impression.

It will however treat the underlying pain and the analgesic effect is significantly stronger than PO, much closer to that of opioid analgesics. Often a good choice if the initial dose of an opioid did not touch the pain and/or there is drug seeking behaviors or situations where what is already on board is unknown and additional opioids could result in resp depression.

I just mentioned it because a year ago we were not using it at all, but since then we have started to add it to our toolbox and seen good results with it.

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