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

[CaptCrzy]

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?

[JBudd, MSN]

Article in the JEN about a year ago did the analgesia rates doing a blind comparison with IV Tylenol, Morphine and placebos. The Tylenol IV was just as effective as 2 mg MS, while placebo was way down the chart. Won't get you high, but very effective for actual pain relief.

[Dragonnurse1, ASN, RN]

Treat the patient 1st, in everything including pain. Zmansc was right. The pain scale is a guide not a rule. I must say I have seen better pain scales than the 1 - 10 but most cannot be used for the general public due to language choices. However over time you will learn about the true drug seekers. The patient that comes in at night complaining of a migraine. In triage they list off all the symptoms, nausea, vomiting, photophobia....oh wait back up you said photophobia what is that? Watch their face as they desperately try to remember what they read. Or they are sitting in the treatment room with friends chatting, eating with the overhead lights on. Or this patient is back for the 4th day in a row claiming they lost their meds, or they dropped them in the sink. It is Friday night and they ran out but cannot see their doctor until next week. Or better yet the cops arrive to arrest your patient for selling drugs just like the ones you just handed her(been there, done that). With all that said then you will have the patient with sickle cell that you will push 34 of dilaudad and he is still writhing in pain with vitals to match.

We all get jaded to some extent. We all bring personal beliefs about pain management to work. There is nothing worse than a doc that has never had a broken bone, headache, migraine, kidney stone or even a hangnail and therefore does not understand pain. He did not give any thing stronger than toradol until he suffered a herniated disk and back surgery.

Look at the whole patient. The way they walk, sit up, facial expressions, and vital signs. Pain can drive up your blood pressure, heart rate and respirations. You will learn to recognize the "kidney stone walk" in an instant. Take a complete history then tell the doc - this patient has a history of whatever. If you stay in the same ED long enough the names will start staying with you as well, if they are abusers. If the patient is a true drug seeker then it is up to the doc on to tell them no. Do what we did. If the doctor will not give them the drugs they request and refuse to treat have the doctor sign the patient out.

I had migraines for years, I went to my local ED for injections for years, Depending on the nurse I was treated nicely and sometimes as a drug seeker. When the pain was coming weekly I was in nursing school. Imagine how I felt when I went in for an injection? Turns out I had two herniated disks and had to have my neck fused while in school. I never looked at a patient in pain in the ED the same after that.

Be compassionate but be aware. The more questions you ask the better you will be able to differentiate between the two. Good luck.

[Anna Flaxis, BSN, RN]

I wasn't there, but maybe the patient was already known to the staff, and has employed extreme antics in the past in order to manipulate the physician into prescribing narcotics.

The fact that PO meds were ordered tells me that the patient was not seriously injured.

It's true that we are not the gatekeepers, and we are not going to cure an addict in one ER visit.

On the other hand, physicians have sworn to "do no harm", and it is arguable that prescribing narcotics when the clinical picture does not indicate them, to a patient with a pattern of repeated ER visits for spurious complaints, is potential harm. So what is the physician to do?

In this instance, I might have suggested Zofran ODT and Toradol IM.

[Lunah, MSN, RN]

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.

We use it in my Georgia ER. I have converted to the Church of Ofirmev! It has relieved pain in so many of my patients, so I ask for it for my patients if it seems appropriate.

[fitzfan82]

Oh boy, I just read this after posting about how I'm scared to go to the ER with my (suddenly severe, intractable) chronic pain (as well as neuro symptoms) because I'm afraid of being labeled and dismissed. I do have my MRIs on file with this hospital which shows my condition and the severity, but I'm still nervous. That's sad, when a nurse is scared to go to the ER...