Treating pain in ER

Anna Flaxis, BSN, RN · Apr 26, 2011

Also be aware that opioid-tolerant folks are much more difficult to deal with because their therapeutic thresholds are very near the toxic thresholds and it's easy to push these folks over the edge and kill 'em. It's happened more than once in our neck of the woods where chronic pain folks with other narcs at home have gone home and woke up dead d/t the synergistic effects of the various narcs and the required levels to attain pain control.

This. Because you are so opioid tolerant, they could pump you full of enough narcs to kill a herd of elephants and still not touch your pain. Don't assume that just because a doc doesn't want to kill you trying to control your pain, that you're being labeled an addict or a seeker. It could just be that the doc has enough experience to know that it's a losing battle, and it's safer to get your nausea under control so you can go home and take your prescribed meds, thus the "We don't treat chronic pain in the ED.".

Butterfly0328 · Apr 26, 2011

This. Because you are so opioid tolerant, they could pump you full of enough narcs to kill a herd of elephants and still not touch your pain. Don't assume that just because a doc doesn't want to kill you trying to control your pain, that you're being labeled an addict or a seeker. It could just be that the doc has enough experience to know that it's a losing battle, and it's safer to get your nausea under control so you can go home and take your prescribed meds, thus the "We don't treat chronic pain in the ED.".

It's not like I was asking OR wanting 5ml of dilaudid or anything. I would have been very grateful for just one more ml of dilaudid. I have been on much higher doses of Oxycontin in the past and when having a kidney stone attack been given more pain meds in the ER. It had been over 10 hours since I had had ANY pain meds due to the nausea and vomiting. Once I got home I did take my pain medication, but it didn't even touch my pain because it was so bad. You see, what I wish doctors would do with those of us that have, unfortunately, been on pain meds due to chronic pain is ASK us how we have been treated in the past etc. WE know our bodies more than anybody else. If what we are asking for is reasonable and not outrageous then work with us. Obviously if I present to the ER on a regular, or even semi-regular basis then OK, red flags go up. But I have NEVER been to the ER due to this chronic pain. All I was asking for was to bring my pain level from a 9 or 10 to maybe even a 5. I didn't expect to be pain free. I wouldn't know how to act if I was EVER pain free. If the ER doctor would have been receptive to open communication then perhaps he would have realized that I was not unreasonable. But most of them are so cocky with their heads up their ass. This particular doctor was harping on the nurses because they weren't getting EKG's done on 4 patients, plus blood draws etc in like 5 minutes. For those who have never experienced chronic pain, count your blessings. It is very easy to speculate and give opinions when one has never experienced it.

Esme12, ASN, BSN, RN · Apr 26, 2011

It's not like I was asking OR wanting 5ml of dilaudid or anything. I would have been very grateful for just one more ml of dilaudid. I have been on much higher doses of Oxycontin in the past and when having a kidney stone attack been given more pain meds in the ER. It had been over 10 hours since I had had ANY pain meds due to the nausea and vomiting. Once I got home I did take my pain medication, but it didn't even touch my pain because it was so bad. You see, what I wish doctors would do with those of us that have, unfortunately, been on pain meds due to chronic pain is ASK us how we have been treated in the past etc. WE know our bodies more than anybody else. If what we are asking for is reasonable and not outrageous then work with us. Obviously if I present to the ER on a regular, or even semi-regular basis then OK, red flags go up. But I have NEVER been to the ER due to this chronic pain. All I was asking for was to bring my pain level from a 9 or 10 to maybe even a 5. I didn't expect to be pain free. I wouldn't know how to act if I was EVER pain free. If the ER doctor would have been receptive to open communication then perhaps he would have realized that I was not unreasonable. But most of them are so cocky with their heads up their ass. This particular doctor was harping on the nurses because they weren't getting EKG's done on 4 patients, plus blood draws etc in like 5 minutes. For those who have never experienced chronic pain, count your blessings. It is very easy to speculate and give opinions when one has never experienced it.

You are not a nurse yet and couldn't possible know that MD's don't want to be told ANYTHING and that dealing with the general public has left many with a jaded point of view. Unfortunately, may people utilize the ED for drug usage and hop ED to ED trying not to visit the same one in the same night. In most instances an increase of chroinc pain is NOT considered emergent by any ED standards. The difference with the kidney stone is that the stone is an acute attack that requres immediate attention not a chronic issue that is really bothering you. If you continue in nursing you will see how very judgemental, critical, and biased the profession really is.....we aren' supposed to be be we are......I'm sorry.

I have always did my very best to avoid these behaviors and I fully believe that even "seekers" can hav real pain that needs to be treated. The was an initiative to "better treat" patients pain....but the reality is that a few bad apples spoiled the whole crop. States and the DEA monitor MD's and facilities for narcotic use so much that some PCP's refuse to prescribe narcs and rely on "pain clinics" exclusively. As a nurse that has become very ill recently I too have experienced the biases of the medical profession because I am overweight "obese" with a documented neuromusclar disorder (muscle and skin biopsy) with a CPK of 23,000 and was old recently by a "specialist" that all I needed was bariactric surgery and my infalmmatory myopathy will go away........you will run into morons everywhere.

Don't get upset with those who may be empathy deficient and dignify it with a response. I applaude your statement that you are attempting to "wean" off the narcs......they really can affect you ability to work in this field.....I wishyou luck....

Butterfly0328 · Apr 26, 2011

You are not a nurse yet and couldn't possible know that MD's don't want to be told ANYTHING and that dealing with the general public has left many with a jaded point of view. Unfortunately, may people utilize the ED for drug usage and hop ED to ED trying not to visit the same one in the same night. In most instances an increase of chroinc pain is NOT considered emergent by any ED standards. The difference with the kidney stone is that the stone is an acute attack that requres immediate attention not a chronic issue that is really bothering you. If you continue in nursing you will see how very judgemental, critical, and biased the profession really is.....we aren' supposed to be be we are......I'm sorry.
I have always did my very best to avoid these behaviors and I fully believe that even "seekers" can hav real pain that needs to be treated. The was an initiative to "better treat" patients pain....but the reality is that a few bad apples spoiled the whole crop. States and the DEA monitor MD's and facilities for narcotic use so much that some PCP's refuse to prescribe narcs and rely on "pain clinics" exclusively. As a nurse that has become very ill recently I too have experienced the biases of the medical profession because I am overweight "obese" with a documented neuromusclar disorder (muscle and skin biopsy) with a CPK of 23,000 and was old recently by a "specialist" that all I needed was bariactric surgery and my infalmmatory myopathy will go away........you will run into morons everywhere.
Don't get upset with those who may be empathy deficient and dignify it with a response. I applaude your statement that you are attempting to "wean" off the narcs......they really can affect you ability to work in this field.....I wishyou luck....

Thank you so much for your insight. I will not take any such medication if/when I become a nurse. I will have to wait and see what happens with my back before making that decision. Either way I will continue to wean down, as I have been doing for about 6 months now. Thanks again. I am so sorry you are being treated so badly because of being obese. The discrimination is horrible. I just wish people could see people for who they are as a person. Good luck to you and God Bless:redpinkhe

Anna Flaxis, BSN, RN · Apr 26, 2011

"Empathy deficient", I like that. I think it can really seem that way from the point of view of the person who presents to the ED for a chronic health problem.

The staff must prioritize their interventions according to severity of illness. So, the person with the flareup of chronic pain falls lower on the priority list than the person potentially having an acute MI, because, while chronic pain can be unbearable, it will not kill you, unlike an MI, which very well could kill you.

I wouldn't fault the doctor too much for being uptight about getting those EKGs done rapidly. When a person is having a STEMI, they need immediate intervention. Getting the EKGs and bloodwork done and determining who is having an MI and who is not is a top priority, and for all you know, he may just be one of those docs that gets a little testy when things are tense, but buys everyone a round of drinks after work. They may all be facebook friends and go hiking together on weekends, for all we know!

Anyway, I think the important thing is that you did leave feeling better (nausea resolved) than when you arrived, which allowed you to get back on your regular medication regimen. That's a good thing, right?

Anna Flaxis, BSN, RN · Apr 26, 2011

...and not that I think it should matter, but I suffer from migraines as well as bursitis in multiple joints. I would caution you against assuming that someone who sees things from a different point of view than you is lacking in empathy.

Anna Flaxis, BSN, RN · Apr 26, 2011

Can't seem to leave this thread alone!

While another milligram of Dilaudid wouldn't have been unreasonable, Toradol 30mg, Dilaudid 1mg, and Phenergan, nausea resolved, DCd home to resume regular pain meds, is not unreasonable either. I'm sorry that your expectations weren't met, but you did receive reasonable treatment.

As far as the doctor's bedside manner, yes, he could be just a jerk. But I've worked with a lot of brilliant doctors who happen to have terrible interpersonal skills. I might not want that doctor to be the one to tell me that a loved one has passed, but my God, if I'm coding, I want that one!!!

Anyway, I think it helps to keep an open mind. Glad you're feeling better.

keikei · May 24, 2011

Thank you so much for understanding. I just hate it so bad when I am labeled as an addict. I have never even taken one hit off a cigarette, nor have I ever even been drunk in my life, and I am 42. I am just simply someone who has had to deal with chronic pain. This is the first time I have had to visit the ET for this reason. Usually it is for kidney stones. But, none the less. I do understand the other points of view with the ER doctors to a certain degree because of there are so many just seeking the high. Thanks again for your kind works. :)

I just wanted you to know that I do understand. I have huge kidney stones too, but they don't know how to treat them because I have PKD. So sometimes the pain from the stones flares up and it's seriously the worst pain ever. Or if a cyst starts bleeding. Like you, I have pain meds at home and like you, I am tolerant. I've also never drank, smoked or taken a street drug. It is very difficult the few times I've been sent to the ER (my dr sends me as she only sees patients once a week and that's the only place for me to get care outside of those times for my kidney issues) to tell the drs. it is NOT my gallbladder, but my kidneys and that normal painkillers won't work for me (and in fact, I'd rather not have them at all unless necessary).

Patients like you (and myself) are what still draws me towards nursing. I want to be that one nurse that you meet that you know is really listening and really wants to see you feel a little better. They are out there, I've met them. Sometimes it's something as simple as them just bringing you a hot pad for your side or placing their hand on your head & smoothing your hair that makes ALL the difference in the world. Sometimes the painkillers don't work that well, but feeling a connection to another human being who you know has really listened to you & sees the "real" you behind the pain makes all the difference in the world.

Butterfly0328 · May 24, 2011

Thank you so much for your reply. I am so sorry you have been through this hell. I do agree with you with regards to having a nurse just show some empathy. I once had a nurse tell me to stop making "faces". Most people would be moaning or screaming in pain, but I was obviously making contorted faces or something. Unbelievable. Yea, we will make amazing nurses one day, especially because we have had the experiences we have had. Thanks again.:)

wwfd · May 24, 2011

I just wanted you to know that I do understand. I have huge kidney stones too, but they don't know how to treat them because I have PKD. So sometimes the pain from the stones flares up and it's seriously the worst pain ever. Or if a cyst starts bleeding. Like you, I have pain meds at home and like you, I am tolerant. I've also never drank, smoked or taken a street drug. It is very difficult the few times I've been sent to the ER (my dr sends me as she only sees patients once a week and that's the only place for me to get care outside of those times for my kidney issues) to tell the drs. it is NOT my gallbladder, but my kidneys and that normal painkillers won't work for me (and in fact, I'd rather not have them at all unless necessary).
Patients like you (and myself) are what still draws me towards nursing. I want to be that one nurse that you meet that you know is really listening and really wants to see you feel a little better. They are out there, I've met them. Sometimes it's something as simple as them just bringing you a hot pad for your side or placing their hand on your head & smoothing your hair that makes ALL the difference in the world. Sometimes the painkillers don't work that well, but feeling a connection to another human being who you know has really listened to you & sees the "real" you behind the pain makes all the difference in the world.

And you and patients like you are what are driving me out of ED nursing. I know that sounds harsh but its the truth. If your doctor is really aware that you have flareups then you and your doctor should have a plan in place to deal with these situations. and going to the ED is not an appropriate plan. That entire statement of "my dr sends me and tells me to tell the ED that normal painkillers won't work for me" screams drug seeking. Why doesn't your doctor call the ED in these cases and talk to the ED doctor, or set up a pain management plan for you. Just because i don't rub your trouble brow doesn't mean that I don't want you get better, perphaps by your ED nurse trying to talk with you about dealing with your pain with your PCP he/she is trying to help you deal with your pain in a more appropriate way.

okay blast away.

Butterfly0328 · May 24, 2011

Not worth my time.

keikei · May 25, 2011

And you and patients like you are what are driving me out of ED nursing. I know that sounds harsh but its the truth. If your doctor is really aware that you have flareups then you and your doctor should have a plan in place to deal with these situations. and going to the ED is not an appropriate plan. That entire statement of "my dr sends me and tells me to tell the ED that normal painkillers won't work for me" screams drug seeking. Why doesn't your doctor call the ED in these cases and talk to the ED doctor, or set up a pain management plan for you. Just because i don't rub your trouble brow doesn't mean that I don't want you get better, perphaps by your ED nurse trying to talk with you about dealing with your pain with your PCP he/she is trying to help you deal with your pain in a more appropriate way.
okay blast away.

My doctor does call the ED and does have a pain management plan in place. It's all in my chart and she always calls in advance, tells them why she is sending me in, what she would like done, etc. And they are waiting for me when I arrive. This particular hospital has a separate unit in the ER for longer term patients - people who are sick and need immediate medical care for whatever reason, but avoiding admitting them if possible. The patient is allowed to stay for 17 hours and either be discharged or admitted. It's quiet, each room is private (with a curtain for a door, the nurse is sitting right outside of the door at her station) and the nurse/patient ratio is low. None of the nurses in this department have been cruel or made me feel like it is my fault I am in pain and that since I already take painkillers on a very carefully regimented basis at home, throwing a percocet at me isn't going to help in any way. Kidney stones are very painful and there are those of us who don't have any control over when they are going to form, when they will lodge & cause pain or how long before they pass (IF they pass). And it's not my PCP that handles this issue, it's my nephrologist who depends on her co-workers in the ED to take care of her patients when she isn't able.