Two Big Questions For Pain Experts

cardiacfreak, ADN · Nov 25, 2013

An anesthesiologist had been consulted in both cases.

What was his/her orders? I guess I am confused about what you are asking. I thought you were asking what someone would do in those situations, if so follow MD orders. We are not going to fix people who are seeking pain meds in acute care, intense psychiatric therapy doesn't always work.

Esme12, ASN, BSN, RN · Nov 25, 2013

Although you continue to quote without the members name, making it hard to tell if you have quoted out of context, just because a patient has a history of long term use of oral pain meds doesn't mean that they do not deserve pain relief. Historically, these patients are difficult to treat....even long before the use of the "pain scale" (which admittedly has it's limitations). Frankly, I think back in the day when we used some placebos....I found they were useful in some patients. However....they really do not have a place in the PACU.

I find the lack of a previous medical record unusual as most OR cases I know of usually have the old medical record accompanying the patient making it rather easy to look into the record. As a supervisor.... I have called for many middle of the night records with fax machines and electronic records making this a relatively painless process. I can see how a free standing surgical center would have difficulty with this but they don't do emergencies and require a H&;P.

A nurse can only do what one can do. These days, with nurses being dime a dozen, it limits recourse and choices in treating patients....which is where documentation comes into play. In the first scenario the smiling guy will probably get his meds. The second however has clear medical evidence to the contrary. This is the standard and personal feelings about an "inadequate" assessment tool is not a consideration....David, meet Goliath.

Every nurse faces ethical dilemmas in practice and each nurse decides which battle to fight and which battle to comply after considering the consequences of his/her actions.

I once gave enough Dilaudid to send an elephant into a coma on a pill popping well known patient who thought it was a brilliant idea to light a bonfire with a can of gas....guess who arrived with facial and upper body burns? Did he deserve less intervention because he was a frequent flyer to the ED? Absolutely not.

SocratesJohnson · Nov 25, 2013

I thought you were asking what someone would do in those situations

I am asking that. We're talking about discharging a person who reports their pain as "10". Given that the experts say: "A patient's pain is ALWAYS what they say it is" I'm curious about how to proceed in this example.

. We are not going to fix people who are seeking pain meds in acute care, intense psychiatric therapy doesn't always work.

I agree.

SocratesJohnson · Nov 25, 2013

, just because a patient has a history of long term use of oral pain meds doesn't mean that they do not deserve pain relief.

I agree. My premise is that patients deserve pain relieve whether they are addicts or not....The cause of my concern has to do with the extreme difficulties involved in treating their pain.

I find the lack of a previous medical record unusual as most OR cases I know of usually have the old medical record accompanying the patient making it rather easy to look into the record

The record is easily accessible but it gives few clues on how to best control the patient's pain.....We don't get involved pain management records on patients.

Did he deserve lees intervention because he was a frequent flyer to the ED? Absolutely not.

I'm not talking about being punitive. I work my ass off trying to relieve pain in people with a lot of tolerance.......I'm considered good at it and I often get thanked by patients with tolerance for working hard to control their pain.

My co-workers sometimes suggest that I be the one to take care of people with tolerance mostly because of my dedication to controlling pain.

My concerns have nothing to do with wanting to be punitive and everything to do with controlling pain.

Esme12, ASN, BSN, RN · Nov 25, 2013

If you use the ( " ) icon at the bottom of every post you can properly quote multiple posts from multiple members.

What is it you are looking for then? People are answering your questions. giving you insight and advice...yet it seems to not be adequate.

SocratesJohnson · Nov 25, 2013

If you use the ( " ) icon at the bottom of every post you can properly quote multiple posts from multiple members.

Oh yeah! That's very cool! Thanks!

People are answering your questions. giving you insight and advice...yet it seems to not be adequate.

Some very well thought out answers have been trickling in. At first I was getting responses that seemed to be more about resentment of the questions than considering the questions.

Esme12, ASN, BSN, RN · Nov 25, 2013

Oh yeah! That's very cool! Thanks!
Some very well thought out answers have been trickling in. At first I was getting responses that seemed to be more about resentment of the questions than considering the questions.

Not resentment...suspicion/skeptical. Nurses are skeptical and cautious by nature.

SocratesJohnson · Nov 25, 2013

Not resentment...suspicion/skeptical. Nurses are skeptical and cautious by nature.

I get suspicion.....I remember the first time I got wind of the current pain control theories being put into practice almost 20 years ago.

I was at a talk one of the Hospital Dr's was giving and he said that opioids only worked to decrease pain directly at the pain receptors rather than working centrally to make the patient not mind the pain. I argued with him....I cited "The Pharmacological Basis of Therapeutics" and he told me I was wrong.......He told me that opioids don't work by making a patient mind the pain less.

Right then I knew that incredible stupidity was being introduced into pain control. I knew that getting stupid with pain control was going to lead to serious problems.........I hate being right all the time!

Anyhow.....Nurses invested in current pain theory (based completely on the patients report of pain and whatnot) have a strong tendency to resent it being questioned.......I've encountered that many times.

heron, ASN, RN · Nov 25, 2013

Actually, those theories have been around far longer than 20 years. They were not new when I first began investigating them 40 years ago after a harrowing experience with a 35 year old woman with sickle cell and an intern who refused to "make her an addict". It took 20 years or so before they became generally acknowledged. Unfortunately, the profession as a whole is still stuck 20 years in the past. What you're calling "current pain theory", isn't.

The situation is also complicated by an over-burdened system in which practitioners tend to gravitate toward the easiest/fastest answer in order to move on to the next issue.

heron, ASN, RN · Nov 25, 2013

oops - double post!

SocratesJohnson · Nov 25, 2013

. What you're calling "current pain theory", isn't.
It is for me.....It's what we're using. We're forced to use the pain scale on all patients whether it works or not.
The situation is also complicated by an over-burdened system in which practitioners tend to gravitate toward the easiest/fastest answer in order to move on to the next issue.
That is very true. Our pill culture is by no means limited to opioids. Pills are the fix for everything.....Of course some work and some are just profitable.
"Let's argue. Let's have the great American debate about the role of government and the best policies for the country. It's fun. It's activism. It makes the country better when we have these debates. And your country needs you. It needs all of us. But two things disqualify from this process: You can't threaten to shoot people, and you have to stop making stuff up." - Rachel Maddow

ladybear77872 · Nov 25, 2013

As a fellow nurse and one that suffers from chronic pain. I will say this. Because a surgery is not expected to be painful does not mean that this is the case with Every patient. Blood pressure is a useful tool when assessing pain. Goofy smiles can be because the patient may have just recently taken a dose of pain meds. But if they admit to you that they're going to say it's a 10 because they like the medicine. They should be tapered off and referred to substance abuse counceling.

If it's assumed that the patient's pain is ALWAYS what they say it there are two major questions that arise. The questions arise because they are real-life situations.
1. A patient has had surgery that isn't expected to be painful. The patient has had 4mg of Dilaudid for pain that is reported as 10. The patient has a goofy grin and says: "I'm going to say that my pain is a 10 because I like pain medicine." (This actually happened)
Do you continue to administer Dilaudid in this situation? Do you take his report of pain at face value? I was advised by my co-workers to send the fellow home and I did so.....He left smiling......Did we do the wrong thing?
2. A patient is close to being in a Dilaudid coma after receiving 10mg of Dilaudid. The patient appears very comfortable and, when awakened, rates his pain at 10. (This actually happened)
Do we have a pain emergency here? (I've seen many situations that are clearly pain emergencies but this one doesn't seem to be a pain emergency.) Can you in good conscience send the patient to the floor with a pain of 10 under these circumstances?
O.k.....I asked more than two questions but the other questions are tied to the main ones.