Of Pain Control, Teaching and Intimidation

For some strange, inexplicable reason, my internet access just died.

Just up and died.

And in just as strange fashion, it came back from the dead.

Totally bizarre.


Speaking of bizarre, ever have patients who complain about their pain being a "12/10", grimacing and carrying on, demand pain medication that-I-wanted-yesterday ?

Same patient who, upon bringing said pain medication, is found snoring away in bed with drool dribbling from mouth?

The very same patient, who, the next day insists to the physician that s/he has had a "horrible night in pain", was "ignored by the nurse. He never gave me a damned thing for my pain!", and claims that the "Darvocet did nothing for my pain!" - despite having being found as above... snoring in bed with drool dribbling from the mouth?

Well, I'm sure some of you somewhere have met this patient.

I'm just talkin' because it seems that off late, 5 out of my load of 7 patients per night seem to be of this kind. The gorked-out-of-their-minds type who demand more and more meds and then wonder why the hell do they feel constipated, bloated, nauseated and "funny".

Speaking of constipated and funny - how about the ones who demand opiates because their "stomach hurts". Yeah, it hurts. It hurts because you've been doping yourself on so much pain meds that you've got "gas pains". Taking more morphine and lying in bed ain't gonna help - it's only gonna make it worse.

It is, of course, at this very point then that you are accused of being a "mean nurse". I think people in general don't like being told "No."

Don't get me wrong. I acknowledge that a hernia repair can be painful. Hell, someone just cut you up and sewed you back on. I know it hurts. And for some of you, it's probably the worst pain in your life. Alls I want folks to think about is that every med and every intervention carries consequences and risks. I find it distressing that so many think their post-op recovery is going to be "pain free" - even the ones who end up getting say fusion surgery from T1 to L4 vertebrae because of scoliosis.

Dude, you just had a 14 hour surgery where they ripped your back and built you a new one. Do you honestly think you are going to be pain free?

And of course, you have the concerned, worried family.

Concerned Girlfriend: "Can't you see he is in pain? Why don't you give him his Xanax?"
Spook: ('Ummm, yeah. Xanax for pain control on a post-op ACF guy. That'll work!') "Ummm. I'm sorry but I haven't assessed the patient yet. I need to see him and assess him before I can intervene".
Concerned Girlfriend: (annoyed) "But he's hurting real bad! How can you just sit around and do nothing?"
[I was faxing med orders to pharmacy. Unless pharmacy has med orders, I can't even pull out a Tylenol, much less the PCA and Dilaudid bolus per orders]
Spook: "Ma'm, I'm sorry but unless I assess his condition, I cannot and I will not intervene. He can end up having complications that could be potentially fatal. I'm not going to risk his life for wont of patience and time. I understand you are concerned about his pain, but you have to let me do my job."
Concerned Girlfriend: "That's so easy for you to say! I don't think you understand at all!" (Twirls on heel and walks away in a huff).

Barely 5 minutes after this conversation, patient has had a 1 mg bolus (instead of the 2 mg ordered) of Dilaudid, a PCA set up and explained and pain down to a 4 (and falling). All it took was 5 minutes - yes, I realise, 5 minutes of pain... but it was 5 minutes that potentially prevented a serious complication.

I actually like assisting family members in dealing with their loved ones illness - teaching is a secret passion of mine. Symptoms (such as pain, fever etc.) often tell a wide and varied story. Rather than jumping at the first sign of a symptom and attempting to "cure it", it's better to assess and think for a while. This is why, for example, I prefer to give Toradol to my hysterectomy patients rather than the Morphine ordered for their abdominal pain because it has been my experience that the anti-inflammatory action of Toradol kills their pain better than the masking-opiate effect of morphine. Also, if the Toradol doesn't work, I at least have the stronger dose of Morphine to fall back on.

Now if Concerned Girlfriend had given me 30 seconds of her time, I could have patiently explained me reasons to her. But she didn't and all it made for was an unpleasant experience necessitating a rant on my blog now.

Family members who follow you around with a notepad and pencil, jotting down everything and anything you do, waiting for you to make a "mistake" really get on my nerves. It destroys the atmosphere of mutual assistance and trust. Not helping anyone and least of all the patient. If you have an issue with the way I work, please pull me aside and bring it up to me. If we can't resolve it, I'll direct you to my boss.

But please. Please. Please, don't try to "intimidate me". It doesn't work. I don't get "intimidated into doing my best" - I just get royally pissed off.