Ok, sure, sometimes you shouldn’t prescribe pain-killers. I totally get that. What I don’t get is why most doctors seem so proud to be hard asses about pain control. I get the feeling that to say that a doctor is easy on pain control, or quick to “give in” to patients is the worst thing you could possibly say. On the other hand, to describe them as “tough” would be a compliment. I have known several doctors who talk about prescribing pain meds as “giving in” which to me is very telling. I also think Doctor J’s callous remark on the first page of this thread was very telling.
By the way, when I had chronic pain (bulging disc) my MD was happy to give me pain meds. They didn’t work and made me drowsy, so I pretty much quit taking them except to sleep, but my bitterness doesn’t come from my experience as much as watching my patients get mistreated when I worked as a psychologist in a hospital.
I should know better than to make a flippant post and then leave for the weekend. I can see how Brynda’s conclusion might have been drawn from my remarks, but it couldn’t be further from the truth.
I just don’t find pain scores to be that useful. Their only real utility is in a single patient over time, but I don’t consider them any better than the patient simply telling me if it’s better or worse. At the extremes, they tell me a lot about the patient; you sometimes see a patient clearly incapacitated by pain who calls it a 6/10, and another who interrupts his laughing and playing with his kids to tell me of his 12/10 pain. That isn’t to say that the second patient isn’t in pain and doesn’t need some sort of treatment–the number just tells me absolutely nothing about it.
And yes, I believe that most people who describe their pain as more than 10/10 are overplaying it. I can’t believe that’s controversial. That doesn’t mean I don’t treat them appropriately. I also believe that people who describe their pain as 1-2/10 are underplaying it.
I take pain treatment very, very seriously, and I treat it aggressively, especially in the acute setting. My treatment has nothing to do with an arbitrary number that I’m given.
I can’t decide if you’re in a fantasy world or if my part of the country is simply that much different than everyone else’s.
My neck of the woods (eastern KY) is considered by most to be the worst area in the country for prescription drug abuse. You’d be hard-pressed to find someone who doesn’t have a close relative (first cousin or closer) who is addicted to one prescription drug or another. It’s a part of our culture; if you stopped ten people in our local Wal-Mart, I’d bet that seven of them could tell you what doses Vicodin and Percoset come in, and three of them could probably tell you that a 5mg Percoset goes for about eight bucks.
We have a system that tracks scheduled prescriptions in our state, and a doctor can pull up a list on a patient almost instantaneously. How often would you think I’d kick someone out of our clinic (or, at least, deny them scheduled drugs) for getting narcotics or benzos from multiple providers? Every couple of weeks? Once a week? Try once a day, at least.
So when you have a constant stream of healthy young men and women come through your office describing their pain (without me asking) as 10/10, then you can get high and mighty about the way I treat pain.
I am not a doctor/nurse, but from my experience in hospitals ( much more than average, but not to the level of Ubervisitor.) From friends that are Nurses and doctors, if they can make noise they don’t worry nearly as much as the ones that quiet and stone still.
Still, if you want fast service at the emergency, I highly recommend puking everywhere, ah la Carrie style.
1st class ticket to your own room or personalized attention ASAP.
Because some patients have pain and don’t complain about it.
Either they’re not complainers by nature or they don’t realize their pain isn’t normal and that it can be treated. Or it just doesn’t occur to them to bring it up or they’re embarrassed because of the location of the pain. No matter what the reason the patient has for not complaining, if the nurse or doctor asks about it, the patient will admit to it (if it exists), and diagnosis and treatment can be initiated.
A good example of this is arthritis in older patients. Some think arthritis is a normal part of aging and don’t bother to say anything, so they treat themselves. When the nurse or doctor asks about pain, the patient may tell him/her, who can then prescribe better medication and treatment.
Paprika --and I thought you were indirectly accusing me of having a hard ass attitude towards overmedicating pts.
We are posting at cross purposes.
I have only visited Appalachia, so have no knowledge of the drug seeking behavior there. I also do not work ER, so don’t see Joe Blow off the street who comes in for whatever.
My comments are based on 20 years of acure critical care experience–I am familiar with the articles that Paprika kindly linked to. Post-op pain, pain due to recent injury, pre-op pain, acute new onset pain, chest pain etc–these I know well.
Chronic pain and addiction-not so much. Dia knows we have enough admissions that have some kind of “habit”, usually alcohol, and we get our share of opiate addicts.
Call me a naive fool, but I still say that the “drug seeker” is IN pain–just not physical pain, perhaps. Or perhaps they are self-medicating the depression brought on by suffering from an untreated chronic pain. IMO, this is an ignored portion of the population–and one that is incredibly hard to deal with as a caregiver. They’re whiney, they’re manipulative, they’re demanding and they act out-meal trays are thrown across rooms for example, and most seriously, they’re litigious. Health care workers usually have to walk a fine line of setting limits but also helping the pt. And so many of them do NOT want help via AA or NA or whatever. So, it’s a problem.
Would that this were true. I cannot tell you the many many times that the elderly have complained of “soreness” to me–and I tell the doc. Doc goes in to see pt and pt denies any pain or soreness at all. Nurse looks like a fool. Nurse goes back in after doc has left and elderly pt says to nurse–“I didn’t want to bother that busy man/sweet young woman!”
Oy. :rolleyes:
We nurses ask about pain because that is part of our basic assessment of the pt. We not only want to know IF you have pain-we want you to describe it in terms of quality, intensity and duration. Does movement help or make it worse? etc etc etc. Once you tell us this, we go to doc and state that Ms Jones complains of abdominal pain 8/10, it is a stabbing pain in her left lower quadrant, seems to come in waves and walking helps alleviate it.
This gives doc a whole lot more to go on than Ms Jones says she hurts.
The nurse should also follow up with the pt after a painkiller is given. Did you get relief? Relief does not mean no pain at all, sometimes.
When it comes to chronic pain, I have found that many individuals somatize nearly all of their mental, spiritual, and emotional pain into physical pain. (NB: This should not be construed as saying that chronic physical pain doesn’t exist)
Getting them to recognize that fact is very, very difficult.
The best thing I’ve seen for acute pain is what my wife and I call the “morphine machine.” Whenever she has surgery (she’s had 3 thoracic and 2 abdominal) the doc wires her to a neat little machine and allows my wife to control the analgesia.
It seems to work extremely well. My wife never uses more than about 25% of what is in the machine and yet she suffers very little pain. The machine usually contains fentanyl and works extremely quickly when she pushes the button.
It seems to be the best of both worlds but I don’t know how common this is.
Testy --they’re called PCA or Patient Controlled Analgesia over here. They can be a godsend to most pts, but they are not without dangers and dilemmas.
Ethical question: if pt has a PCA device and is unable to communicate pain(or communicate at all) to the nurse or doctor (for whatever reason)–should the health care provider push the button that releases the analgesia and provide relief for the pt that way or is that medicating a pt without his/her knowledge or consent?
Thanks QtM -for the pithy summary. I would also say that somatization happens because alot of people lack insight and vocabulary with which to describe and/or analyse their situation.
Absolutely not. It isn’t so much inethical as it’s a misuse of PCA; a patient who cannot communicate pain (or who can’t push the button himself) should simply not be on a PCA pump. That patient should just be on scheduled doses of pain medicine.
I agree with you–but there was a big brouhaha in nursing a few years back about if pts aren’t using the pumps(and are in pain), should nurses be pushing the buttons for them…I probably shouldn’t have put the bit about unable to communicate in there. Anyway, it was a debate, and like most, was not resolved completely.
I also think it’s an inappropriate use of the device and pain relief should be obtained by other means (in the above scenario with the pt unable to communicate).
Whew. I feel a little better now about describing my broken wrist as a 7 or 8 while in the emergency room. Because that certainly was an accurate assessment of my perception of the pain based on Qadgop’s scale. The Percoset was great. My only complaint is that it took an hour or so to kick in once taken, and that the doctor didn’t give me a script for Vistaril at the same time. (I suffered through a few days of itching in a drugged out haze before it dawned on me to call and ask if there was something stronger than Benadryl to kill the side-effect itching.)
I would disagree with Dr. J on this one. If I weren’t there for some reason and a nurse thought my wife was in pain and needed her analgesia, I’d want her to go ahead and push the button. Yes, she admittedly didn’t ask permission but on the other hand, she didn’t do anything harmful and saved my wife some suffering. I’d thank her for it.
I wouldn’t think it would arise very often anyway. In our own case, when my wife gets out of ICU, they usually have the thing set to provide small, intermittant doses of fentanyl. (As Dr J says) In about two days, they rearrange the thing to give her the controls.
She has had one surgery where we depended on the nurse to bring her injections of some opiate analgesic and that was not nearly as satisfactory. It seemed to work out to larger doses at longer intervals. Now, it may be my imagination as I didn’t actually measure the dosages or medications, but she seems to use less of the opiate when she is controlling the PCA. Is that generally true? Sometimes true? An artifact of my imagination?
No doubt, having the nurse or someone else push the button on the PCA pump is preferable to the patient remaining in pain. What should happen, however, is that the nurse calls the doctor and tells him that the patient is unable to push the button for herself and therefore is not a candidate for PCA. The doctor discontinues the PCA pump and replaces it with scheduled doses of IV opiates at similar doses.
It’s called “patient-controlled anesthesia” for a reason; if the patient can’t control it, it isn’t appropriate.
The Percoset was great. My only complaint is that it took an hour or so to kick in once taken, and that the doctor didn’t give me a script for Vistaril at the same time. (I suffered through a few days of itching in a drugged out haze before it dawned on me to call and ask if there was something stronger than Benadryl to kill the side-effect itching.)