I take your point, certainly. If such an unlikely thing happened, I’d try to get the thing back ASAP. The PCA seems (admittedly a subjective measurement) to work enormously better than the regular practice of having a nurse show up every 4 - 6 hours and give her a larger dose. She can delay the medication to get a chance to talk with her visitors or just give the thing an extra push when she wants to sleep. I can’t recommend this thing highly enough.
Regards
Testy
During my last pregnancy, I spent 2 months in the hospital because my cervix, which should have been 4cm long, was 4mm long. They were afraid I’d deliver precipitiously any day, starting at 24 weeks. Every week, the doctor would take me off to a special room and check my cervix. She preferred to do the exam manually. The manual exam hurt me beyond description.
I said, it hurt. She said, soothing/placating, “I know it’s uncomfortable…”
I said “No, listen to me. Don’t try to comfort yourself with words like ‘uncomfortable’. I’m telling you it’s EXCRUTIATINGLY AGONIZING, and if there’s ANY alternative, like the ultrasound wand, then please do that instead.”
Her eyes got big. She said “…oh. Well if that’s the case, then I won’t do it that way anymore, and I’ll tell my colleagues the same.” And she was true to her word. But it took me saying so in words she could not brush off, ignore, or somehow explain away. Then she was very solicitous about my comfort level. Previous to that, one of her colleagues hurt me so badly during an exam that I lay shaking and crying on the bed…and she never so much as apologised. She acted like it didn’t happen. I never let her touch me again, it was like rape. But, you know, it didn’t matter if it hurt me, right, because the only thing that matters is a healthy baby and it was all for the best, etc.
Thank god I finally found my voice and made the one doctor understand what my experience was, because she was an angel to me after that.
I am in the early stages of research (the “figuring out who I should talk to” stages, to be precise) for a book on the subject. It really is fascinating to me.
Then we are not really talking about the same thing. Having seen other doctors in action in my own hospital, I couldn’t agree more that most doctors use too little pain medicine in the hospital setting. (They also use way, way too many antibiotics and don’t give nearly enough IV fluid most of the time, but that’s another rant.)
I’m on the other end, in the primary care office, where plenty of people tell me that they have been in flesh-tearing, worst-imaginable 10/10 pain every second of every day of their lives for the last five years, except for the days when it is far worse than that, and no other doctors will “help them” by putting them on four 10mg Lorcets a day. They are allergic to every non-narcotic pain medication in existence; I sometimes ask them if a doctor has ever tried Remoulade, and you’d be surprised how many people had near-fatal adverse reactions to it despite the fact that it’s a mustard-based Cajun sauce that’s tasty on shrimp.
(I actually had a woman try to tell me once that she was allergic to the 5mg Percoset, but she could take the 10mg OK.)
In short, drug seekers are an everyday thing for me. I have to do everything I can to weed out the obvious malingerers and outright liars, but I’m certain that a lot of the opiates and benzos that I give out end up being misused, snorted, or sold. I’m comfortable with that, because the alternative is erring on the other side and withholding meds from people who will use them correctly and benefit from them.
I was about to wonder why anyone would choose to take Percocet for fun, as my experience was that it made me itchy and very constipated, but then I remembered the Saturday after my Tuesday surgery. (Distal radius fracture – I had an internal fixation done.) By Saturday, the pain had really lessened, and I thought I could do without the Percocet. I did manage okay with the pain in the morning, but I was so freaking depressed that I ended up crying by noon. Mr. Lisa kept trying to gently suggest that maybe I should take a pain pill, but I kept sniffling and insisting that wasn’t the problem. Then I decided to check the patient info which came with the script, and lo, you’re not supposed to abruptly stop taking Percocet. I took a dose, and man, when it hit my system, the feeling of well-being was just fantastic. I could totally see how someone could get hooked on it.
I tapered off over the next week or so, going from three doses a day, to one dose in the morning and one at night, to one as needed, and eventually down to Tylenol 3 as needed during occupational therapy.
Did any of you see the movie ‘The Doctor’ with William Hurt?
About this doc who gets cancer and notices for the first time what’s it like to be a patiënt.
All the pain and indignaties his patiënts suffered, he is suffering now.
I don’t mean to imply that all doctors ought to break an arm now and then, to feel what pain is like 
, but I too would appreciate it if they’d stop using words like ‘uncomfortable’, or some discomfort.
My son had to get his first injection and he heard a lot of children crying, so he asked: “Will it hurt?”
I told him it would hurt like hell, but only for a little while.
I had no problem with him whatsoever.
Some people prefer honesty, you know.
I’ve had exactly the same experience with my daughter when she was small. For drawing blood and the like she’s sit in my lap and when she asked if it would hurt I’d tell her “Sure, they’re going to poke a hole in you and suck out some blood.” She’s sit there very quietly and not even whimper.
On the other hand, when she was about 5 or 6 she got dysentary in Thailand and the hospital folks wanted to hook her to an IV but didn’t explain things. I wasn’t there but kiddo fought her mother, one doctor and a nurse to a draw. They finally decided that if she was that lively she probably didn’t really need the IV. 
Regards
Testy
That is interesting about the IV fluids. Do you usually find people are dehydrated or do they get that way while in the hospital? Dehydration is a big deal in Riyadh where you never obviously sweat and if you aren’t careful you wind up like a raisin.
As an FYI, Eastern Kentucky is no different on drug-seeking behaviour. Everybody and their dog is on benzo-type drugs or some kind of opiate. Maybe Ky. is just depressing.
Regards
Testy
Another tactic is for someone in legitmate pain to go to several doctors to get the exact same prescription – so they’re really in pain, but gathering a hoard. Some for now, some for later…
THEN you get the old person who decides to just take half their heart pill, either to save money or avoid supposed side effects or … well, I don’t pretend to understand the whole mindset.
Then there’s the taking of other people’s medications… when we go down there and there’s a substantial family gathering we usually keep my husband’s perscriptions locked in the car. Pain pills, diabetes meds, whatever - someone will get nosey and, quite frequently, help themselves.
I just do NOT understand that sort of behavior.
If I may add to your most excellent scale:
3 - Wish for Death.
You might want to Google the “KIP Scale.” I have cluster headaches and used to use it. It is also a 1 - 10 scale where 1 is no pain at all and 10 is where you start seriously thinking about suicide to stop the pain. Strangely, opiates don’t work very well on this kind of pain anyway. I don’t know why.
Regards
Testy
Doctor J, I appreciate your contributions to this thread. I am glad my first impression was wrong.
2 usually implies 3, Shirley, but, okay.
Am I the only one here who thinks my pain is no one else’s bid’ness but my own? As for meds, I’d love to ask my doc just to tell me how much’ll kill me and then leave me alone. I’ll promise not to sue and everything. Honest.
I won’t really ask him, of course, but as a patient, I am greatly weary of this whole conversation. [Note: I very rarely take narcotics, only triptans and preventatives].
Had good and bad doctoring for 62 years now. Had chronic pain and dentist pain and blood and guts pain.
Took a wreck in 96 to find the doc that I will trust and knows what is what.
Why and how you might ask.
Well, he has the ability to read me and understand me. Paid attention to my history and the way I talked about it. So I get no lies, I get sent to other docs a lot because he is a orthopedic surgeon and does not do general medicine ( he does make exceptions for me because I am one of his stars. LOL ). He understood my addiction problems for the get go and never downplayed or lied to me.
A doctor in an ER usually does not have this advantage. Well, doc Ron never did before the first surgery because I was not in a condition to talk much. But as soon as possible he did. We are still in sporadic contact by email to this day.
I was an unusual medical case and so he got a bit of notoriety from me.
I have learned to be up front with the docs and to stop them and make them listen. If, when I say, “Doc, stop reading the chart and listen to me.” And the doesn’t, if I am not dying in an ER, I go to a different doc. The not listening is the biggest failure across the board that medical; people have IMO.
I have spent way to many years in pain to fall into that trap again.
I live with chronic pain now, do not take meds for it and am doing just fine. When you get the kind of bone damage that requires prosthetics and replacement surgery, you will have chronic pain. You learn to hold your body different, even if it is just a bad toe A whole shoulder and all the muscles there of turned into hamburger is a really good way to find out…
The brain can tune out a lot of chronic pain. But the brain and body will compensate and an observant doc will see that and it can many times tell them more than the patient can.
I have found that communication is the key and while it should be a two way deal, it isn’t most of the time so I take that responsibility upon myself and do not give the doc a choice. He will get the information or if I am unconscious, my advocate will pull me out and get to one that will.
Just remember that lying to yourself and to your doctor can be the most deadly thing you can do.
YMMV
Dunno 'bout the abx,but I am with you on the fluid. I had a 100 year old pt yesterday with possible small bowel obstruction and an massive hernia–he was on 1 liter q 12. He had an NG-and the drainage was so thick–he is so dry. (IMO, most old folks are walking around at least partially dehydrated, when they are not fluid overloaded d/t CHF etc). Here’s a taste of some common pain “management” that I run across: He was Tordadol 15mg IM q 6. This was not touching his pain–all I managed to do was get his Toradol increased to 30 and got Demerol 25 mg IVP q 8 added. Supposedly, he is “allergic”* to morphine, so that was out. I do hope the noc nurse pressed for Dilaudid.
*I asked him (he was sharp as a tack, BTW) what happened when he gets morphine and he said he gets “silly”. <sigh>
This made me laugh. I had no idea that rural southern areas were glazed over in a
haze of opiate-induced stupor…I bet when that is added to the alcohol problem, things must get “fun”.
Note: re the PCA device. These are a godsend to most post-op pts. Then again, most post-ops are awake and alert, and able to understand the PCA use and do it correctly. But, they can be used inappropriately. Testy is correct in that a small, constant stream of analgesia does work better than larger (and that larger is open to debate) doses spread apart. As a nurse, I can tell you that I would rather my alert pt have a PCA, and I will intervene for breakthru pain, if any, rather than having to juggle the timing of the “pain shot” with the care of 3 or more other pts-all who needs of the same, if not higher priority. (sorry, another thread).
I’ve enjoyed the back and forth of this thread and there is much insight and wisdom to ponder in this thread regarding treatment of pain. However I have a different contribution regarding the issue raised by the OP…
With the benefit of maturity and introspection, enforced or otherwise achieved, I have discovered what I believe to be a plausible explanation for why we doctors and other healthcare professionals use the euphemistically inferior term discomfort rather than pain. And, I don’t think it is because we are willingly trying to deceive – I think it is an emotional imperative for us.
My thought: doctoring, particularly doctoring in which procedures are involved, requires the knowing and willful infliction of pain on our patients. We do it purportedly for good, but there can be no denying that we recognize at some level that at that moment in time, we are individually the person who is actually causing that pain. In order to knowingly inflict physical pain on another human being, we use the term discomfort to temporarily distance ourselves from the humanity of the person we are hurting. By discounting pain, we are thus able to inflict it.
Hummmmmm, now that is a good point… Might be onto something there.
Sorry, but I don’t really want a doctor who’s “emotionally distanced.” The point is for the *patient * to feel better.
Better you should recognize and learn to deal with the fact that you sometimes have to inflict pain. Yes, pain. NOT discomfort. Then you will be more certain that you are only doing so when it’s really needed. And you can be honest with your patient.
The alternative is the all-too-frequent repeat blood samples, catheterization and other procedures without considering alternatives. Or in the case of the OP, appropriate communication. Surely you’ve read enough in this thread to know how negatively miscommunication affects patient outcome.
Sure, you can’t get all emotionally involved with the suffering of the patient, and when you go home at night you have to leave your work at the office/hospital.
Osler --I think you make an excellent point.
We have come far in pain management (believe it or not). My father, who went to med school in the '50’s was taught that small children have “underdeveloped nervous systems” and so could not feel severe pain. He also never had a nutrition class.(tangent) :eek:
Nursing wasn’t much better, really.
We need to do more, but we are not alone in this. The pt must advocate for her/himself–or a family member/significant other should, if the pt cannot.
Pain is now referred to as the 5th vital sign, after heart rate, respirations, BP and temperature. Hospitals get dinged when Joint Commission comes to audit them if there is no pain scale in use (whatever their limitation, they are a start in the right direction), for example.
So, it is better than before. And we are learning all kinds of things about things like phantom pain and the cultural impact on pain and its expression/perception.
I don’t think that most pts want their doctor (or nurses) to hold their hands and make it all better–I do think that most pts want some honesty and some recognition on the part of the health care team that they are suffering(I am referring to acute pain in a hospital here-but the same is true as an outpt, for the most part).
Some clarification might help advance the discussion. My post said “plausible explanation”, not “justification”. I’m certainly not trying to justify what has been properly vilified in this thread. Misleading a patient about pain damages the healing relationship, period. Perhaps though, my explanation could be seen as a glimpse into the psyche of the physician who is confronted with the disequilibrium and discontinuity of attempting to render care while knowingly causing pain. Recognition of why we might say discomfort when we mean pain might be the first step to “dealing” with the fact that we inflict it, and becoming more honest with our patients.
And actually, I do think that you want a doctor who is “emotionally distanced”, but the kicker is “appropriately emotionally distanced”. Struggling with the delicate balance of objectivity and empathy is a lifelong task for those of us who value the relationship part of the healing dyad. It is my obligation to try to find that balance, but certainly even after more than 20 years of practice, I still fail at times because it is never the same from patient to patient. But when the doctor finds that balance (for you or for me when I am in the reverse role as the patient), that’s what we equate with good bedside manner, it engenders trust, and its presence becomes a healing force of its own. It is no coincidence that new accreditation standards for all post-graduate medical training programs in the US includes a mandate for demonstrated competence in communication skills.
Well, that’s good news.