"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"

Tuesday, September 27, 2011

Ohhhh, the Agony.

Dilaudid. Percocet. Morphine. Fentanyl.

The four most common painkillers I've seen thus far administered to patients in my hospital. I have never taken any of the above, but supposedly, they work pretttttty well. I've seen many reactions, some sleep for hours and hours, some go into la-la land and act like they are 5 years old and don't remember any of it, and I had a patient yesterday who went from being a not-so-social elderly gentleman to a guy that suddenly was talking my ear off, thanks to dilaudid.

In this day and age, hospitals are so drastically focused on their ratings, their scores. With so many hospitals being built in this day, patients now have the ability to choose (if they are lucky and its not an emergency) where they would like to be a patient. Smart patients check the hospitals scores before they choose. How does this hospital score in cleanliness? In nosocomial infection rates? In service? In food? How about pain management. Well, lately hospitals have been noticing a decline in scores because of one thing: Lack of effective pain management.

Okay, so then what? Well, hospital management teams revolutionized their thinking. We know now that a hospital is a business. Patients are the "customers", and as the old saying goes, "the customer is always right". So in our book, the patient is always right. This has been brought down to nursing care so much so now that we are trained to always ask about pain. We ask when we take your vitals. We ask when we stop in on rounds. We ask when we take you to the bathroom. We ask in the middle of the night when we switch your IV bags. We ask so frequently that sometimes I think we plant it in your head that you do in fact have pain!

I'm all for effective pain management.  No one should have to bear unmanageable pain for any length of unreasonable time. But sometimes we as nurses (and doctors) will never truly know if you are having pain. I have had many different types of patients: Those that I think are in true pain but are too proud to admit it and needing a painkiller, those that I doubt the true pain and yet are on the clock the minute they are due for the next dose, and I've had patients that fabricate ailments just to get a pain medication ordered. The other day I had a young gentleman as a patient with a bad case of cellulitis. It really did look painful. He had Morphine and tylenol ordered. He started complaining of pain, and I asked- Do you want your morphine or tylenol? To be honest, given his age, I half expected him to answer Morphine. But he actually said- "I took morphine last night and I don't want to overdue it. So I think I'll go with the Tylenol today." I was pleasantly surprised.

The other week we had a patient on our floor that, in the middle of the night, complained of awful pain in her chest. Being chest pain, of course we have to go through all the steps to diagnose the cause of the chest pain. We need Oxygen, we need chest x-rays, we need respiratory therapists, we need doctors...etc. Well eventually they gave her Morphine and she was as happy as a clam, went to bed, and the pain never appeared again. Now, did she have the pain in the first place? Maybe. Probably. But who is to say?

Recently I had a patient who was addicted to Fentanyl. So addicted in fact, that she overdosed. While in our care, she also came down with severe chest pain, and shortness of breath. Well, her team of doctors were hesitant to give her anything too powerful for the pain because of her history of multiple opiate addictions. However, what if the pain really does exist? We couldn't let her suffer either. So, we found a painkiller that is effective and less addicting (much to her dismay- she was after Dilaudid) and ran a chest x-ray. Turns out she had a pretty bad case of pneumonia, so the pain really did exist.  

I've had patients that are fine all day and then when the doctor comes, suddenly they are keeled over in bed and in agony, asking for pain medication. And then the doctor leaves, and then they are on the phone talking or watching tv.  And the best we can do, as nurses, is to therefore document what we see, what we observe on the patient, all day. The doctors read that. They read when we write, "patient resting comfortably in bed, denies having any pain", or "patient complaining of severe pain in mid-upper back". And its critical that we document that we followed through with that pain, and document we gave them something and what the reduced pain level was after. Its all about documentation.

Just a year ago, when I spent a week in a hospital myself, I was having some severe migraine pain (thanks to lack of sleep, stress, anesthesia recovery, etc). Well, they gave me a medication for the pain called "Toradol", which, is one of the ones that is pretty strong but not addicting. I guess given my age, they went with that because it was less addicting. However, I didn't even know anything about Toradol- all I knew was that I was in pain, and that helped the pain. Did I want the toradol when I wasnt in pain? No. Did toradol make me feel like I was on a cloud? No. It made the pain go away. Thats all I wanted, and thats all I want for my patients.

I've also encountered the situation many-a-times when a patient is dying, like literally on their death bed, and are in a lot of pain. And then the doctors are afraid to give powerful painkillers because they are "addicting". That drives me crazy! So what! They are dying and are in pain! Who gives a flying shit if they will be addicted? It won't matter! Get rid of their pain for crying out loud, no one should die while in pain. They fight over that and yet give Fentanyl to 20 somethings. Go figure.

Just recently I had a patient with a severe leg injury that resulted in a very large hematoma that had formed into a very grotesque blister, bigger than two of my hands together. It looked really painful and I was constantly asking if he needed anything for that. I would have given him something in a heartbeat without question if he asked. And then we have the all to common patient with "invisible pain" (abdominal pain, headache pain, muscle pain, back pain,etc.) And I don't think they are lying, they probably do have pain. But it definitely is a fine game to play. They probably thought when I was in the hospital that since I was a young twenty something, I was making up the migraine and was looking for some painkillers while I was there.

So, just goes to show that there is no way to truly know. We as nurses want to give effective care. So if the patient is in pain, we administer pain medication. It is not up to us to judge whether or not they really do have pain or what their ulterior motives are, if any. We just make them feel better.

With love,

A Writer in A Nurse's Body

1 comment:

WNB said...

I'd like to officially add to this post by stating I gave morphine and dilaudid 5 different times today. To two different patients. Roommates. I think they were having some sort of pain competition, who could ring faster for the next dose?? Geesh, it's just....Oy.