I give a lot of pain medicine to my patients, but from everything I am reading I am not giving enough. In the last week I gave pain medicine to the following:
1. An 80 year old man with a compression fracture of the lower back. He slept all the way to the hospital.
2. A 69 year old woman with sciatica. Her 10 out of 10 pain and inability to get out of bed went down to a 5 and she was able to stand and pivot onto the stretcher, but still grimaced throughout the ride.
3. An 86 year old man with the worst abdominal pain of his life. He was still in pain, but perhaps no longer in agony. Pain went down to an 8
4. An 11 year old girl with a possibly fractured ankle. She stopped crying, and seemed sad, but calm.
I did not give morphine to:
1. A 62 year old woman in a minor motor vehicle, who claimed shoulder pain. I saw no deformity, but she seemed to have trouble moving her arm over her shoulder. She cried when we moved her off our stretcher onto the hospital’s bed.
2. A 37 year old woman with knee pain (no deformity) from a minor motor vehicle who looked me cold in the eye and told me her pain was “A ten.”
In retrospect, I should have given more to the 69 year old with sciatica, and I should have given it to the woman with shoulder pain.
My preceptee, who rode with me on a couple of these calls, when he started riding with me, was at first shocked, and then gradually came to accept and understand the need to properly medicate patients. After a call in which he failed to give pain meds to another elderly man with a compression fracture, telling me he was more conservative than me, and that the man’s pain was not that bad, and that the man did not seem to be in agony (So we now have an agony scale? I questioned later), I had him read the following powerpoint bt Dr. Bryan Bledsoe.
Note: It is a long download.
Fortunately our next call was the 80 year old man who also had a compression fracture, and my preceptee was able to compare the two calls and 1) the relief the patient recieved and 2) the satisfaction he recieved knowing he made the patient feel better.
I have been reading an excellent book called Pain Management and Sedation: Emergency Department Management.
It is a book intended for ER Docs, but I think any book written for an ER doc can only benefit a medic. It has some fascinating information about the damage acute pain can do to a patient.
“In addition to the obvious moral, ethical, and legal/regulatory reasons to treat pain adequately and expeditiously, failure to properly treat may make it much more difficult to treat future pain and may increase the likelihood of developing chronic pain…There is evidence that inadequate analgesia and /or sedation leads to worse clinical outcomes and more complications. A possible pathophysiologic mechanism for the negative effects of inadequate analgesia/sedation may be an excess of stress hormones causing catabolism, immunosuppression, and hemodynamic instability.”
“…Early and aggressive therapy for acute pain holds the promise of preventing or ameliorating physiologic changes that may set the stage for prolonged or chronic pain states. A great deal of work remains to be done in this area and despite these considerations, the treatment of acute pain and suffering is justified in and of itself.”
There are also chapters on opiod dependent patients and sickle cell anemia patients that will make you think twice about withholding meds on suspicion on their being drug seekers, which I will address is later postings.
I’ve been really involved in capnography lately; I think my next teaching/learning project will be pain management. I owe it to all the patients I let suffer in the past, not knowing any better.