My Pain Philosophy

1) The smallest dose of narcotics that is effective in relieving pain is the optimum dose.

2) Higher doses of narcotics than are required to relieve pain cause problematic and sometimes dangerous side effects.

3) The optimum endpoint for a patient who presents to the ER with a painful condition is to be discharged in a pain-free state while also being awake, alert, and able to ambulate without assistance. Just like a normal person, in other words.

4) Some patients are not able to obtain relief of pain and still meet the criteria in #3, so compromises are often required in one or more of the endpoints. The preferences of the physician and the patient regarding the ideal balancing of these compromises (and the risks involved) do not always agree.

5) Some patients do not want to achieve the optimum endpoint in #3, instead desiring the euphoric side effects of the narcotics whether or not their pain is relieved. In fact, their desired endpoint is not exclusively pain relief but rather the state of narcosis. These patients refuse non-narcotic medications that are often superior pain relievers because pain relief is not their only goal (and occasionally not even their primary goal).

6) A patient's expectations regarding pain relief and the setting in which it is provided greatly affect the outcome and success of the visit.

7) A patient who comes in to the ER asking for a specific dose of a narcotic and gets it without an argument is likely to ask for another dose before discharge. A patient who asks for a specific dose of narcotic and gets only half of that dose (and is informed of that fact) is certain to ask for the other half 30 minutes later, but they usually won't ask for a third dose before discharge. Thus their total narcotic dose is minimized, and is therefore more optimal.

8) A patient who agrees to take whatever medications that my years of experience have taught me will relieve their pain will sometimes require no narcotics at all. But if they do require narcotics, the total amount will nearly always be less than the dose that they thought would be necessary, as long as they trust me and accept my promise that when they leave they will be comfortable. These patients will also be much closer to the optimum endpoint stated in #3 than any other group.

9) If a patient refuses that reasonable approach and still insists on getting "their usual shot," then they are probably a drug-seeker and will be treated with suspicion.

The Sixth Right?

A commenter ("poky") on another post suggested that letting a patient know what medication they were being given was one of the "5 rights." I believe this referred to the five rights of medication administration, which are: right patient, right drug, right dose, right route, right time.

I see nothing in there about letting the patient know what medication they are getting. Am I missing something? Is there a separate statute in the code of nursing ethics that states that an agitated patient has the right to know if they are getting Haldol instead of Ativan?

Are nurses also really required to inform their patients that they are only getting 2 mg of Dilaudid instead of the 4 mg they requested? Drug-seekers ALWAYS want to know how exactly much narcotic they are getting. Do they really have the right to know?

Hearing Things

Things I don't want to hear with a psychotic or demented patient:

1) He's climbed up on the roof of the parking garage.
2) He's thrown something at one of the nurses.
3) He's banging his head on the siderail.
4) "We can't find him."
5) Yelling.
6) Cursing.
7) Spitting.
8) The call light.

Things I like hearing with these patients:

1) Snoring (that means they are still breathing).
2) "The transfer has been approved and the bed is ready."
3) An ambulance crew arriving to take a patient from the ER. That's truly one of life's little pleasures.

Nursing Ethics

A decompensated psychotic patient who happened to be a large muscular angry man presented for evaluation in the ER. He was demonstrating auditory hallucinations, multiple paranoid delusions, and expressions of homicidal ideation towards various individuals who he perceived to have mistreated him (including the staff at one of the local psychiatric facilities).

The bottom line was that he was a scary tightly-strung dude who was potentially a danger to himself and others, and we happened to be not only understaffed but also without any security that night. So he needed to be sedated.

He was coherent enough to discuss his medication history, however, and he completely refused any antipsychotic medications. Over the years he had been given numerous antipsychotics, he said, and he didn't like the way they made him feel. He insisted he wasn't psychotic and got even angrier at the implication. He was willing to take a shot of Ativan though, so I asked the nurse to give him a shot of Ativan with some Haldol mixed in, but not to tell him.

The nurse refused to administer the medication without telling the patient what was in the syringe. Because we were able to verbally calm the guy down a bit and he didn't make any attempts to escape, I guess she didn't feel justified in medicating the patient against his will. And yet, if he had tried to escape, an ugly and dangerous situation might have occurred.

I don't think that a psychotic patient who is hallucinating and threatening harm against others has the right to know what medication I am going to administer to him. Heck, I'm going to be incarcerating him against his will as soon as I can get a court order, what's the big deal with medicating him against his will? But I've never seen a nurse not tell a patient what medication (and what quantity) they were giving when asked.

I ended up giving the shot myself. I skipped the B-52 and gave him a Big 10-4.

Nighty night.


UPDATE: Interesting blog reactions by GuitarGirlRN, Shadowfax, Girlvet, and ER Nursey

Merry Christmas

The Perception of Time

Why Time Seems to Slow Down in Emergencies
By Charles Q. Choi, special to LiveScience.com
(my new favorite website, but I can't find a direct link to the article, so I reprinted the whole thing)

In The Matrix, the hero Neo could dodge bullets because time moved in slow motion for him during battles. Indeed, in the real world, people in danger often feel as if time slowed down for them.

This warping of time apparently does not result from the brain speeding up from adrenaline when in danger. Instead, this feeling seems to be an illusion, scientists now find.

To see if danger makes people experience time in slow motion, scientists at Baylor College of Medicine in Houston tried scaring volunteers. However, roller coasters and other frightening amusement park rides did not cause enough fear to make time warp.

Instead, the researchers dropped volunteers from great heights. Scientists had volunteers dive backward with no ropes attached, into a special net that helped break their fall. They reached 70 mph during the roughly three-second, 150-foot drop.

"It's the scariest thing I have ever done," said researcher David Eagleman, a neuroscientist at Baylor College of Medicine. "I knew it was perfectly safe, and I also knew that it would be the perfect way to make people feel as though an event took much longer than it actually did."

Indeed, volunteers estimated their own fall lasted about a third longer than dives they saw other volunteers take.

To see if this meant people in danger could actually see and perceive more — like a video camera in slow motion can — Eagleman and his colleagues developed a device called a "perceptual chronometer" that was strapped onto volunteers' wrists. This watch-like device flickered numbers on its screen. The scientists could adjust the speed at which numbers appeared until they were too fast to see.

If the brain sped up when in danger, the researchers theorized numbers on the perceptual chronometers would appear slow enough to read while volunteers fell. Instead, the scientists found that volunteers could not read the numbers at faster-than-normal speeds.

"We discovered that people are not like Neo in The Matrix, dodging bullets in slow-mo," Eagleman said.

Instead, such time warping seems to be a trick played by one's memory. When a person is scared, a brain area called the amygdala becomes more active, laying down an extra set of memories that go along with those normally taken care of by other parts of the brain.

"In this way, frightening events are associated with richer and denser memories," Eagleman explained. "And the more memory you have of an event, the longer you believe it took."

Eagleman added this illusion "is related to the phenomenon that time seems to speed up as you grow older. When you're a child, you lay down rich memories for all your experiences; when you're older, you've seen it all before and lay down fewer memories. Therefore, when a child looks back at the end of a summer, it seems to have lasted forever; adults think it zoomed by."

This work could help better understand disorders linked with timing, such as schizophrenia. Still, in the end, "it's really about understanding the virtual reality machinery that we're trapped in," Eagleman told LiveScience. "Our brain constructs this reality for us that, if we look closely, we can find all these strange illusions in. The fact that we're now seeing this with how we perceive time is new."

h/t QKShooter

Gilding the Lily

From now on, whenever I think of Seaspray, I'll be reminded of her signature Bajingoland glitter.

Eating Flour

I've seen two different patients recently who admitted to eating flour right out of the bag with a spoon. One young lady said that she was consuming two pounds of flour every day, eating little else. That was her chief complaint...."I need help to stop eating flour."

Sometimes it would make her stomach cramp up, but she had no other complaints. She seemed like an otherwise normal person, but she was embarrassed about her addiction.

Some things they don't teach us in medical school or residency. Or if they did, the specifics have been long forgotten by your humble narrator. I remember the pica lecture, of course, but I don't recall the management part. So as with many situations that present to the ER, I found myself shooting from the hip.

Is she in danger from eating flour? Of course not...it's flour. Maybe it could cause a doughy bowel obstruction if she didn't drink enough water, or perhaps some vitamin/mineral deficiencies in the long-term, but it wasn't really an emergency. But since I am the caring, compassionate type of physician who always tries to help patients in need, I came up with the best plan that I could think of.

Her examination, lab tests, and X-rays were normal, so I recommended that she take a vitamin every day and try to taper off the flour (setting aside a limited and greatly decreased amount each day for her pleasure) while trying to introduce a more balanced diet. I recommended that she follow up with a Dietitian and a Psychiatrist.

I suspect this is a more common addiction than we realize, but less harmful than many.

The Angry Migraineur

UPDATE (12/18): Welcome spine-health message board visitors!

I'm not sure what I wrote that set this reader off, but he or she let it all hang out. Spelling errors, inappropriate use of the 'enter' key, satanic curses, graphically violent revenge fantasies about healthcare workers (me and Nurse K, primarily), and suicide threats. A cornucopia of crayzee.

Read it yourself (starting at the 19th comment). Or I'll save you the trouble of clicking:

Scapel,
You need to get out of the er.You are too much of a risk to be giving care there and way to uninformed.
How I wish someone would bang you upside the head with a frying pan every day when you get up and at least 5-10 times throughout the day when you least expect it.That pain still would not come close to what a chronic migraineur goes through that has a high level migraine constantly.(...)
I hope you become a migrainuer.I hope you get it so bad that it never stops.I hope it goes to the highest level so that you want to put a gun to your head to make it stop and that no one cares.And that they tell you that you don't matter.
I hope it for you and everyone with the same attitude that you have.I hope that it happens to you soon.I hope your life becomes a living hell,so that all you want to do is die.No one deserves it more.You are ignorant.You deserve the pain.And you deserve it now and for you to never get releif no matter what treatment you seek.
You are an educated idiot.There is so much information out there about migraine.But you don't want to be informed.You want to sit on a throne and judge.I hope the throne that becomes your closest friend is a toilet that you're dry heaving into.
You've made yourself judge,jury,and hangman.I hope I see you hanging right there with the rest of us.

and...

You really are a dumb ass.Take your degree and wipe your ass with it.Wishing discomfort,no,I don't wish you discomfort,I want you to suffer the tortures of hell.I want you to feel what you try to make people feel with just your words,let alone your ignorance.You are a disgrace to the human race.
I may wish this on you,but you bring it to people.And by the way,how the hell do you know what I do?You are a coward.
If I diserve this for wishing,imagine what you deserve you scumbag.
Oh my,big shot."That's the difference between me and you, and why I'm "in the ER" and why you are in the waiting room at the end of the line behind the truly sick and injured people." Truly sick,that would be you.The thought of you treating any paitient for anything is disgusting.
You are a self centered moron.And nurse k,chronic pain by definition is not an emergency.Define this.Stick your head in a doorway.Now,slam the door on your head about 20 times.How do you feel.Better yet,do it to scapel and don't treat him.
Migraine is a disease.It's not just chronic pain.
As I read scapel's idiotic writings,I'd say he's a disease that needs to be gotten rid of.
It's bad enough to put up with the pain,throw up for hours then have to face a pain in the ass like scapel.It's doctors like him that make people go home and slit their wrists due to the mistreatment he enjoys giving out.
He needs to be banned from coming near any patient ever.What a dumb ass.

Wow. I hope you get the help you need.

And thanks to KevinMD for the Kevilanche.

And here's some commentary by other bloggers that you might want to check out: WhiteCoat Rants, ER Nursey, The Physician Executive

Yup, He's Dead

So we were enjoying one of the "not so busy" interludes that have become increasingly uncommon lately, when we got a call from an ambulance crew en route to our ER. An elderly gentleman had been picked up from a local nursing home with agonal respirations. Fortunately, either he or his loving family had the foresight to sign an advance directive well in advance which declared that he was not to be intubated or suffer the useless indignity of advanced cardiac life support.

However, he stopped breathing on the way to the ER, and according to the paramedics his heart rhythm was as flat as a Texas highway. So they were calling us for advice.

"How about taking his body back to the nursing home?" we suggested.

The nursing home refused to accept him back. So we were forced to generate a chart (and in the process, a bill) for a patient who wasn't really a patient at all anymore. Still warm, but pulseless, apneic, and without any trace of cardiac activity. His asystole was so flat that I jiggled the lead for a second to make sure that it was actually connected, fooling the nurse into thinking he had a brief moment of fibrillation. Sorry about that. Time of death, 0945.

And despite the time that I spent on phone calls and paperwork, I couldn't bring myself to bill for the encounter. It just didn't seem right. The family will already get a bill for the unnecessary ambulance ride, the ER facility fee, and the funeral expenses. I'm not going to charge them more for someone else's mistake.

Why I Carry a Gun

I carry a gun because I can.

I carry a gun because I love my family, and I consider it my responsibility to protect them from harm. I value my life and the lives of my family more than anything else in the world. If we were ever threatened, I'd rather die with a gun in my hand than watch helplessly while the ones I love were brutalized.

I realize that I cannot depend on anyone else for protection. When seconds count, the police are minutes away.

I carry a gun because the safest place to keep a loaded gun is on your person at all times. An unloaded gun is as useless as a paperweight, and a gun in the safe is no help when you need a gun RIGHT NOW.

I carry a gun because even though I'm a big strong intelligent man, without a gun I would be no match for a drug-crazed skinny punk who had one.

I carry a gun because I have trained myself to use it properly, and I know that if required I would do so without hesitation.

I carry a revolver because when I pull the trigger, it always goes BOOM. I don't have to worry about a safety, or wonder if there is a round in the chamber, or whether it might jam. The heavy trigger pull ensures that the gun is not going to fire accidentally. Plus it is so lightweight, it conceals easily in a pocket without bothering me.

Texas Style

Among my most cherished fringe benefits of this job is the opportunity to get to know some of the people I admire most: the policemen, firefighters, and paramedics who are fellow links in the safety net of our society. I consider these men and women to be the ultimate VIPs and I would do anything for them, expecting nothing in return.

So I was totally surprised and deeply touched when after I treated an officer "on the side," he brought me a speedloader and some hollowpoints for my snubby.

I love Texas.

Letter from a Chronic Pain Sufferer

I get letters like this from time to time, so I thought I'd share this excerpted one along with my reply.

Doc,

During a flare where my pain is intolerable, how can I present myself at my local ER/ED to where I don't have to go through an hour of verbal jousting with the doc, even when I bring my pain contract and a personal letter from my neurologist explaining the situation and giving directions for treatment? I take along all meds with me, including the Actiq suckers so the doc can see when it was prescribed, when it was filled and how many suckers I have left.

You struck a chord with me with your comment to the effect of leaving someone in the waiting room for an extended time because they are seeking pain control.

I really am asking for your honest opinion here.

Thank you,

A Reader

First, I don't believe I ever wrote that I would leave someone in the waiting room because they were seeking pain control. However, someone with pain might have to wait in the waiting room a long time if we're busy and if they don't have a life or limb threatening condition. That's just the way it is. And if that person acts out or is rude or abusive to the staff, then they might wait longer than they would otherwise. That's just the way it is too.

Second, you should understand that ER docs don't take orders from Neurologists or pain doctors who aren't on staff, particularly in letter form. If you have a letter which either recommends specific heavy-duty narcotic treatment or is an open-ended "give him whatever he needs for pain" then you might be better off not flashing it around to everyone and expecting us to follow it like it were etched in stone, because it's just as likely to have the opposite effect. A letter that details your medical condition and some of your test results would be better received. There are plenty of unsavory doctors who write the first type of letter, and we hate them.

Third, I wonder what your goal of coming to the ER is. At best, you might get a shot or two providing a maximum 4-6 hours of relief, then you're right back where you started. If you come to a new ER with certain types of pain, they're likely to order lots of expensive tests to work you up for dangerous conditions, which will cost you a bundle and delay your pain therapy. You already have Actiq, and no ER doc is going to prescribe anything stronger than that for you to take at home. You might be better off trying to arrange better pain management from your personal physician.

How to present yourself if you do decide to come to the ER? Just be polite, be patient, be honest, and don't try to BS anyone. If you do those things (as it seems that you already are) and you still aren't able to receive appropriate treatment, then you should write a calm and rational letter to the hospital administrators explaining your dissatisfaction with your treatment. I don't think complaining to the administrators at the time of service helps much, and the letters honestly probably don't help much either, but if the hospital gets enough letters from different people then they might make a difference eventually.

Unfortunately for people who suffer from chronic pain and seek care in the ER, their condition is not (usually) a true emergency, and their management is purely dependent on the mercy of the individual physician they draw that visit. Some docs are assholes, but even the ones who aren't are often cranky, tired, busy, or stressed out from time to time. The bottom line is that we are under no obligation to give anyone narcotics ever, so once an emergency medical condition has been ruled out, then all we really have to give anyone is our advice. Anything more than that is personal preference and medical judgment, which is quite variable (as you have undoubtedly discovered).

Good luck with your condition, I hope you get some relief.

-scalpel

The Most Popular Blog in the Ecosystem

Instapundit, you might think? The Daily Kos? Michelle Malkin?

Hardly. Those heavy hitters are insignificant microbes compared to the new Higher Being on the block. No, the most popular blog by far in the TTLB Ecosystem is a blog about grandfather clocks.

Weird glitch in the system, I suspect.

Can I Give You a Paper Cut?

EMRs produce some weird charts sometimes. This is an actual notation from a patient's electronic medical record:

Patient complains of pain.
On a scale 0-10 patient rates pain as 0
Comfort Goal: 2-5.

I'd rather give a paper cut to the pencil-pushing genius who came up with the concept of the "comfort goal." I'm sure he was also involved in the decision to create a paragraph with a misleading opening sentence to help us document information which should only require two words to convey.

No pain.