Jane the Pain

My sister taunted a little ditty that started like that when we were small & frivolous...

Let's discuss P A I N, is it a four-letter "p-word"? It's starting to become one due to my current working environment.

Emergency nursing/healthcare is about knowing a little bit of everything (and not a lot about anything?). Every ailment walks through those doors, not just anything, but everything. So where does a provider start? That's where my role begins, I prioritize patients, triage, pinpoint chief complaints, perform focused assessments, vitalize, anticipate procedural and pharmacological needs, order them, discuss these with the Emergency physician in my zone, prepare piggybacked machine pumped triple intravenous lines, after I've placed an IV line and collected blood specimens and sent them to the lab. Oh and I dole out our prized creature comfort; the toasted blanket.

Pain is a large part of why folks arrive in my unit, why any one goes to the ER. I work with adults, so we use the numerical pain scale; "Zero being 'No Pain' and ten being the 'Worst Pain of Your Life', where exactly would you place yourself at this moment?" kind of an assessment. Pain is considered a sixth vital statistic regarding your medical presentation and subsequent care, along with blood pressure, pulse, respirations, temperature and oxygen saturation. Pain is important and while we cannot detect a standardized measurement of a person's pain, we can ask and we can believe and trust and respect that individual's pain experience.

Here is where it gets tricky, two things can happen; 1) someone becomes a victim of a fear-mongering society full of shows and stories of friends of friends co-workers who are addicted to pain medications. So, your patient doesn't want to take pain meds, or won't admit to the severity of their pain to avoid requiring pain meds. 2) people are in fact addicted to pain meds, and will do almost anything to receive them.

Jane's adapted response to assessing PAIN:

To confront patient #1 who is presenting with right sided flank pain (read: kidney stones) and says she prefers not to take narcotics, she needs to hear some patient teaching regarding pain receptors and cost-benefit analyses. First of all pain is your body indicating to your brain that something is intrinsically wrong.  Pain is a helpful signal to let us know we need to do something about what is wrong. Kidney stones, to choose a random, common, and excruciating example (see also; appendicitis, migraine, symptoms of a myocardial infarction, fractured limb) is not good. All of these things are not good for you, therefore when they present, they trigger pain receptors. When your body is lighting up its pain receptor circuit board, it is waiting impatiently for that special someone, an opiate-derivative narcotic pharmacopeia that will switch it off thereby releasing the tension build up that pain creates, release and relax the contracting muscles and organs and allow normal body functioning to return to baseline.

Note the number one thing people say to me when I inject a milligram of dilaudid into their vein is "how can people be addicted to that stuff? that feels awful!"

Now, for patient #2, I tend to see a presentation along these lines; woman walks to room chasing three little kids around the hallway, reaching, running, bending, carrying and then tells me she fell and her wrist, back, neck, ankle and foot are a 10/10 pain.... and "could I just get an IV and 2 mg Dilaudid to start and some Phenergen as well,... thanks." This is when I don't have to start an IV and I can give her an oral tablet of a single Percocet and try to convince her that it is not okay to take medical equipment from the supplies locker in her patient room. OR, how about the woman who tells me she is having 32 out of 10 for pain. So I given the prescribed 2 mg Dilaudid. Well, she tells me she is "a little bit better, maybe a 9/10 now" So another 2 mg dose slides into her vein, she relays that she is definitely an 8 now, but still having a really hard time, so this time I give 1 mg of Dilaudid to her. At which point, she has become completely snowed, and is barely rousable, to the point that I have to poke and yell and slap on the blood pressure cuff and oxygen tubing, cranking it up from the wall source and try to perk her up. So, as she's stabilizing I, just curious, ask her what she would rate her pain now? "I'm... uh-......" and I poke and prod and stimulate her awake again, what number, I ask? "-uh, 7." she manages to say, and falls asleep again.  OR the middle aged man who comes in with his wife, he's here for abdominal pain and has been nauseated and vomiting all day and night. Currently he is writhing on the gurney. I am trying to get an IV in so we can replenish fluids, bring his blood pressure back up, and have access so as to draw blood for samples and provide alleviating medications, so I prep my lidocaine numbing medicine to give a tiny--skinny shorty--needle injection to the site where I want to place the bigger, longer, more painful IV needle. I break the skin and my patient yelps and cries out, I pause looking up blankly and ask flatly "was that excruciating?" and he snaps "yes!" Well, this makes me think he has a very little pain tolerance, and therefore is being awfully dramatic about the whole abdominal pain and violent writhing acrobatics. In a phrase; loss of credibility.

Two take home messages:

One, working in situations like those mentioned above where patients are clearly, and sadly addicted, dependent or otherwise exceptionally tolerant of pain medication is slowly but surely already turning me into a nurse who maintains judgment, cynicism, a lack of respect and ultimately annoyance and embarrassment for the patients I work with. I am completely devastated when I am lied to about a person's pain. Tactics that are used to obtain unnecessary pain meds, all back-fire, I can turn my mr. nice nurse off completely if I am being taken advantage of, manipulated and treated rudely, and bottom line is I don't like the way it makes me act and feel toward patients. I can see how positive spirits are broken down in this line of work.

Two, pain is a bad sign unless you are in labor and going to give birth (did you think I wasn't going to bring up birthing?) then pain means Purposeful Anticipated Intermittent Normal experiences your body undergoes to prepare you for the transition Earthside your baby makes with you. Birth pain does not harm you or your baby, there is a system of hormones in place to guide your body through it (provided you aren't taking drugs in labor to speed up labor or stop the pain, that messes with your hormones and thus the whole process).

So cheers to real pain, good or bad.