…back to the pain issue, that is. I had a terribly interesting experience the other night at work. A middle-aged patient came in by ambulance complaining of chest pain. She typically has chest pain due to some heart condition I’d never heard of, but it worsened due to activity. She’s usually treated at another hospital, but the paramedics brought her to ours because it was closer.
When she arrived in the ER, she got the internist on call. No cardiologist, although she has this heart problem. The patient says that during these “flare-ups,” only one drug helps: Dilaudid. The patient is being treated at a pain clinic and is currently on oral narcotics at home, plus a benzo (anti-anxiety drug). The internist refuses to give this patient Dilaudid because she’s being treated at a pain clinic. MD prescribes Morphine, which patient says does not help. Next day, patient gets a slightly more… aggressive nurse, and said nurse repeatedly calls MD because of patient’s unrelieved pain throughout the day.
MD finally relents to one dose of Dilaudid, which the patient says helps. Awhile later, MD comes to see patient, and patient tries to fire MD due to inadequate pain management throughout the night before. MD says she isn’t flustered, but clearly looks it, and when told that it is her responsibility to find another MD for this patient, says that it is not. The MD says it is the patient, who is in an unfamiliar hospital with unfamiliar docs, who is supposed to find her own 2nd opinion.
A cardiologist is FINALLY consulted, and ultimately clears the patient, saying that the echo looks okay. The patient is relieved to hear this, but is still having chest pain, and is not too happy about not being able to get more Dilaudid. Since there is no other MD to call, I call the MD that has supposedly been fired. She still insists on not giving any more Dilaudid, saying the patient is drug seeking. She offers more Morphine, the patient states that MS doesn’t work, and she’s leaving AMA to go to the other hospital.
MD discourages this somewhat, but what can you do? And did I mention that the nurse got to be in the middle of all this? I’m not used to drug-seeking patients. I’ve had only a few. But where they were shaky, manipulative, needy, and had a general desperation about them, this patient had none of that. (Except the MD’s claims of manipulation, that is.) MD insists that the patient is going from hospital to hospital to get pain meds and that it must stop somewhere. Patient states that she has had unrelieved pain for a day and a half, and the MD is negligent. Patient brings up lawyers and lawsuits a lot. She also brings up the competancy of the MD, which I find ways around commenting about. Lots of noncommittal and vague “huh’s” on my part. The patient seems very intelligent, calm, and even though she’s making these “threats,” she isn’t ranting or anything. Is this manipulative? I personally have no idea. It could be taken either way quite easily.
Here’s a kicker for you then. When I went back to the patient to offer some IV Morphine, she was already sitting up in bed, and told me when I walked into the room that she had decided to have her husband drive her to the other hospital. She said the treatment we were giving her was the same treatment she could give herself at home, and there was no point in being here. I said that was fine (she was still calm and matter-of-fact… not overtly angry in any way) and that I’d just gotten off the phone with the MD, who said she could have some Morphine. (Remember… she’d received Morphine all night and claimed it didn’t work). The patient was quiet for a moment, and I asked her if she needed for me to do anything to help her get ready to go. She looked at me and said, “I wish that I would have known you could give me Morphine before I told you that I wanted to leave.”
What on earth am I to make of that? I’m aware that we have our own responses to pain, but she was sitting up, in no obvious distress. She spent the whole previous night complaining that Morphine didn’t work. Why, then, would she get all weird on me? Up until that point, I was on the patient’s side. I thought the doctor was being unreasonable and was sore that the patient tried to fire her. Pain is subjective, and even when I myself was having moderate kidney stone pain, I could have sat up calmly, too. (When it was severe, that was another story… but this patient wasn’t claiming severe pain anyway).
I’m interested to know what other RN’s and MD’s would have done in this instance, only knowing what I’ve described. If I get a few good responses, I’ll post in the comments what I myself ended up doing.