pain is the sixth vital sign, or so everyone has been trained. working on a trauma floor, EVERYBODY is in pain. the narcotics are due every 1-2 hours and the reassessments of pain levels never end. most often, people are under the impression that hospitalization is supposed to be painless...right. for the record: when you are shot or stabbed or fall out of your tree stand or get hit by the city bus, you're going to have pain. my job is to give you your medicine, make the doctors order you more if it's genuinely not working, and be sympathetic. most often this involves offering to make you a heating pad. while i realize that this probably won't do much for your 4 broken ribs, it's the thought that counts. every staff meeting on the floor begins with a little blurb about how we're supposed to be doing our pain assessments, and how we score low on controlling our patient's pain. as most people would like to be medicated until they stop breathing, i honestly don't take all that too terribly seriously. bottom line: i can tell when people are truly in pain, i bring them medication as often as i can as long as it won't hurt them, and then i push tylenol and ice packs and deep breathing like it's going out of style. most of the time, this works fairly well. this week? not so much.
it always starts with an admission that i think is going to be easy. this time it was 'just abdominal pain'. unfortunately what i thought was a tummy ache turned into bounce back admission with a history of heroin and crack use and no IV access. so i picked this patient up as we were waiting for a PICC line so i could give her fluids and IV pain meds. unfortunately in the meantime, percocet wasn't working to control her pain. i'm not surprised, as NOTHING WORKS FOR PAIN AS WELL AS CRACK. i genuinely felt bad for this lady, though. she was writhing in pain and we just couldn't get the line in. each time the IV nurse repositioned the PICC, it was in the wrong place. the hours went by, the line got repositioned 4 times, and the patient still had no access for IV medications. this is where i got creative. and i'll admit, i was pretty proud of myself for being innovative. if i couldn't give the meds IV, i could give them another way!! intermuscular medication was the solution!! i could give her a little shot of fentanyl and then she would know that i was serious about controlling her pain and maybe it would even help a little. so i called up the pharmacist who told me to go ahead, and gave my lady 50 mcg of fentanyl in her bicep. then i gave myself a little pat on the back for coming up with a solution.
45 minutes later, i was in the room with the patient and a med student. the student was doing her assessment, and i couldn't help but notice that my patient was getting pretty sleepy. as she started to slur her words, i got a little concerned. the med student was kind of weirded out too, so i grabbed a set of vital signs. i was in the middle of telling the student that i was pretty sure she was fine as her oxygen levels, pulse, and respirations were all normal, when the BP recorded. 80s/60s. in a patient with previously high blood pressure. at this point, the patient was only waking up to sternal rubbing. i called the medicine resident, who said that he'd be down in 5 minutes. i called the Stat RN, grabbed some oxygen just in case, and went to get a vial of narcan.
in my head i knew that this had to all be because of the medication i had given her, but the whole situation didn't make much sense. first of all, 50 mcg of fentanyl shouldn't have had that much of an effect on someone who uses hard drugs. secondly, the intermuscular route usually isn't absorbed that fast, and i mean really, blood pressure of 80s/60s just because of narcotics? the whole thing seemed wrong. so i was running around the room getting things set up, and the commotion attracted the attention of the on call trauma resident. this guy just happened to be specializing in emergency medicine and i could tell from the gleam in his eye that he really wanted in on the action. he stood in the hallway for a few minutes watching, and then stopped trying to fight the urge to participate and came in the room. he started checking reflexes, and sternal rubbing the patient, then checked her pupils. tiny, of course, as is common when someone has gotten too much narcotic. he suggested that i "give the narcan before she codes". we gave the narcan. it took a looooong time for her to wake up, which is weird as the drug usually reverses narcotics pretty quickly. the medicine resident arrived, i bolused her with a couple liters of fluids, and her blood pressure came up. she was still really sleepy though, which made me nervous. naturally, i felt awful. even though i knew i hadn't done anything wrong by giving her the fentanyl, i felt like i caused all this drama. so as i usually do when i don't feel right about something, i held a little vigil. i ran around to all my other patients, and in between grabbing meds and changing dressings, i would pop in her room to count her respirations and take a blood pressure. when it came time to do report sheets, i sat in her room to write them. my computer charting got finished from the chair that i pulled up to her bedside. her blood pressure was stable, she was still really sleepy, but everything else was ok, so i felt a little better. when she woke up to me yelling her name or shaking her arm, the patient said she had no pain. well, at least i accomplished something.
it was finally time to punch out and go home, and i should have left well enough alone. but nooooo, i had to get just one more blood pressure so i could sleep that night. i snuck into her room, blew the cuff up, and wasn't too terribly surprised when the result came back at 70s/50s. and so we started the whole process over again: bolus, Stat RN, medicine resident, narcan...deja vu. then i pushed her upstairs to the medical ICU for a possible narcan drip. then i punched out, an hour and a half after my shift ended. i checked up on her the next day: completely fine. awake. stable BP. go figure.
pain control is officially dead to me.
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