pain control

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.

cupcakes

when i got to work today, there was a box of beautiful cupcakes in the fridge from a patient that i had a year ago. the note on top thanked us for all of our care and went on to say that we are responsible for this patient's new outlook on life. "it has been one year to the day, and thanks to you all, i have many more to enjoy". needless to say, at this point there were tears. there are lots of thing that i'm accustomed to hearing on the floor, such as "you're overstaffed" or "you need to be doing your hourly rounding" or countless demands for pain meds and bedpans and water. but thank you? thank you is something that is rare. a kind word spoken about a job well done? an acknowledgement of the fact that i pour my heart and soul into this job? that was startlingly unexpected. it was a good start to a week that i was praying would go well.

1800: lasix and metoprolol were due for a lady in a-fib. since both the drugs lower blood pressure, i got a bp. 80s/40s. not good, not good. maybe the other arm? 60s/30s. very very very bad. manual BP? 70s/50s. three strikes for me. now this patient is (of course) sick and complicated. she was up in the icu for a long time on pressors to increase her BP and has been having an irregular heart rate with 3 second pauses. naturally, she is the one that i am scared of. so i paged the doctor, who told me that she hadn't gotten sign out from the primary team. she suggested that i page the chief resident, which i did.

then i waited.

and waited.

then after 10 minutes, i paged again.

and waited.

and waited.

then i paged the chief resident who was covering.

and waited.

and waited.

by this time it had been over a half hour and my patient is still sitting in the 70s/40s. low blood pressure means not enough blood to the brain, not enough blood to the kidneys, and passing out and coding and dying.

so i thought about calling the attending, but quickly changed my mind when i saw that the attending on call tonight is seriously one of the most frightening people i have ever met.

by this time i was obviously in distress. i was mad because no one was calling me back. i was mad because well-meaning people kept telling me that "she's fine" as if that's some sort of excuse to ignore unstable vital signs. i was mad at my coworkers who were telling me "don't get so worked up". this situation was no longer about the patient's blood pressure. this situation was now about the negligence of the trauma team and brought to mind all the other times that i have felt abandoned and been forced to fend for myself because the doctors were "too busy" to help me. so i turned redder and redder as i do when i'm upset, and one of the trauma nurses went upstairs to the icu to find me a doctor. she came down with the icu resident who knew my patient and thought that she just needed some fluids because of the all diarrhea she was having. i was still mad, but at least a little pacified by the fact that someone was giving me an order.

and then of course, 45 minutes later, the chief resident saw fit to call back. i politely told him what was going on, and asked if he was at home. yes, he said "you know that" (no i didn't). he then barked some questions at me about admission weight and how many liters of fluid she is 'up' for this admission. when i told him that i thought the patient was dehydrated, he told me that she wasn't. i argued my case for dehydration respectfully, bringing up the fact that she was nothing by mouth for 14 hours and having lots of diarrhea. he didn't seem to agree, and told me that she was up 25 liters since admission, and therefore wasn't dry. so i brought up her edema and suggested that her fluid might be in her tissues instead of in her vessels. he didn't seem to agree. i suggested a catheter so we could monitor her urine output. no. i suggested some fluids so we could increase the volume in her blood vessels. no. then came the most horrifying part of the conversation:

he told me to give the lasix.

with a blood pressure of 78/44.

lasix is a diuretic. lasix makes you pee out all your fluid. fluid comes out, blood pressure goes down. blood pressure much lower than 70s/40s is not compatible with life.

i told him that i didn't feel comfortable giving the lasix. he told me it wouldn't drop her blood pressure. i said it would. he said "i've been around for a little while, you know". i said "i've been around just as long as you have". the whole conversation went nowhere, and at this point i just said "ok" to everything that he said until he finally stopped talking.

i didn't give the lasix.

the patient is still sitting at a BP of 84/44. and we are just going to 'watch her' for awhile. because when she starts to have altered mental status we will know for sure that her brain isn't getting enough blood and then maybe we can do something to treat her. until then, it is apparently my job to keep my mouth shut and follow orders. psssh.

so my day started with a thank you and ended with a screw you.

but at least i got cupcakes.