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Monday, September 19, 2011

Hate Mail

I feel like I've hit a mile stone with my blog. My first hate mail, er, comment anyways. And when I tried to answer it and explain my position a little better, I got another one. So instead of trying to explain things in the comment section I decided to do a post about it.



The original post, 50mg of Benadryl And Some Morphine, was about a drug seeker and my refusal to give them Morphine. In it, I mentioned that we have to ask a patient to rate their pain on a 1-10 scale. I think this is a waste of time because there's no real way for a health care professional to know what the patient's worst pain is. If your worst pain is a stubbed toe than a sprained finger is a   10. If you have had cholecystitis, then a sprained finger is a 2. So if the number rating is arbitrary then I have to go by my assessment to determine how much pan management is needed. 


Evidently Mr. (assumed from the typos and un-lady like language at the end of the first comment) Anonymous didn't like this. He said, 


""We always ask the patient to rate the pain. I generally don't care what they say their pain level is, their body language always tells me what I need to know. So why do we ask? I digress."

how woudl ur boss feel if they saw that? cunt
"


I tried to understand where they were coming from. I reread my post and tried to explain where I was coming from. I replied, 


"My Chief is a medic as well and I think he would back me up 100%. I think you may have misunderstood what I was saying. I don't care what number they assign to their pain. My 4 may be your 10. The number is a waste of time but is used for paperwork. I treat my patient instead."


He really didn't like that. Mr. Anonymous commented,


"You have a God complex. It's not up to you to "decide" what a person's pain level is. "My 4 may be your 10". You're not the one in pain so you have no clue how bad their level is. You're what's wrong with the medical field nowadays-you don't listen to the patients and make assumptions based on how YOU judge a persons body language."


So I am going to make a couple of assumptions based on these comments. First, I think Mr. Anonymous has had a bad experience with someone in the medical field that did not his pain or pain management seriously. Having been in severe pain I can imagine the anger of someone that wasn't properly treated for pain. Second, I don't think that Mr. Anonymous is in the health care field. More specifically, in the pre-hospital setting. If I'm wrong, I'm sure he'll let me know.


Mr Anonymous, you obviously think that I'm in the wrong, at least as far as patient care is concerned. Let me explain my approach to pain management. If, through a thorough assessment and examining the signs and symptoms of my patient, I determine that they are in pain, I do everything in my power to relieve that pain.


In a perfect world all I would have to do is trust a person when they say the hurt. Unfortunately, we don't live in a perfect world. I have to deal with people that lie. One of the more common misrepresentations is that of being in pain. People addicted to narcotics have been known to call 911 with the intent of getting morphine. If we as medical professionals were to just give out MS to every patient regardless of our own assessment we would not only possibly be causing more harm to our patient by feeding their addiction but we would then have every addict in the country calling 911 to get their fix. So to keep from doling out medication unnecessarily we have to judge for ourselves how much "pain" a patient appears to be in.  

How do we check someone's pain level? There are actual, physiological changes to the body when someone is in pain. There's a great paper (do you still call it a paper if it's online?) on the subject on the NursingTimes website. I'll provide a quick overview but you can find better detail in the article.


We'll start with the patient's heart rate, it goes up. As does their respiratory rate and blood pressure. There can be impaired thinking if the pain is severe enough. Oxygen saturation may be low. Nausea and vomiting often accompany intense pain. Because of the sympathetic response the patient may appear pale and sweaty. There are many other things going on with the body as it reacts to pain but those are the most obvious and easiest to assess.




So Mr. Anonymous, when I'm dealing with a 30 year old patient, with a known history of seeking narcotics, what would you have me do? Should I listen to them as they calmly tell me that they are in the worst pain of their life? Should I immediately dive for my morphine and draw it up stat? Or should I look at her vitals and perform an assessment? If her heart rate is 62, she's breathing 12 times a minute with a pulse oxygenation of 100%, their skin tone is normal in coloration, temperature and moisture, no nausea or vomiting, and their BP is normal should I ignore all the clinical data that says the patient is probably not in severe pain? I think not. 





Somehow I get the feeling that you, Mr. Anonymous, are still going to say that I need to listen to my patient. So is that true in every case? When a woman is having a heart attack but she denies it should I just trust her? No. That's why I went through schooling to become a medical professional. Contrary to what you may think we medical professionals have to do more than just listen to you. We have to look at clinical data as well. I'm sure there are some people out there in the medical field that have taken things too far the other way and they rely solely on the signs that they can observe, never listening to their patient. I am not one of those people.


Have no fear, if I respond to your home and you or a loved one are in pain, I will treat you appropriately. 
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