Making pain a vital sign caused the opioid crisis. Here’s how.

[shrike]

http://www.kevinmd.com/blog/2016/10/making-pain-vital-sign-caused-opioid-crisis-heres.html


I remember the first time I experienced the paradigm shift when it came to pain management. Sometime around the late nineties while I was on call, I received a phone call from a floor nurse stating that a patient that had their ankle operated on that day by another surgeon was having increased pain that was not controlled by the pain medication that had been ordered. As I had been doing for many years, I inquired as to what procedure was done, what pain meds were ordered, any allergies, any associated symptoms such as numbness or tingling and, most important, whether the patient had a splint on with tight bandages.

More often than not in the past, this simple inquiry revealed that there was an identifiable, correctable reason for the patient’s pain and the proper course of action would be to correct the problem — in this case to loosen the tight bandages. Just changing the pain medication was the last thing I did and for years it worked well, but this time it was different.

The nurse insisted on repeating to me that the patient’s pain was “10 out of 10.” I insisted that I understood that the patient was in pain but that it was necessary to “listen to the message not just shoot the messenger” and try to loosen the dressings first then call back if that did not work. Clearly annoyed, the nurse just hung up.

Several days later, I ran into the surgeon who was clearly upset. He told me that apparently instead of loosening the dressings the nurse called her supervisor who contacted the hospitalist who ordered stronger pain meds. The next day on rounds surgeon found the patient’s leg grossly swollen, dusky and almost developing a compartment syndrome, a very dangerous condition where the patient could have lost their leg. He then told me that what happened was that the hospital staff had been re-directed to be more aggressive in treating pain and that they were following new guidelines which included the “pain scales” and now labeling pain as a “fifth vital sign.” I thought he was kidding. How can be pain levels be considered a vital sign when there is no objective way to measure it like a heart rate or blood pressure? He just shrugged his shoulders.


POV I've read nowhere else. Wondered what med professionals on DU would think of this.

[unblock]

1. former emt here ...

the issue there isn't treating pain as a vital sign (well, symptom, really). in fact, in the story, it was specifically *not* treated as a vital sign. it was treated as a problem in and of itself.

the issue there is (a) ignoring a medical directive (loosening the dressing) and (b) treating the pain as if that was the condition to be treated, as opposed to evidence pointing to the underlying problem.

there's nothing wrong in and of itself treating the pain and taking the comfort of the patient into account, but it shouldn't overshadow the treatment of the underlying condition. and it doesn't, if done properly.

the story has more to do with problem involved when any bureaucracy changes its procedures. some people get it wrong at first, but they learn.

[stone space]

2. As a patient, I never know how to respond when asked to rate pain on a scale of 1 to 10.

I don't have a clue what the numbers mean, nor how to attach those numbers to what I am feeling.

If somebody would give me a kick in the balls and tell me that was an 8, it would help me to calibrate the scale, but I always feel like I am just making a number up out of nowhere, and that my response contains little or no information.

If I'm doubled over in pain, some conclusions might be drawn from that, but how does me picking a random number tell anybody anything?

[alfie]

10. I am a retired RN, primarily in ER

First off, the nurse should have followed the doctor's orders. They were a simple and no brainer first step. He said to call him back if that didn't solve the problem. He didn't need to get up in the middle of the night to loosen a bandage. Nurses learn to take comfort measures either instead of meds or in addition to them. Those few minutes can reassure the patient and enhance the effects of the medications, especially since they take some time to take full effect.

As far as the pain scale as a vital sign, when used properly it is useful. It allows some bit of objective measure of how effective pain control is working. If I come in with a pain level of 8, receive whatever treatment, and that brings my level down to a 4 then that is a measurement of the effectiveness of whatever treatment was given. In this instance, say the level dropped from 8 to 5, pain medication would still be indicated but in a lower dosage than if the 8 had been used outright. She/he wouldn't have been zonked out by the more powerful medicine and might have let the nurse know that her/his toes were getting numb and cold because of the compromised circulation.

[LisaM]

3. Here's a line in all this that jumped out at me (bolded portion)

'While we’re at it get rid of pain scales, fifth vital signs, and anonymous patient satisfaction scores.'

I don't think customer "satisfaction" surveys necessarily apply in a hospital setting.

The other thing that was awry (to me) in this article was that the patient complaining of the pain didn't seem to have access to a physician other than on the other end of a phone. I think nurses are fantastic, wonderful, don't get me wrong, but sometimes the doctor needs to tell the patient directly, not leave it in the hands of a nurse who didn't perform the operation and now has to deal with a demanding patient.

[Warpy]

4. Yeah it's so much better to tell people with serious pain to buck up

and just live with it. Eventually they go away and commit suicide, problem solved.

This guy is freaking out because he couldn't be bothered to get to the hospital off hours to check on a patient and the nurse on duty didn't keep up with the CSMs and a patient suffered. Perfect storm of unmotivated doc and nurse out of his/her depth.

My own pain story is of a little old man who was admitted as "failure to thrive," meaning he'd pretty much lost the will to keep living. I looked in the door and saw an old man grasping his knees and rolling back in forth in bed. A check of the chart revealed he had severe rheumatoid arthritis and his doc was a notorious hardass when it came to pain control. So I called his cardiologist and wheedled a narcotic order. An hour after I gave him one pain pill, he was sitting up in bed in his own pajamas, doing a crossword, and asked if there was anything to eat. He went through three boxed lunches. Failure to thrive, my ass. The poor man was in PAIN.

This idiot doctor needs to know that pain control is essential even when it's chronic pain that nobody can hang a number on from a lab value. People are in pain when they say they're in pain and studies have shown they're pretty accurate when they pick out a number on a pain scale. Post op patients who report a sudden increase in pain need to be checked out, preferably by the surgeon. All other pain, even when the provider suspects it's psychological pain, needs to be treated. Period.

The chronic pain patients who do run into trouble need to be detoxed and monitored more closely. Nobody yet has the will to do this with them so the drugs are blamed and pain patients are blamed and the beat goes on.

[pnwmom]

11. This wasn't the doctor's fault, it was the nurse's.

The doctor directed the nurse to take certain actions, and get back to him after she did them. If his instructions didn't help, then he should have gone to the hospital to check the patient himself -- and, if necessary, order more pain medication. But if the nurse carried out the orders and the patient improved, then the doctor wouldn't have needed to go in.

Instead, the nurse ignored his instructions and got more pain med from another doctor instead. She was wrong.

The doctor wasn't an "idiot." He was properly trying to determine the cause of the symptom -- the pain being the symptom -- not just making the symptom go away with more pain medication, while the cause remained untreated.

[shrike]

5. Thanks for the feedback, particularly unblock and Warpy

I'm a complete layman here. All I know is, when pain's got you it overrides everything else.

[Doodley]

6. I agree with the POV of Shrike, the OP

A lot of pain is treated in isolation of first looking at all options to reduce pain. This is my firsthand experience. The doctor's default position is often to write out a prescription and not take other appropriate or timely actions. External factors and lifestyle are often the cause of medical issues or the cause of the issues being worse than they would be. It is no coincidence that the fast-food capital of the world with an obesity epidemic is also the most over-prescribed nation. Yes, obesity leads to painful back problems, knee problems, foot problems. The answer in these cases isn't just to pop pills. Consumption of narcotic-based prescription drugs in USA quadrupled from 1999 to 2010. This isn't a question of being compassionate or not, but a question of a legalized mass addiction problem that is boosting big pharm.

[shrike]

7. Thanks for your feedback

[Aristus]

8. I tend to lean to the side of objectivity. One can't measure pain objectively.

And offering the patient a scale with which they can measure it is a mistake.

There are always the patients who think we'll take them seriously if they report '20 out of 10'. In other words "I'm really in pain, and need these highly-addictive controlled substances more than the guy reporting 9 out of 10."

I'm a firm believer in treating the underlying condition, and not just the symptom. I can either fix the hiatal hernia that's causing your GERD, or I can just give you proton pump inhibitors until you either develop osteoporosis or die of esophageal cancer. I opt for the former.

[shrike]

9. Thanks. Interesting.