frustration & disappointment with the ER

[chrsjav]

My sis went to the local (level II) ER by ambulance, and when I arrived I found her in an exam room moaning in agony waiting to be seen by a doctor... you all don't need to hear the details since we've all seen this volunteering and in rotations. (I'll be starting med school in the fall.) It was just a little different for me this time since it was my sister waiting for 30 mins before someone even ordered morphine, and then she had to wait another 20 mins to get the injection.

I looked at the board and saw 4 doctors serving 8 patients... no trauma cases either. Of course, every doc I saw who wasn't with a patient was doing paperwork. Please tell me that when I'm at least a third-year I will be able to say a few magic words to get the docs to pay a bit more attention to the patient instead of the paperwork?

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[AmoryBlaine]

My sis went to the local (level II) ER by ambulance, and when I arrived I found her in an exam room moaning in agony waiting to be seen by a doctor... you all don't need to hear the details since we've all seen this volunteering and in rotations. (I'll be starting med school in the fall.) It was just a little different for me this time since it was my sister waiting for 30 mins before someone even ordered morphine, and then she had to wait another 20 mins to get the injection.

I looked at the board and saw 4 doctors serving 8 patients... no trauma cases either. Of course, every doc I saw who wasn't with a patient was doing paperwork. Please tell me that when I'm at least a third-year I will be able to say a few magic words to get the docs to pay a bit more attention to the patient instead of the paperwork?

Sounds terrible. A few thoughts though from an M3...

1. Trauma is not the most complicated stuff that comes in. They might have had some critically ill people who looked like they were just "laying there."

2. Emergency physicians (and M3s for that matter) tend not to be all that impressed by "moaning in agony."

3. You don't know how long it took for the morphine to be ordered. There are 20 different reasons why it could've taken a long time to get to her.

3.5. As terrible as it sounds, giving pain meds is not always the best idea for pts with abdominal pain. If the diagnosis is clear then you can often treat the pain, if not you might be a bit more judicious. For instance, I was taught that in the case of a r/o bowel obstruction you hold the morphine b/c while it may hurt, it will hurt alot more if it perfs. If it perfs, you need to know fast.

4. The "paperwork" they were doing is probably called "charting" which is what allows them to get paid and hopefully helps them when they get sued.

4.5. You will find that MDs unfortunately have to split time between patients and paperwork pretty evenly. For instance, when you do internal medicine you willl probably spend more time writing your note than you do talking to the patient.

5. If there were 4 attendings for 8 pts you might have came in at sign-out, so 2 of them were probably not picking up new pts.


Hope your sis is ok. Was it surgical?

 

[chrsjav]

Sounds terrible. A few thoughts though from an M3...

1. Trauma is not the most complicated stuff that comes in. They might have had some critically ill people who looked like they were just "laying there."

2. Emergency physicians (and M3s for that matter) tend not to be all that impressed by "moaning in agony."

3. You don't know how long it took for the morphine to be ordered. There are 20 different reasons why it could've taken a long time to get to her.

3.5. As terrible as it sounds, giving pain meds is not always the best idea for pts with abdominal pain. If the diagnosis is clear then you can often treat the pain, if not you might be a bit more judicious. For instance, I was taught that in the case of a r/o bowel obstruction you hold the morphine b/c while it may hurt, it will hurt alot more if it perfs. If it perfs, you need to know fast.

4. The "paperwork" they were doing is probably called "charting" which is what allows them to get paid and hopefully helps them when they get sued.

4.5. You will find that MDs unfortunately have to split time between patients and paperwork pretty evenly. For instance, when you do internal medicine you willl probably spend more time writing your note than you do talking to the patient.

5. If there were 4 attendings for 8 pts you might have came in at sign-out, so 2 of them were probably not picking up new pts.


Hope your sis is ok. Was it surgical?

Thanks AmoryBlaine for the info and your concern. No surgery, it was just pyelonephritis caused by a failure of cipro to treat her UTI. Now she's on a different antibac and feeling a lot better w/ pain meds. I guess if they can hear a new patient moaning than they already know the patient is not too critical.

Good point about the morphine. I suppose you have to r/o surgery before giving pain meds.

Let's hope EMRs shorten some of time spend charting.

 

[MartianOddity]

I guess if they can hear a new patient moaning than they already know the patient is not too critical.

In emergencies, as far as I know, and as you say, it goes like this:

If the patient can moan, the situation is normally not considered very critical.


I guess it applies in ER as well.

 

[psipsina]

A random aside, I had pyelo recently and I wasn't given anything but tylenol for my fever in the ER. I also agree that certain things need to be decided before narcs are given, especially with abdominal pain.

As much as it sucks you never know who's worse than you in an ER so you have to tell yourself that if they aren't with you its because there is something more imperative going on. Even if it only looks like they are doing paperwork, they might be doing what they need to to order scans or meds on more critical patients. The attendings in ERs tend to be pretty big hearted people, you have to be to deal with the regulars, so if they are ignoring you its probably not out of a lack of desire to help.

 

[Flopotomist]

Sounds terrible. A few thoughts though from an M3...

1. Trauma is not the most complicated stuff that comes in. They might have had some critically ill people who looked like they were just "laying there."

2. Emergency physicians (and M3s for that matter) tend not to be all that impressed by "moaning in agony."

3. You don't know how long it took for the morphine to be ordered. There are 20 different reasons why it could've taken a long time to get to her.

3.5. As terrible as it sounds, giving pain meds is not always the best idea for pts with abdominal pain. If the diagnosis is clear then you can often treat the pain, if not you might be a bit more judicious. For instance, I was taught that in the case of a r/o bowel obstruction you hold the morphine b/c while it may hurt, it will hurt alot more if it perfs. If it perfs, you need to know fast.

4. The "paperwork" they were doing is probably called "charting" which is what allows them to get paid and hopefully helps them when they get sued.

4.5. You will find that MDs unfortunately have to split time between patients and paperwork pretty evenly. For instance, when you do internal medicine you willl probably spend more time writing your note than you do talking to the patient.

5. If there were 4 attendings for 8 pts you might have came in at sign-out, so 2 of them were probably not picking up new pts.


Hope your sis is ok. Was it surgical?

OK.. I just gotta speak out against your 3.5. It is hogwash. There is no reason to withold pain meds to aid in diagnosis of a pt with abdominal pain. This myth needs to just hurry up and die.

 

[TysonCook]

Agree w/ above. The data shows that giving pain medication in no way causes a change in medical/SURGICAL management. This has been studied many times and is department specific, but has really been hammered over the last several years. Do a pubmed search for many articles etc.

As far as the ED experience goes, we don't always get the pain rx's right out becuase I want to speak with you first. If during the interview it's obvious you need pain releif, I'll jump on it at that time.

It's irresponsible for any physician to order any medications with out first taking a basic history (even if it's a one liner), and a quick physical, and lastly allergies.

Oh, and I can't get ANY meds out until your name pops up in the computer system (the Pyxis wont allow the RN"s to get it out), so sometimes no matter how fast I see you, your Rx may be a bit lagging for the secretary and admin to get the info in.

 

[SanDiegoSOD]

I looked at the board and saw 4 doctors serving 8 patients... no trauma cases either. Of course, every doc I saw who wasn't with a patient was doing paperwork. Please tell me that when I'm at least a third-year I will be able to say a few magic words to get the docs to pay a bit more attention to the patient instead of the paperwork?

Sorry that your sister had to wait, being in pain really sucks. I can promise, however, that the docs doing paperwork would rather be doing something else. There are a lot of problems in the emergency room, but not many of them are due to lazy ER docs. Excessive paperwork is thrust on ER docs from above from such magnificient organizations as JCAHO, insurance companies, hospital risk management, etc.

 

[chrsjav]

Sorry that your sister had to wait, being in pain really sucks. I can promise, however, that the docs doing paperwork would rather be doing something else. There are a lot of problems in the emergency room, but not many of them are due to lazy ER docs. Excessive paperwork is thrust on ER docs from above from such magnificient organizations as JCAHO, insurance companies, hospital risk management, etc.

I hope I didn't imply that ER docs are lazy... they are quite the opposite to work in that environment. Now I feel bad about the title because I think it's unavoidable to be somewhat unsatisfied about an ER experience.

What bugged me is that even after I graduate and finish residency, I probably won't be much help to my family and friends who need medical care... is this true? Sure I can give my advice and refer them to the physicians I trust, but other than that, would I have improved the quality of treatment that my sis got had I been a physician? Probably not. And now that I think about it, that's a good thing.

 

[Tired]

Sure I can give my advice and refer them to the physicians I trust, but other than that, would I have improved the quality of treatment that my sis got had I been a physician? Probably not.

If you were there as a MS3 or resident, I suspect you would have gotten a reasonable degree of professional courtesy. Especially if you had made friends with the nurses. RNs, in my limited experience, can really go the extra mile for you if you let them know that a friend or family member of yours is in their care.

Not that I'm talking about much, a pillow and blanket, extra "just checking to see how you're doing" visits, maybe get moved up the list of priorities once orders are written. But sometimes this can really mean a lot to patients, and make your family members feel like you went to bat for them.

 

[AmoryBlaine]

Agree w/ above. The data shows that giving pain medication in no way causes a change in medical/SURGICAL management. This has been studied many times and is department specific, but has really been hammered over the last several years. Do a pubmed search for many articles etc.

I learned something new today. I was taught the exact opposite by a surgical chief resident.

Thanks man.

 

[pillowhead]

OK.. I just gotta speak out against your 3.5. It is hogwash. There is no reason to withold pain meds to aid in diagnosis of a pt with abdominal pain. This myth needs to just hurry up and die.

Very true. This is a myth perpetuated by uninformed surgeons/surgery residents. Check out Annals of Emergency Medicine, 2004 by Rupp and Delaney. "Inadequate Analgesia in the Emergency Department." (I tried to do a link but it wouldn't work)

 

[TysonCook]

I learned something new today. I was taught the exact opposite by a surgical chief resident.

Thanks man.

Bummer your cheif resident doesn't believe in evidence based medicine:
It is a myth that surgery residents learn from old texts and old school attendings. It has been published in multiple journals in multiple fields that analgesia may affect the PE, but in NO WAY causes any change in management.

From JAMA: Do Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain? Sumant R. Ranji, L. Elizabeth Goldman, David L. Simel, and Kaveh G. Shojania JAMA. 2006;296:1764-1774. "Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors"

From Journal of American College of Surgeons: "...Results: There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy...." - Journal of the American College of Surgeons Volume 196, Issue 1, January 2003, Pages 18-31

From Society of Acedemic Emergency Medicine: Academic Emergency Medicine, Vol 3, 1086-1092 ...."CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients"

From European Journal of Emergency Medicine. Narcotic analgesia in the acute abdomen-a review of prospective trials. 8(2):131-136, June 2001.
McHALE, P.M. 1; LoVECCHIO, F. 2 *
Withholding administration of narcotic analgesia in patients with acute abdominal pain for fear of masking pathology is still pervasive in current medical practice. We reviewed all the prospective trials that investigated the safety, adverse affects, and ultimate outcome in patients with acute abdominal pain receiving narcotic analgesia within the emergency department (ED). No adverse outcomes or delays in diagnosis could be attributed to the administration of analgesia. Based on this research, we propose that it is safe and humane to administer narcotic pain relief to patients presenting to the ED with acute abdominal pain provided no contraindications exist.


There are several meta-analysis looking at prospective studies that show no change in management, just peruse and you'll find them. The results have been repeatedly shown from Annals of Critical Care, to Pediatrics, to IM and anesthesia. Please please please spread the word. (and print out an article for your misinformed resident from ACOS ).

 

[PreMedDocMD]

Something similar happened to my mother. ( Remember I am still a pre- med so I can't explain things with great sophistication.)

My mother has a pinched sciatic nerve, and she had an MRI done that showed she has a hole in her spine that leaks fluid. She goes to a doc for pain managment and has 2 epidrals done already. Anyways, she woke up one morning just SCREAMING in pain, which she said that was more intense than labor pains. So, called for an ambulance and went to the ER. Anyways, she was SCREAMING there for 6 HOURS before they gave her anything. Her doc was a D.O., which probably dually (but wrongly) contributes to my dislike for D.O.s and EPs. Every once in a while he would walk over to her, sip his coffee for a minute or two, and then examine her again. Touch her a couple of times, and say she is fine.

I think my dad was right in saying that EPs know a little about a lot of topics, but its a shame because they don't know too much about specific issues. My mom's pain managment doc said to her after that if he was there, she would have gotten the morphine immediately, because he knows exactly how much pain there is (he actually has the same thing, this is why he became a doctor) in this sitation.

Since then, my mothers right leg has gone numb, and the doctor says she probably won't get feeling back.

 

[Tired Pigeon]

We all know that moaning volume is not the most objective indicator of pain. This is not to say that your sister wasn't in pain, just that the fact that she was "moaning in pain" probably was much like the dozen other moaning-in-excruciating-pains that were looking for their Lortab fix and the assorted overreactors with minor abrasions or lacerations screaming like they're giving birth.

 

[USArmyDoc]

Something similar happened to my mother. ( Remember I am still a pre- med so I can't explain things with great sophistication.)

My mother has a pinched sciatic nerve, and she had an MRI done that showed she has a hole in her spine that leaks fluid. She goes to a doc for pain managment and has 2 epidrals done already. Anyways, she woke up one morning just SCREAMING in pain, which she said that was more intense than labor pains. So, called for an ambulance and went to the ER. Anyways, she was SCREAMING there for 6 HOURS before they gave her anything. Her doc was a D.O., which probably dually (but wrongly) contributes to my dislike for D.O.s and EPs. Every once in a while he would walk over to her, sip his coffee for a minute or two, and then examine her again. Touch her a couple of times, and say she is fine.

I think my dad was right in saying that EPs know a little about a lot of topics, but its a shame because they don't know too much about specific issues. My mom's pain managment doc said to her after that if he was there, she would have gotten the morphine immediately, because he knows exactly how much pain there is (he actually has the same thing, this is why he became a doctor) in this sitation.

Since then, my mothers right leg has gone numb, and the doctor says she probably won't get feeling back.

You dislike D.O.'s b/c you had a bad experience with one? Don't ya think thats a little rediculous? Oh well, like you said, you are a premed. Good luck in your career.

 

[USArmyDoc]

Something similar happened to my mother. ( Remember I am still a pre- med so I can't explain things with great sophistication.)

My mother has a pinched sciatic nerve, and she had an MRI done that showed she has a hole in her spine that leaks fluid. She goes to a doc for pain managment and has 2 epidrals done already. Anyways, she woke up one morning just SCREAMING in pain, which she said that was more intense than labor pains. So, called for an ambulance and went to the ER. Anyways, she was SCREAMING there for 6 HOURS before they gave her anything. Her doc was a D.O., which probably dually (but wrongly) contributes to my dislike for D.O.s and EPs. Every once in a while he would walk over to her, sip his coffee for a minute or two, and then examine her again. Touch her a couple of times, and say she is fine.

I think my dad was right in saying that EPs know a little about a lot of topics, but its a shame because they don't know too much about specific issues. My mom's pain managment doc said to her after that if he was there, she would have gotten the morphine immediately, because he knows exactly how much pain there is (he actually has the same thing, this is why he became a doctor) in this sitation.

Since then, my mothers right leg has gone numb, and the doctor says she probably won't get feeling back.

One last thing, I just witnessed a simple case of pneumonia be misdiagnosed by 4 MD's and it took a D.O. 10 minutes in his office to diagnose and prescribe the right antibiotics. The MD's prescribed the wrong type of antibiotics since the patient had an atypical pneumonia. My point? There are good and bad docs...regardless of the degree

Again, good luck

 

[Random]

Okay, before this turns into a flame war, we should probably just move on to somewhat less well-worn, not to mention unproductive paths than MD v DO but let me just point out that the DOs suffer just as much during school as MDs.

Anyway, to the OP, first of all, I'm glad to hear your sister's okay. As far as EMR, I've used several systems and I'm still much, much faster doing my notes by hand. Hopefully this'll improve as these systems get more user friendly, though. For pain control, I've only done a couple of shifts in the ED so I can't comment much except to say that the ED attendings and trauma surgeons I've worked with were advocates of medicating while evaluating. What I have seen plenty of is in the inpatient setting, where a number of old-school docs, esp. surgeons for whatever reason, seem to be so worried about dependency that they'll deliberately air on undermedicating.

There are some legitimate reasons for recalcitrance in giving narcotics, even with people in real pain. My first patient on my oncology rotation, who sticks out in my mind because he was an inpatient a couple of days before and pulled a knife on the nurses, was a sickle cell patient who was seeking (he was a dealer on the side).

Finally, while it's already been said, what's happening with the care team and what the patient's family thinks is happening are not necessarily the same thing. I think a good example of this, at least here, is with demerol. We don't give demerol for pain control since it's been known to cause so many seizures but people know about demerol and want it. When we don't give it, the occasional patient or family member's been known to think they're getting less than the best care.

Anyway, that's my $.02. Oh, and an IM attending told me last week not to bother asking where a pt.'s pain is on a 1-10 scale since it's so inaccurate.

 

[Tired]

There are some legitimate reasons for recalcitrance in giving narcotics, even with people in real pain. My first patient on my oncology rotation, who sticks out in my mind because he was an inpatient a couple of days before and pulled a knife on the nurses, was a sickle cell patient who was seeking (he was a dealer on the side).

Reminds me of a guy in Seattle in my days as a CNA. Bilateral AKAs from multiple MRSA infections (IV drug abuse). Came in all the time ostensibly for further soft tissue infections, but really for narcotics. When he was admitted, sometimes at night he would leave the light in his room on, and put up a big "X" with duct tape in his window. That's how his customers knew where he was so they could get their product.

 

[megadon]

There are some legitimate reasons for recalcitrance in giving narcotics, even with people in real pain. My first patient on my oncology rotation, who sticks out in my mind because he was an inpatient a couple of days before and pulled a knife on the nurses, was a sickle cell patient who was seeking (he was a dealer on the side).

Excellent point, which underscores management with sickle cell. They live with a great deal of pain normally, and thus when have a crisis need more pain management than one would expect. Flip side, high risk for addiction. They are weird patients, cause if they are truly in crisis, they need pain meds in high levels. Hate to say it, but they all look like addicts, while many aren't. All I have to say for them is that they need to learn everything about their disease, what their blood levels should be, what they are in a crisis, etc, cause then they can talk to you on a level where you understand they aren't an addict.

 

[Random]

Excellent point, which underscores management with sickle cell. They live with a great deal of pain normally, and thus when have a crisis need more pain management than one would expect. Flip side, high risk for addiction. They are weird patients, cause if they are truly in crisis, they need pain meds in high levels. Hate to say it, but they all look like addicts, while many aren't. All I have to say for them is that they need to learn everything about their disease, what their blood levels should be, what they are in a crisis, etc, cause then they can talk to you on a level where you understand they aren't an addict.

My point exactly. Even though this is quite common in SCD (the need for high doses of narcotics, not the dealing), there are any number of processes in which this can happen. Hopefully your average acute care doc will take every patient as they come and not instantly treat everyone in legitimate chronic pain like they're asking for meds out of proportion to their need but the more cynical among us, and it's easy to do with the ones like we've described, may very well go into the exam room or bay thinking that it's seeking behavior and the patient will be undermedicated for a legitimate complaint. It shouldn't happen but it does and I suppose what we as students should take from it is to take a wary eye to such cases but not compromise pain management unless we're quite sure there's a reason to do so.

 

[AmoryBlaine]

Bummer your cheif resident doesn't believe in evidence based medicine:It is a myth that surgery residents learn from old texts and old school attendings. It has been published in multiple journals in multiple fields that analgesia may affect the PE, but in NO WAY causes any change in management.

From JAMA: Do Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain? Sumant R. Ranji, L. Elizabeth Goldman, David L. Simel, and Kaveh G. Shojania JAMA. 2006;296:1764-1774. "Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors"

From Journal of American College of Surgeons: "...Results: There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy...." - Journal of the American College of Surgeons Volume 196, Issue 1, January 2003, Pages 18-31

From Society of Acedemic Emergency Medicine: Academic Emergency Medicine, Vol 3, 1086-1092 ...."CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients"

From European Journal of Emergency Medicine. Narcotic analgesia in the acute abdomen-a review of prospective trials. 8(2):131-136, June 2001.
McHALE, P.M. 1; LoVECCHIO, F. 2 *
Withholding administration of narcotic analgesia in patients with acute abdominal pain for fear of masking pathology is still pervasive in current medical practice. We reviewed all the prospective trials that investigated the safety, adverse affects, and ultimate outcome in patients with acute abdominal pain receiving narcotic analgesia within the emergency department (ED). No adverse outcomes or delays in diagnosis could be attributed to the administration of analgesia. Based on this research, we propose that it is safe and humane to administer narcotic pain relief to patients presenting to the ED with acute abdominal pain provided no contraindications exist.


There are several meta-analysis looking at prospective studies that show no change in management, just peruse and you'll find them. The results have been repeatedly shown from Annals of Critical Care, to Pediatrics, to IM and anesthesia. Please please please spread the word. (and print out an article for your misinformed resident from ACOS ).

That's good stuff. I guess I understood his rationale so it just always seemed reasonable to me. I mean, an SBO might be painful but you would certainly want to know pretty quickly if it perfed...

My theory is that we are all only selectively open to EBM. There was a study (admittedly small) a few years back that showed that M3s with 2 hours training in u/s were like 2x more accurate than cardiologists at dx'ing structural heart lesions. All of my attendings still want me to describe that freaking murmur though...

 

[deleted77919]

My theory is that we are all only selectively open to EBM. There was a study (admittedly small) a few years back that showed that M3s with 2 hours training in u/s were like 2x more accurate than cardiologists at dx'ing structural heart lesions. All of my attendings still want me to describe that freaking murmur though...

I remember reading that study. The only consolation is all the old school stuff will make me a better desert island doctor. Not that I could do much about a structural heart lesion on a desert island though . . .

 

[USArmyDoc]

Okay, before this turns into a flame war, we should probably just move on to somewhat less well-worn, not to mention unproductive paths than MD v DO but let me just point out that the DOs suffer just as much during school as MDs.

Anyway, to the OP, first of all, I'm glad to hear your sister's okay. As far as EMR, I've used several systems and I'm still much, much faster doing my notes by hand. Hopefully this'll improve as these systems get more user friendly, though. For pain control, I've only done a couple of shifts in the ED so I can't comment much except to say that the ED attendings and trauma surgeons I've worked with were advocates of medicating while evaluating. What I have seen plenty of is in the inpatient setting, where a number of old-school docs, esp. surgeons for whatever reason, seem to be so worried about dependency that they'll deliberately air on undermedicating.

There are some legitimate reasons for recalcitrance in giving narcotics, even with people in real pain. My first patient on my oncology rotation, who sticks out in my mind because he was an inpatient a couple of days before and pulled a knife on the nurses, was a sickle cell patient who was seeking (he was a dealer on the side).

Finally, while it's already been said, what's happening with the care team and what the patient's family thinks is happening are not necessarily the same thing. I think a good example of this, at least here, is with demerol. We don't give demerol for pain control since it's been known to cause so many seizures but people know about demerol and want it. When we don't give it, the occasional patient or family member's been known to think they're getting less than the best care.

Anyway, that's my $.02. Oh, and an IM attending told me last week not to bother asking where a pt.'s pain is on a 1-10 scale since it's so inaccurate.

Sorry, I did not mean to turn it into a flame war. I was just pointing something out. As you said though, there are more important things to discuss. Its cool to listen to MSIII's and IV's speak about their experiences. Right now, my heads are constantly in the books!

 

[AmoryBlaine]

I remember reading that study. The only consolation is all the old school stuff will make me a better desert island doctor. Not that I could do much about a structural heart lesion on a desert island though . . .

Ha ha, that's the classic preamble to making students learn about worthless physical exam steps. "Dr X, why do we have to learn about the succussive splash and tactile fremitus?"

"Well when you are working in the jungle in Guatemala..."

 

[Random]

Ha ha, that's the classic preamble to making students learn about worthless physical exam steps. "Dr X, why do we have to learn about the succussive splash and tactile fremitus?"

"Well when you are working in the jungle in Guatemala..."

Isn't that why I bought my otoscope?

 

[jbar]

Anyway, that's my $.02. Oh, and an IM attending told me last week not to bother asking where a pt.'s pain is on a 1-10 scale since it's so inaccurate.

While the patient's rating of pain may be very subjective, I think it can be valuable as an indicator of trend. Even if a patients 5/10 pain is different than my 5/10, if they then say their pain went to a 2/10 or a 9/10 it tell me two different things. A good clarification is to say "what's your pain on a scale of 1-10, ten being the worst pain you've ever felt in your life?" Then following up with "what was your worst pain before this?" If somone who broke his femur skiing is now telling you that his abd. pain is 9/10, it's prob. pretty high.

 

[deleted77919]

Isn't that why I bought my otoscope?

Yes, just remember to take it on all long distance flights where you have the chance to crash on a small island filled with creepy people and strange happenings ala Lost. Then you'll be glad you bought that otoscope.

 

[Tired]

While the patient's rating of pain may be very subjective, I think it can be valuable as an indicator of trend. Even if a patients 5/10 pain is different than my 5/10, if they then say their pain went to a 2/10 or a 9/10 it tell me two different things. A good clarification is to say "what's your pain on a scale of 1-10, ten being the worst pain you've ever felt in your life?" Then following up with "what was your worst pain before this?" If somone who broke his femur skiing is now telling you that his abd. pain is 9/10, it's prob. pretty high.

Yeah, because putting a number on it is different from saying, "Did you pain get better after the medicine? Do you need more pain medicine?"

And why would I care if it's worse than when he broke his femur?

 

[Random]

Yeah, because putting a number on it is different from saying, "Did you pain get better after the medicine? Do you need more pain medicine?"

And why would I care if it's worse than when he broke his femur?

I think jbar has a point but typically, you're not going to get a patient coming in with a complaint of 2/10 pain. Unless you're following a patient long-term, scaling tends to be pretty useless (as in your run-of-the-mill ED setting). In the acute setting, which was where my attending told me this, I think the point was that while there may be some use to asking about the pain scale, more objective indices like pulse, resps, and BP are probably more reliable for determining efficacy of pain control.

Another potential issue is that pain reporting is extremely variable, far beyond just prior trauma. This can even include cultural mores about expression of pain, which may cause someone to be stoic in spite of extreme pain.

 

[Xerxes1729]

Cultural differences definitely influence the pain scale. I remember patients in the rural, western ED I used to work in who would come in with 11 out of 10 pain resulting from a muscle strain or constipation. These people tended to be younger and irritating (i.e., talking on their cell phones in triage). On the other end were people like the old cowboy who had had 3 out of 10 pain after being trampled by some cattle - broken limbs, ribs, and a nearly detached ear.

 

[Tired]

more objective indices like pulse, resps, and BP are probably more reliable for determining efficacy of pain control.

Your point about cultural pain differences is important, and I'm sure frequently overlooked.

However, the vital signs correlation is frequently mentioned, but is completely false.

I don't understand why docs are so reluctant to take a patient at their word. Drug addicts are not that hard to pick out, and I'd be much happier giving a fix to a junkie once in a while, than undertreating real pain.

 

[LJDHC05]

http://www.msnbc.msn.com/id/18598633/site/newsweek/

this was an interesting article about EM realities for those who are interested

 

[Flopotomist]

I'd be much happier giving a fix to a junkie once in a while, than undertreating real pain.

Amen. I would MUCH rather unintentionally get a junkie a little high (no real harm) than leave somebody suffering (real harm). I think we need to reexamine our priorities as care providers when we are spending so much effort to try to make sure that the junkie doesn't get any of the good stuff that some people in pain suffer (I am looking at you DEA and your obnoxious triplicate forms).