Monday, March 13, 2006

Pain in the ER

Doctors witness a lot of unavoidable pain. Whether it’s from trauma, from surgery or from labor, we become sensitized to it. We couldn’t be good doctors if we were not. Yet sometimes we become so used to the pain of others that we do not take the easy steps that would reduce avoidable pain.

When my son teenage son broke his arm in a snowboarding accident, I knew what to expect in the emergency room and I girded myself for a battle over pain medication.

My son is a big, strong kid with a high tolerance for pain. On the drive to the hospital, he appeared to be in agony, and no wonder. His shoulder was swollen to twice normal size. Either his upper humerus was broken or his shoulder was dislocated.

When he was taken into a treatment room for examination, I introduced myself to the nurse and told her I was a physician. I requested that my son receive pain medication before he was examined, and was informed in no uncertain terms the hospital policy was that patients could not receive pain medication until after X-rays were done. I was adamant though, so the nurse returned with the ER attending.

The ER attending also told me about the hospital policy. As a physician, I am aware of drug seeking behavior, but when a physical exam tells you that a patient is in legitimate pain, there is no need for X-ray confirmation. The ER attending did not have any doubt that may son had a significant injury. Fortunately, he was amenable to the reasonable suggestion that since we already knew he was injured, it would be quite appropriate to treat his pain. My son went to radiology feeling more comfortable. The X-ray showed a displaced fracture of the surgical neck of the humerus. The distal part of the bone was riding more than 1 cm above the proximal portion. Subsequently it turned out that the distal part of the bone had punctured the deltoid muscle.

Because I am a physician, because I insisted on speaking to the ER attending, and because I insisted on pain medication, my son received a painkiller immediately. Another child would have had to wait at least an hour for relief. How have we gotten to the point that the ER personnel feel free to disregard a patient’s pain until they have an X-ray to look at? Allowing the nursing staff to make an assessment of the patient’s pain would cost no additional time and no additional money. Isn’t it the least that we can do for the patients we treat?


Blogger Kim said...

Hi Dr. Amy,

Every assessment in my ER includes a pain assessment and all it takes is a verificiation of no allergies and a check with our ER doc to get pain relief.

In fact, a patient in as much pain as your son with that type of injury would have been at least seen by the doc rather quickly....

Heck, I can often medicate at triage for bad ankle spains.

9:43 PM  
Blogger zaphod said...

At our facility we have a nurse-initiated standing protocol for treatment of pain with oral meds while waiting (including a dose of hydrocodone if nurse feels it is warranted). Patients in whom oral meds may not be appropriate (they might need surgery), or insufficient are brought back as rapidly as possible for an IV or nerve block.

Considering how many delays can occur prior to getting radiographs, and how painful it can be just having the radiographs done, the local hospital policy seems ill-considered if not a little cruel. Perhaps they have been so badly bitten by abusers/diversion that this draconian policy seemed the only way to stem the tide.

12:51 PM  

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