What’s Your Pain?

It’s something we ask all of our patients.  As nurses we want, no, need to know if our patient is in pain.  So we ask, “On a scale of 1-10, with 10 being the worst pain you have ever had, how would you rate your pain?”  Or we use the faces method, or whatever method of assessing pain is in vogue at the moment.

So very often with a straight face, the patient looks at you and says, “I’m in 9 out of 10 pain.”  Just like that.  Straight faced.  Vitals are completely normal.  Face calm, nearly serene, talking and laughing on the cell phone, with not a single outwardly visible sign of any discomfort.  Since we rely on out patients to report their pain to us, it is not something we can objectively monitor, you have to accept what they say it is.

Now I know people in chronic pain.  I know that you can learn to block, modulate, go into a Zen-like trance to mitigate your pain.  But I have never seen anyone in true 9/10 pain who is calm.  That would be impossible.  I always try to give a scenario with pain, so that the patient will understand what I mean.  I’ll say, “0 is no pain, 10 is being doused in gasoline and set on fire.” or for the ladies, “10 is giving birth.”  But still I get the odd answers.

The reason I bring all of this up is that we have had a preponderance of folks in “pain”.  These painieurs always report their pain is 9/10 and that the only thing that works for them is Dilaudid.  They watch the clock and call 5 minutes before they are due to “remind” us that their meds are due.

We actually had one come up to us who immediately complained about 9/10 chest pain.  The nurse, being thorough asked, “What do they give you normally?  Nitro?”  “No” she replies, “They just give me Dilaudid.”  Straight-faced, looking like she is in a café ordering a latté, yet still having 9/10 chest pain.  To me it is a total disconnect.

Partially the disconnect comes from the fact that we color the patients’ report with our own perceptions.  The other week I re-injured/aggravated an old ankle/foot injury.  It throbbed mercilessly and then it would spasm.  At times, the spasms were so painful that I felt like I would vomit from it.  Even my wife looked at me grimacing, sweaty and pale and asked if I was OK.  Sure I was being John Wayne-esque about it and stoic, but it hurt.  I popped a couple of Tylenol, grabbed the ice pack and put my foot up.  Even with me almost vomiting from the pain, I would only have rated the pain a 7, maybe a soft 8 of 10.  I can imagine what 9/10 pain feels like and I have no desire to feel that.  I know that if I was truly in 9/10 pain, I would not be calm.  That’s why it is so hard.  You wish you could tell the patient to “cowboy up” and deal with the pain, but you can’ – although I did overhear an orthopod tell his patient we was going to have to do just that.  We have created a culture where it is never OK to have some discomfort.  Just look at the rash of relatively healthy folks showing up to EDs complaining of the sniffles and low-grades temps thinking it is the flu.

So sometimes you don’t ask.  You observe from a distance and document.  Even when you’re assessing the patient, unless they bring it up, you stay away from it.  What I hate the most about the painieurs is that they color your assumptions of everyone else.  Where you normally would try to reduce the pain of your patients, you ask yourself, “Are they faking it?  Do they just want the buzz?”   And I hate they have done that to me.

I know there is no easy answer to this dilemma.  I try to take the road where unless they have proven themselves to be dodgy, I treat the pain full force.  But with some that you deal with time after time after time, you know that they are drug seeking and all they want is the rush.  But moreso I try not to let my own perceptions of pain color my view.  I may be able to deal with 7/10 pain better than others due to my nature, so I can’t let that get in the way of effective treatment.  And for the most part I don’t.  It is just those rare occasions where I question, but more often than not I give the meds and hope we’re not being taken advantage of.

And as for the patient who only wanted Dialudid?  The nurse called the doc who pretty much said they were a known drug seeker (which we knew already) and she would not provide their drug of choice.  The patient realizing they were not going to get Dilaudid promptly signed out AMA.

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5 Comments

  1. You’re right — no easy answer. I’ve learned who not to ask about pain. We can usually tell who really needs to be medicated and who’s drug seeking. But, I know from personal experience that it doesn’t always work. Before I became a nurse, I ended up in our local ER on a Sunday after three straight days of a headache that was so bad I could barely lift my head up off the pillow. I had never had one like that & it scared the crap out of my husband, so off to the ER I went. Ended up going alone because we didn’t want our young children hanging out there. Being a stoic, I wasn’t going to sit there & moan & cry. And, the whole pain scale crap seemed ridiculous. Like you, I knew that I wasn’t a 9 or a 10, so I probably said a 6 or 7 (seemed severe to me…). Being the skeptics we all know & love, they must have thought that I was drug seeking. I got a shot in the butt & sent on my way with a lecture about what the ER is for & not to abuse it. Insurance didn’t cover the visit thanks to the way the dr wrote it up. Long story longer…sometimes the calm ones really are in pain.

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  2. Daughter sitting on floor, puking from pain – calls it an 8, after pain-killers. Finally decide on ER after not being able to reach doctor. Get the ER is for stabilization lecture, her (new) chronic(??) condition is the same. Offers an Ativan, she calms some, from fetal to curled up. They call it a reduction of pain, and f/u with physician, and send us home.

    I want to tell her to insist her pain is a 10. I want to tell her to not feel better, until her pain is what she would consider a 2. I want to tell her to cry and moan in front of the doctors the way she does at home, and to stop trying to be strong. I want to tell her to not bite back or apologize for the screams when examined.

    But I don’t want to raise a drug-seeker. I don’t want this to become a manipulation of the system. So I just trust and pray that we will find the appropriate care and pain management. That being sent home, means we should be grateful it wasn’t serious enough to keep her, and trust that the pain will pass.

    All we got, trust, right?

    Sam.

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  3. Drug Seekers: The Undoing Of A Nurse or Why I Don’t Care Anymore is going to be the name of my autobiography. I’m so sick and tired of chronic drug seekers taking up space on my unit and usually eating up my time when I could you know be at the bedside of really sick people. Prescription drug junkies are bleeding the system dry. Not the 98 year olds.

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  4. These drug seekers drive me nuts, even though I don’t know any. My husband and I are pretty normal people. We don’t drink, don’t smoke, our only real vice is overindulging in food a bit too much. So, when he woke me up at 3am to drive him to the ER because he herniated a disc and was in extreme pain, I didn’t really expect to have the ER docs doubt that he was really in pain, but my husband was being the strong-man and trying to stay calm.
    I suppose it is fortunate that his medical history had one prior herniated disc and did not show drug-seeking behavior. They gave him the dialudid and a prescription for percocet that lasted long enough for him to see his doc, who made him get an MRI and get surgery (it was bad).

    I can understand not wanting to give drugs to drug seekers, but I would rather see the occasional junkie get a fix than see someone in that kind of real pain have to wait while the nurse decides if he seems like he might be faking it.

    My question is…what happens when a known drug seeker really does herniate a disc, or something? Do they get the meds or not?

    Reply

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