Monday, October 31, 2011

Managing Pain Properly - No Matter What Age

Everyone experiences pain at some point in their life, be it the sudden (acute) pain from a bad cut or a broken bone or the chronic pain of a back injury or migraines, just to name a few causes. Acute pain is generally well treated because it is usually caused by something you can see (a cut, a surgical incision, a broken bone), and many analgesics (pain relievers) are meant to handle the pain. Chronic pain, however, can't be seen clearly, can't be identified easily, and certainly can't be treated easily. But is it because it *can't* be treated, or because it *isn't* being treated. There are arguments for both sides.

Throughout my work as a nurse, I saw pain (mis)management for many patients. Rarely were the patients over medicated - they were much more likely to be undermedicated. This happens for many reasons, the most common ones being:

  • The person assessing the pain is using his or her own thoughts of pain as a measuring stick as to how painful a certain situation should be.
  • The person assessing the patient doesn't see the patient acting in a way that he or she feels a patient in pain should be acting.
  • The analgesics prescribed are not effective for the type of pain the patient is experiencing.
Not only did I see it in my professional life, I've seen it personally as well, most recently over this past weekend. My mother fell over a week ago and broke her ankle. Then we were told it was her hip too, now we are back to "just" her ankle. The thing is, she has other chronic problems - in particular a badly damaged back - that cause a lot of pain so at home, she was on a constant dose, every day, of a pain reliever that kept her pain at bay. Once she was admitted to the hospital, this constant pain reliever was discontinued because the doctors needed to assess her overall health.

After a few days of very severe pain, she was prescribed a patch of a medication called fentanyl. It's a great (in my opinion!) way of delivering medication, because the patch goes on your skin and delivers a constant dose of analgesia for three days. There is no up and down of pain reliever levels in your blood, it is always there. After three days, it needs to be replaced, but it is a simple procedure of removing the old patch and applying the new one.

In my mother's case, she had to have the patch removed the same day she was going to surgery for her ankle, so she didn't have a new patch put on. This was Saturday. I went in to see her on Sunday and she was in a lot of pain - more than just post-surgical pain at her ankle, her back was very, very painful. I wasn't sure why, so I looked for her pain patch. She didn't have one. She should have.

I went to speak to her nurse who was puzzled that I would be asking for a pain patch - she said that she would have it again in three days, when it was time for the next switch. I explained to her that she had no patch at that time - nothing. No pain relief other than the short acting acute pain reliever they were giving for her surgical pain. The nurse didn't seem to understand my argument. I kept saying, the patch should have been put back on - it wasn't put back on. It doesn't make sense that my mother (or any patient) should have to wait three days because that is what the medical record said. The medical record is assuming that she had HER PATCH ON.

After much discussion, the nurse said she would call the pharmacy (of the hospital) to see what she should do. Sure enough, she was in my mother's room within a half hour with a new patch for her. When we asked her why my mother hadn't been receiving this pain relief for her chronic back pain, the nurse answered something to the effect of "here we are only concerned with the surgical problem, not her other ones." What?

So, what was wrong with this picture? A lot.

We have an 82-year-old lady who is in a lot of pain from the new fracture and from the old back injury. She has been taking long-term pain medication for years, so her body is used to a certain level of analgesia in her system. This chronic pain medication was taken away from her and not replaced. Therefore, she was in much more pain than she had to be. Because the nurses couldn't be bothered with learning about all of my mother's medical issues, they didn't understand why the chronic pain medication (the patch now) was vital for her recovery. If you are in pain, you can't do your rehab exercises, get out of bed, or even think of getting better. Then the cycle began. Because the nurses didn't understand why her chronic pain relief was necessary, she didn't get it. Because she didn't get it, she had more pain....

Pain is not something that can be ignored, regardless of the cause. A patient who is having pain cannot heal properly. The amount of energy it takes to deal with pain is taken away from the energy needed to heal.

I will be discussing this issue with the hospital once everything has settled down. I do have to say, I was absolutely not impressed with the cavalier attitude of someone who wasn't in pain regarding someone who was.