Pain Management Consult... is such a PAIN!

[Faebinder]

With a risk of bringing the wrath of Pain people around these forums I will rant about Pain Management.

We handle a lot of "opiate tolerant" patients. Crohn and UC end up being on percocet and vicodins for many years before they finally give up and come to get something taken out. And so, we consult pain management knowing that the patient needs a lot of pain meds and you know, giving dilaudid in super doses doesn't leave us comfortable.

It's always a CRNA or a resident (Gosh I wish it was a resident cause at least they respond to pages at night. I have yet to have a CRNA respond to nurse pages at night for pain.) It seems they just dont want to do the job, I dont know. Epidural doesn't help it seems... they give an "above average" dose of dilaudid but nothing that we are scared of giving. I have yet not to have a patient who did not complain of pain despite consulting them.. and in the end I end up coming over and putting the patient on Toradol.

I dont know, my experience (which is like n = 10) with pain management has been awful for postoperative management of opiate tolerant patients. I always get the night call for pain.

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[Tired]

Pain service can be rough at my house too. Half the time we call in the consults and get all sorts of crap from the resident about how it's an unnecessary consult and we should be able to manage it ourselves. There's one particular Anes PGY-3 who is known to be an a$$, and even worse, poor technical skills. I call one consult to him and he told me:

"This is a pretty weak consult, and normally I would tell you no, but since it's July and I know you don't know anything, I'll see the patient."

Like it was my idea in the first place.

Nights usually go okay, and our Pain residents cover 24/7 and are usually good about handling their issues. A month ago though, I got a call from the nurse for a PCA adjustment at midnight:

Me: "I thought pain service was handling him?"
RN: "I called, they said they signed off."
Me: "But they saw him all day!"
RN: "I know, and they saw him an hour ago too and just changed his settings."
Me: "And now they're signed off? At midnight they signed off?"
RN: "That's what they said."

That was awesome. Someday I hope I can sign off of a patient in the middle of the night without telling anyone, not leaving a note, and without attending input.

 

[Faebinder]

Pain service can be rough at my house too. Half the time we call in the consults and get all sorts of crap from the resident about how it's an unnecessary consult and we should be able to manage it ourselves. There's one particular Anes PGY-3 who is known to be an a$$, and even worse, poor technical skills. I call one consult to him and he told me:

"This is a pretty weak consult, and normally I would tell you no, but since it's July and I know you don't know anything, I'll see the patient."

Like it was my idea in the first place.

Nights usually go okay, and our Pain residents cover 24/7 and are usually good about handling their issues. A month ago though, I got a call from the nurse for a PCA adjustment at midnight:

Me: "I thought pain service was handling him?"
RN: "I called, they said they signed off."
Me: "But they saw him all day!"
RN: "I know, and they saw him an hour ago too and just changed his settings."
Me: "And now they're signed off? At midnight they signed off?"
RN: "That's what they said."

That was awesome. Someday I hope I can sign off of a patient in the middle of the night without telling anyone, not leaving a note, and without attending input.

This happens to us soooo much... not necessarily sign off.. but freakin get called for pain even when there is pain management involved. It's pretty much useless.

 

[Tired]

This happens to us soooo much... not necessarily sign off.. but freakin get called for pain even when there is pain management involved. It's pretty much useless.

Our surgical nurses are really excellent, and I can't really expect them to know which patient's Pain manages and which ones I do, so I don't mind them calling me.

But there's really no excuse when the residents give me crap about the consults I call. I mean seriously, you only do one thing. My patient has pain. You manage pain. If I could do it myself, I would, because it would be a lot less trouble than taking their crap on the phone for ten minutes, pretending they're doing me some kind of favor.

The worst part is that there's never a question that they're going to see the patient: You're the resident. You don't decide who you see and who you don't. So why are you pretending like you're some kind of gatekeeper? Shut up and see the patient.

One of these days, I'll work up the cojones to have this conversation:

Me: "Hi, I'm calling in a consult."
PGY2: "<sigh> What's going on with the patient?"
Me: " . . . I'm sorry . . . is this Pain Service?"
PGY2: "Yes."
Me: "Well then . . . WHAT THE HELL DO YOU THINK I'M CALLING YOU FOR?!"

 

[oompaloompa]

I don't know about you guys, but many of our "pain" patients come fully loaded with a big batch of crazy to to add to their issues.

In the pediatrics world, this will inevitable manifest as a neurotic teenage girl. She will be surrounded by family and such, who will feed into the crazy by discussing every single component of her pain ad nauseum. Geesh, if some one actually talked about something else every once in a while, they might stop focusing on it for 2 seconds.

I've also found that these kind of patients' will often give you a number, even though I never ask for one. It's usually like an 11 or a 15, almost never actually on the 1-10 scale.

 

[Faebinder]

I don't know about you guys, but many of our "pain" patients come fully loaded with a big batch of crazy to to add to their issues.

In the pediatrics world, this will inevitable manifest as a neurotic teenage girl. She will be surrounded by family and such, who will feed into the crazy by discussing every single component of her pain ad nauseum. Geesh, if some one actually talked about something else every once in a while, they might stop focusing on it for 2 seconds.

I've also found that these kind of patients' will often give you a number, even though I never ask for one. It's usually like an 11 or a 15, almost never actually on the 1-10 scale.

Oh yeah, Axis II diagnosis glaring with many of them.... i still gotta look up that article that claims that more than 2 allergies is a high indicator of the presence of an axis II diagnosis.

 

[doc02]

My big problem with Pain Management is their unwavering adherence to the adage that "anyone who says they are in pain is actually in pain." We had a guy sitting around all relaxed, normal vitals, always asked for higher doses of pain meds. So we did a semi-dump consult to Pain Management. We figured they'd come in, see the patient, and tell the guy that in their professional opinion he was on appropriate medication, then sign off. It's a dump, but it's a five-minute consult. Next thing we know, he's on a PCA and loving life, hitting the button every two seconds and doing cartwheels. It was pretty sad. And then when they switched him off, since he had "such a high need," they basically gave him the equivalent of a blank prescription. I mean, the amount of narcs they sent him home on was unreal. You could start a pharmacy with it. I'm sure he sold half of it on the streets for some major cash.

Pain Management has helped me on some major pain problems, don't get me wrong. But I've NEVER seen them say someone doesn't need pain meds. It's like they're scared that if they say no to someone they'll go out of business the next day.

 

[Pir8DeacDoc]

I'll save you the time and energy of calling them..


Start everyone on methadone. Mix in your choice of dosing for oxycodone and throw in some Ibuprofen for good measure. Don't forget the IV stuff for breakthrough. At our hospital it seems to be a set formula for every patient.

 

[Tired]

Oh God, those are the craziest patients around.

Me: "How are you doing today?"
Pt: "My pain is a 12!"
Me: "I didn't ask for a number, a$$hole."

As far as recommending pain regimens, thanks for the input, but that's not really the issue. I have a bunch that I'm very comfortable using, and I'd like to think that, especially acutely post-op, I can manage 9 out of 10 patients reasonably well.

The problem is that, on some services, anyone whose pain isn't controlled with low-dose oral narcotics, the chief or attending immediately tries to punt off the problem to Pain. Hell, I've seen some of my residents get all flustered because the T12-Ilium fusion with hardware is having pain despite scheduled Vicodin. Well gosh guys, you just split the dude's whole back open, are you really suprised that we might need to do some fine-tuning beyond what dentists give for tooth extraction?

 

[doc02]

Forget the number system. I like ripping down those lame "face scales for pain" signs from the wall and holding it up next to the patient's head. I match it up and go from there. I don't accept a "10" unless he's actually frowning with a tear streaming down his face. "12" would probably mean that his face imploded into his neck, in which case I'd probably leave the room and pretend I was never there.

 

[Pir8DeacDoc]

As far as recommending pain regimens, thanks for the input, but that's not really the issue. I have a bunch that I'm very comfortable using, and I'd like to think that, especially acutely post-op, I can manage 9 out of 10 patients reasonably well.

I was generally piling on with their lack of helpfullness. Not actually trying to give you a regimen. Totally tongue in cheek.

 

[OB1🤙]

Something I started doing only recently when they give me this nonsense is to say, "Look, let me state this another way. 0 is no pain at all, and 10 is being disemboweled with a rusty saw while having your head dipped in boiling oil." It's actually helped. Gotta be careful who I say it to at the VA tho...

Forget the number system. I like ripping down those lame "face scales for pain" signs from the wall and holding it up next to the patient's head. I match it up and go from there. I don't accept a "10" unless he's actually frowning with a tear streaming down his face. "12" would probably mean that his face imploded into his neck, in which case I'd probably leave the room and pretend I was never there.

 

[doc02]

I used to say "10 is like if you were crossing the street and you were hit by a bus." But then they'd just go, "yeah, I feel like that" even if they were just sitting there relaxed. It's a complete waste of time. So now, I ask them how their pain is and ignore it as long as they look comfortable.

A lot of the patient-doctor interaction is just stupid psychological games, see? A lot of patients will exaggerate their pain because they're scared that you'll ignore it otherwise. (It's sort of like when a small kid hits their head and they don't cry, but they'll wander around until they find their parents and THEN cry.) Or sometimes it's cultural. Hispanics are well-known for that, and I'm not being racist. Like, you go into their room and they're just sitting there, you press on their belly and they melodramatically go, "AY YAY YAAAAAAAYY!!!! DOCTOR, AY YAY YAAAAAAAY!!!!" The ones who actually feel pain don't do that, they just wince or grimace.

Likewise, if you ask them about their pain, they feel like you're paying attention to it, which is what they want. So they say they have a 10 and you nod sympathetically. They feel validated. It's a big game. Don't get me wrong, if they're actually in pain, I treat it with whatever I need to. I'm talking about the people who are sitting around reading a book until you ask them about their pain.

 

[Tired]

I never ask for a number any more either. It's not going to change a damn thing I do. I'm continually amazed that my residents and staff, who will berate me for ordering any test that "won't change management" will then turn around and ask for a g-damn number on the patients' pain. So what, if it's a three, you give Tylenol, and if it's a seven they get Morphine? Bull$hit. And don't give me that crap either about how you can track the effectiveness of pain interventions based on the number, since a 4 will always go to 3 in a normal person, and a 10 will stay a 10 in the addicts, no matter what you give.

 

[doc02]

How about how people act like you can't tell if someone is in pain unless they tell you? Or, conversely, if someone says they are in pain even though they look absolutely normal, they're actually literally dying of pain "inside." I mean, that guy who you just saw trying to hit on nurses is actually screaming like a maniac, but only in his "inner place" that he's hiding from you for some reason. Shame on you for not realizing this! You are a cruel person, like a sociopath. Cool, he got her number, now you can give him that morphine he so desperately needs. Go go go!!

 

[Faebinder]

ARGH!!!

Time for a second pain management story...


I got called in to scrub on a patient in a parallel room. It's a patient case for small bowel cancer and classic large bowel obstruction. Of course it's another opiod addicted patient and this one is even taking neurontin. I write the typical orders.. didnt realize he has an epidural. Nurse pages me like 10 minutes later, "Yo he has an epidural." Oh okay... lemme double check with senior... ok she wants pain management to continue handling him (Duh Faebinder he has an epidural!) Okay... DC PCA and let Pain management handle him. 1 hour later, patient went to the floor and no longer in postop, he is screaming for a doctor, has a lot of pain and wants to talk to the surgeon even though he knows pain management is handling his pain.. Floor pages pain management TWICE... no one replies. I get paged in middle of lunch (yeah well i dont get lunch of course but damn it, i just wanted to bite my sandwich I just bought!) and after being on hold for 2 minutes nurse tells me all that. I tell him to give him some morphine and i go to the attending and tell him the story... says nope, anesthesia pain management needs to know. He tells another attending and boom... 2 minutes later someone is upstairs handling this crap.

I hate painful pain management. So useless, I don't know why we even bother if I am going to be writing the PCAs and breakthroughs.

 

[doc02]

Don't you like how, since the nurse can't get ahold of the correct person, their strategy is to call you? In other words, now they've notified someone else and it's not their problem any more? They're so slovenly and lazy. It's not like you are going to do anything special EXCEPT to continue trying regardless of how much time and energy it takes until you succeed in an outcome. Meanwhile, they're in the break room ramming food down their gullets and belching and farting all over the break room. Not because they're on break. Just because. (Here's a true fact: some of our nurses actually KNIT during their overnight shifts. No joke. It blows my mind.)

 

[Tired]

Don't you like how, since the nurse can't get ahold of the correct person, their strategy is to call you? In other words, now they've notified someone else and it's not their problem any more?

Personally, I want the nurses to call me when they can't reach pain management. I've seen patients languish on the floor too many times as they page those guys over and over again trying to get a med order. Plus, if I know about the problem, it gives us a little bit more leverage when the inevitable confrontation with their service comes.

One of my fellow interns had the anesthesia resident tell him that they would "get to the patient tomorrow morning". He documented that in the note, and it turned into a nasty fight between the attendings, which had been a long time coming. Lately we don't have so much trouble getting them to see patients anymore.

 

[doc02]

I want the nurses to call Pain Management when they can't get in touch with Pain Management. Because, with the exception of Dermatology, you actually CAN get in touch with anyone in the hospital that you want to as long as you actually try.

 

[timtye78]

After reading a few of your shrill pain management stories, I had to comment and teach you guys a little about pain management in the hospital setting, eg acute pain services, etc etc

Myth #1- "These pain people do only one thing" WRONG. In the academic setting, even 'pain' attendings commonly are not fellowship trained- usually about 70% are fellowship trained docs. More often than not, regular anesthesia attendings are on 'acute pain call' Also, some places put their pain fellows on as attendings for acute pain call.Most often this is a consultant call taken from home. Sorry-no one will get out of bed for some chronic known drug seeker and give you some type of miracle solution. Many anesthesia residents take multiple service calls at the same time, and quite possibly be in the OR when they get your page.

Myth #2-Pain consults will elicit a magical solution to your chronic pain persons state of contentment at any hour of the day or night. Ok so your gomer is on high dose oral narcotics, and is allergic to the rest, and he hurts. If he is in the hospital, put him on a morphine PCA, and pain can see him later.

Myth #3-Due to the 'urgent' nature of pain, and you have nothing at your disposal, doctor, call your local anesthesia resident on pain call at 3 am, and demand he/she comes in right away. Basic rule for all interns/residents, call your conslts early, and unless you are consulting cardiology for ST changes, don't be surprised when no one arrives till 10 am the next day. Pain is rarely a true emergency, unless of course, you are trying to sleep and that damn nurse keeps calling you, and you wish to deflect those calls to someone else!

I could go on but my interest has waned.

 

[doc02]

Most often this is a consultant call taken from home. Sorry-no one will get out of bed for some chronic known drug seeker and give you some type of miracle solution.

So for some reason, your reasoning is that since the attending is at home that therefore they don't have to deal with the situation? Wow, you sure set us all back in our place! Oh, and by the way, if Pain Management suddenly "understands" about "drug seeking" after 9 PM, then they should learn about it between the hours of 9 AM and 5 PM, too. Because for some reason, when Pain Management is conveniently in the hospital and they don't have to schlep in, they don't mind billing five times per day for "chronic known drug seekers."

Myth #2-Pain consults will elicit a magical solution to your chronic pain persons state of contentment at any hour of the day or night.

Does anyone sense a trend here? Pain Management doesn't believe in pain control after a certain hour. But during the day they'll bore you to death with lectures about how we have to "respect" pain as they refer everyone to their pain clinic for injections that they can bill for. Appointments only available during the day, fellas!

Myth #3-Due to the 'urgent' nature of pain, and you have nothing at your disposal, doctor, call your local anesthesia resident on pain call at 3 am, and demand he/she comes in right away.

It's like a broken record!

The motto: Pain Management: Our lifestyle is more important than your solution.

 

[Faebinder]

After reading a few of your shrill pain management stories, I had to comment and teach you guys a little about pain management in the hospital setting, eg acute pain services, etc etc

Myth #1- "These pain people do only one thing" WRONG. In the academic setting, even 'pain' attendings commonly are not fellowship trained- usually about 70% are fellowship trained docs. More often than not, regular anesthesia attendings are on 'acute pain call' Also, some places put their pain fellows on as attendings for acute pain call.Most often this is a consultant call taken from home. Sorry-no one will get out of bed for some chronic known drug seeker and give you some type of miracle solution. Many anesthesia residents take multiple service calls at the same time, and quite possibly be in the OR when they get your page.

Myth #2-Pain consults will elicit a magical solution to your chronic pain persons state of contentment at any hour of the day or night. Ok so your gomer is on high dose oral narcotics, and is allergic to the rest, and he hurts. If he is in the hospital, put him on a morphine PCA, and pain can see him later.

Myth #3-Due to the 'urgent' nature of pain, and you have nothing at your disposal, doctor, call your local anesthesia resident on pain call at 3 am, and demand he/she comes in right away. Basic rule for all interns/residents, call your conslts early, and unless you are consulting cardiology for ST changes, don't be surprised when no one arrives till 10 am the next day. Pain is rarely a true emergency, unless of course, you are trying to sleep and that damn nurse keeps calling you, and you wish to deflect those calls to someone else!

I could go on but my interest has waned.

I sooo wanted to reply to this post but I choose silence. I will just refrain from consulting in-house pain management when i call the shots. I'll just keep em all on PCAs.

 

[doc02]

If Pain Management only wants to practice during the day, I'll do what everyone does in private practice. I'll put my consults in when I need them and if the attending doesn't want to help me out, he'll never get any more business ever again. Then he'll go home and have a great night's sleep and the next day the repo man will show up. And if no Pain Management physician wants to help out, I'll just document that and let the patient know.

 

[timtye78]

Generally speaking, a good acute pain service in any hospital, notably excepting some academic powerhouses, will be a rare find. Most of you practice only in the academic setting at this time. Try seeing what you get out there in the community setting before you scoff at what I am telling you.

I haven't met a single doctor who likes inpatient acute pain. Fellows and residents do it only because we are forced to do it.

Acute pain consults do not build any practices or make any money for anyone. It is provided as a service to the hospital. Very few if any docs builds a pain practice from inpatient pain consults. Chronic pain patients usually already get their meds from their FP writing hydrocodone, etc, and the others are usually people with genuine acute pain issues, eg s/p BKA and they need someone to manage their epidural-this doesn't build anyone's practice.

Most Pain management fellowship trained docs despise inpatient acute pain, and are satisified doing their procedures as outpatient. They dont need interns referring them anything.

I am sorry you are having trouble with your consults. What I am trying to tell you is that is sucks almost everywhere. The problem is innate. The consults are usually dumps. There is no quick solutions to these patient's problems. I don't know how many full H&P consults I did on acute pain, and the attending basically tells me there isn't anything we can do, so we recommend TENS unit. I do understand your attending doesn't want any more phone calls, and he wants be able to document that he consulted pain-so he is off the hook. Mission accomplished.

 

[doc02]

I haven't met a single doctor who likes inpatient acute pain. Fellows and residents do it only because we are forced to do it.

OK, there are two different issues here. First of all, we all understand that there are differences between residency and private practice and we DEFINITELY understand that there are things that residents only do because they are forced to do them.

That being said, don't try to shovel a load our way. Pain Management may dislike inpatient pain, but I'll bet you they love outpatient pain. I've talked to a number of Anesthesiologists and they all want to get into Pain Management because it's a great lifestyle and lucrative. (Keep in mind that Anesthesiology already is pretty cush and they're still chasing after something even easier; that's pretty pathetic.) Therefore, seems to me that the issue really boils down to "don't call me at night when I'm sleeping and won't get paid as much, call me during the day when I'm awake and can generate a lot of money," which is pretty sad as a motivation factor.

 

[Tired]

Basic rule for all interns/residents, call your conslts early, and unless you are consulting cardiology for ST changes, don't be surprised when no one arrives till 10 am the next day. Pain is rarely a true emergency, unless of course, you are trying to sleep and that damn nurse keeps calling you, and you wish to deflect those calls to someone else!

I'm not sure who you're arguing with. The major issue we have is not that they won't come in at 3am for a new consult, it's that they don't want to deal with 3am calls on patients they're already consulted on. So the attending doesn't want to come in while on home call? Great, that's why we have anes residents in house covering floor calls. But if you're covering the patient, maybe you could answer the pages. After all, it's your service that gets all pissy if we make any changes to "your" pain regimen.

Personally, I have only ever called a Pain consult after 3pm once. It was a screaming patient aerovaced from Nicaraugua who got dumped on the wards with an epidural catheter coming out his back, that was completely empty. And I only called pain after I dumped 150 of Fentanyl on him and he was still wailing.

 

[Ferdie]

I am at a large academic institution and we have an excellent acute pain service. I think the hospital's nurses and surgeons would agree. We have an acute pain resident (there from about 8 am to 5 or 6 pm or so), who is very responsive. A huge asset for us is our acute pain NP (there from 9-5 or 6), who is very very good and who everyone in the hospital loves. In addition, we have a block doc (acute pain and blocks attending, there from about 6:30 am until 6ish pm), and blocks resident, and a blocks nurse, who are also all available to help if needed (though they are rarely needed, as the NP is wonderful and the residents are also very good). At night an on-call resident covers the pain pager, and we have had very very few problems.

 

[proman]

Don't confuse the acute pain service with chronic pain. The chronic pain (what the fellowship gives you-intervention) docs frequently have no involvement with the acute pain side. We have a good setup: a CA-2 (PGY3) covers the code pager for half the hospital and the pain pager.

 

[doc02]

It was a screaming patient aerovaced from Nicaraugua who got dumped on the wards with an epidural catheter coming out his back, that was completely empty.

Why is a Nicaraguan being aerovaced into the U.S. for medical care? Who was it, Manuel "Grapefruit Face" Noriega? If someone told me a friggin' Nicaraguan was being aerovaced into the U.S. for medical care, I'd do the equivalent of a slow code and get around to him after I had dinner and taken a large, relaxing dump in the call room bathroom. It's bad enough I have to take care of Mexican illegals, now I have to deal with Nicaraguans being flown in? You better have a good story connected to this.

 

[deleted109597]

Why is a Nicaraguan being aerovaced into the U.S. for medical care? Who was it, Manuel "Grapefruit Face" Noriega? If someone told me a friggin' Nicaraguan was being aerovaced into the U.S. for medical care, I'd do the equivalent of a slow code and get around to him after I had dinner and taken a large, relaxing dump in the call room bathroom. It's bad enough I have to take care of Mexican illegals, now I have to deal with Nicaraguans being flown in? You better have a good story connected to this.

Nobody said it was a Nicaraguan. It could have been an American with good insurance. Trust me, you don't want to have a Central/South American splenectomy.

 

[Tired]

Why is a Nicaraguan being aerovaced into the U.S. for medical care? Who was it, Manuel "Grapefruit Face" Noriega? If someone told me a friggin' Nicaraguan was being aerovaced into the U.S. for medical care, I'd do the equivalent of a slow code and get around to him after I had dinner and taken a large, relaxing dump in the call room bathroom. It's bad enough I have to take care of Mexican illegals, now I have to deal with Nicaraguans being flown in? You better have a good story connected to this.

Unfortunately no. It's just one of the many benefits of being active duty military. You have a hideous lumbar disc herniation, get treated by a local doctor with a bizarre treatment modality (who the hell has ever heard of an epidural cath for a disc herniation?), then get aerovaced back to the States courtesy of our tax dollars.

 

[doc02]

Oh, if it's an active-duty military guy, I'll allow it. I didn't know we were still in Nicaragua, though.

 

[Tired]

Oh, if it's an active-duty military guy, I'll allow it. I didn't know we were still in Nicaragua, though.

Wasn't actually Nicaragua, but sometimes I change insignificant details in my story just to cover myself in case anyone from my program is ever on here and accuses me of violating HIPAA by telling details of patient experiences I've had. It was another Central American country though, and I was suprised we had a base there as well.

 

[doc02]

Wasn't actually Nicaragua, but sometimes I change insignificant details in my story just to cover myself in case anyone from my program is ever on here and accuses me of violating HIPAA by telling details of patient experiences I've had. It was another Central American country though, and I was suprised we had a base there as well.

First of all, it's not a violation of HIPAA if you don't give specific identifying information, like a name. Second of all, if anyone on my program was that anal retentive to call me out on talking about a case on an Internet forum, I'd find them the next day and shove a few keyboards and monitors up their butt.

 

[Tenesma]

Okay here is the deal from when i used to do Inpatient pain

1) there are no TRUE pain emergencies - therefore just put them on a PCA overnight until pain service can see them in the morning -

2) the pain team should be viewed as consultants - you need to learn all their tricks to get patients to feel a bit better, because once you are done with your training you will be practicing in a private community hospital (statistically speaking most residents don't stay at large teaching hospitals with 24/7 pain services) where there is NO pain service...

3) What the pain service really should be there for are A) guiding narcotic management when it becomes complicated (odd meds, odd doses, etc..) B) offering neurolytic blocks for cancer patients C) offering interventional approaches to pain (ie: steroid injection for admission for low back pain with radiculitis), etc...

stick to a recipe

1) change tylenol from PRN to 500mg q4 around the clock
2) if NSAIDS ok then NSAIDS around the clock
3) if no open wounds/infections and pain is topical - Lidoderm
4) heating pad x15min q1-2 hours
5) if they are on chronic meds then don't change any of their long-acting narcotic agents (common mistake)
6) increase short-acting agents (dose/and maybe frequency) - only use one agent (ie: no percocet AND vicodin AND dilaudid at the same time...)
7) consider PCA if the patient is driving you nuts and has real organic disease and can't take anything by mouth - otherwise try to avoid it
8) always consider adding klonopin - anxiety plays a HUGE role in inpatient pain and that will usually soften the spikes of pain and most likely let them sleep better through the night
9) if there is any evidence of neuropathic pain throw on neurontin (also sedates them a bit - can't hurt) - stay away from tricyclics (especially if there is cardiac disease or glaucoma or if they have an ileus)
10) if there is any evidence of muscular pain stay away from valium, and instead use something like robaxin or tizanidine (both are centrally sedating - again helpful)

but my gut recommendation for you guys is to remember that one day you are going to be out on your own and that you will have nobody to turn to....

also whenever you guys look at a consult as a dump or "semi-dump" then you should expect the consulting service to recognize it as such and to be very obstinate.... so if you are going to consult after 4pm and it is not an acute post-operative or post-traumatic issue, then just do the above or be lazy and order a PCA and put the consult in but let them know they can swing by in the morning....

 

[Faebinder]

Okay here is the deal from when i used to do Inpatient pain

1) there are no TRUE pain emergencies - therefore just put them on a PCA overnight until pain service can see them in the morning -

2) the pain team should be viewed as consultants - you need to learn all their tricks to get patients to feel a bit better, because once you are done with your training you will be practicing in a private community hospital (statistically speaking most residents don't stay at large teaching hospitals with 24/7 pain services) where there is NO pain service...

3) What the pain service really should be there for are A) guiding narcotic management when it becomes complicated (odd meds, odd doses, etc..) B) offering neurolytic blocks for cancer patients C) offering interventional approaches to pain (ie: steroid injection for admission for low back pain with radiculitis), etc...

stick to a recipe

1) change tylenol from PRN to 500mg q4 around the clock
2) if NSAIDS ok then NSAIDS around the clock
3) if no open wounds/infections and pain is topical - Lidoderm
4) heating pad x15min q1-2 hours
5) if they are on chronic meds then don't change any of their long-acting narcotic agents (common mistake)
6) increase short-acting agents (dose/and maybe frequency) - only use one agent (ie: no percocet AND vicodin AND dilaudid at the same time...)
7) consider PCA if the patient is driving you nuts and has real organic disease and can't take anything by mouth - otherwise try to avoid it
8) always consider adding klonopin - anxiety plays a HUGE role in inpatient pain and that will usually soften the spikes of pain and most likely let them sleep better through the night
9) if there is any evidence of neuropathic pain throw on neurontin (also sedates them a bit - can't hurt) - stay away from tricyclics (especially if there is cardiac disease or glaucoma or if they have an ileus)
10) if there is any evidence of muscular pain stay away from valium, and instead use something like robaxin or tizanidine (both are centrally sedating - again helpful)

but my gut recommendation for you guys is to remember that one day you are going to be out on your own and that you will have nobody to turn to....

also whenever you guys look at a consult as a dump or "semi-dump" then you should expect the consulting service to recognize it as such and to be very obstinate.... so if you are going to consult after 4pm and it is not an acute post-operative or post-traumatic issue, then just do the above or be lazy and order a PCA and put the consult in but let them know they can swing by in the morning....

It's not that we want to dump them on pain.. Heck we manage our own pain for 90% of the patients. The problem is when we consult pain, it's almost better that we didnt consult them. They end up down treating them and we end up being called for PCAs. (BTW, I am pretty much convinced that epidurals for colorectal surgeries is garbage for pain. I pretty much at this point just give them a PCA and dont even read the pain people's note. Otherwise I ALWAYS get called at night for pain.)

You list of suggestions are nice, too bad they dont implement them around here.

 

[Tenesma]

faebinder

you should familiarize yourself with the literature showing that epidurals for bowel surgery are helpful - while they don't affect hospital stay - they do decrease opioid requirements, decrease respiratory issues (related to opioid requirements) as well as decrease ileus... and if used properly would allow you to sleep through the night -

as a recommendation for interns: always check on ALL of your patients before laying low to make sure they and the RNs are tucked in for the night - that way you can focus on the real work of the night...

the easy way around issues with epidurals if there are any issues is to just change it to a plain local anesthetic solution and run a narcotic PCA over night - patient gets a tiny bit of both until the problem gets trouble-shot by the pain team

 

[Faebinder]

faebinder

you should familiarize yourself with the literature showing that epidurals for bowel surgery are helpful - while they don't affect hospital stay - they do decrease opioid requirements, decrease respiratory issues (related to opioid requirements) as well as decrease ileus... and if used properly would allow you to sleep through the night -

as a recommendation for interns: always check on ALL of your patients before laying low to make sure they and the RNs are tucked in for the night - that way you can focus on the real work of the night...

the easy way around issues with epidurals if there are any issues is to just change it to a plain local anesthetic solution and run a narcotic PCA over night - patient gets a tiny bit of both until the problem gets trouble-shot by the pain team

I wish I could, but the attending didnt want a PCA.

 

[Tenesma]

just remember that ativan goes a long way (except for the elderly) for overnight issues

 

[Faebinder]

just remember that ativan goes a long way (except for the elderly) for overnight issues

It'll be hard slipping that to my chief resident at night...

 

[2ndyear]

Few issues here from an anesthesia resident standpoint:
1) Acute pain consults are usually surgery or injury related. If someone is on chronic opiates and they just had surgery or broke some ribs/femur/etc. then they will require their baseline drug (BID OxyContin, whatever methadone they're on, Duragesic, etc.) plus something for their acute pain. PCA's work nice. Yeah, they might need more than you're accustomed to writing, and it might seem excessive, but that's OK for acute pain with a known injury. If you're uncomfortable with things like basal rates, then maybe a call or consult is in order.

2) As everyone knows, the sequence goes: nurse makes pain assesment, pain is 10/10 or greater (regardless of physical status of patient), calls intern. The Joint Commission likes this stuff. For the most part, hospitals aren't the place for weaning off opiates. Its a huge problem in the community but there are outpatient programs for this.

3) When you call a pain consult, at least give a little background on the patient. Do you call cardiology and say "heart", or neurology and say "brain"? Then why do people text page me with a patients name, MRN, and "pain"? Just a little info is nice, like "68 yo s/p ex-lap POD#4 still having pain on IV Dilaudid, would like advice to transition to po meds".

4) A lot of pain services are poorly run, and I apologize for this. When a consult is called, we really should see the patient. Sometimes a curbside is appropriate, in fact a lot of transitioning from IV to po can be done over the phone, but I still think we try to block too many consults.

5) If you have a patient with an epidural, somewhere in the orders should be "if receiving opiate in epidural soln, all pain calls should be directed to pain service". This is to avoid combo IV/epidural meds and there have been several bad outcomes related to this. Same goes for anticoagulation and epidurals. Despite the standing orders, we have had some post op (mostly ortho, no offense) patients get fully anticoagulated with an epidural in.

6) When you're having trouble, it's easier to stick to one thing and keep going up, with multimodal therapy of course. I just saw a consult last week that was on po dilaudid, percocet, darvocet, and OxyContin, and IV dilaudid for breakthrough (of course using it at full written dose around the clock). Team was thinking about adding Duragesic but called us instead. A nice solution in a case like this is start tylenol and NSAIDS, add a long acting narcotic (MS Contin, OxyContin) and then a short acting narcotic for breakthrough (oxycodone, MS IR). Keep going up until you get effect or side effects that are troublesome.

7) I'm sorry, but at night unless the patient has an epidural or regional block catheter I'm usually not seeing them. In addition to the pain pager, I'm in the OR and if I'm not I'm probably at a code or trying to see tommorrow's add on preops. I'll be happy to provide advice over the phone, but the default is mostly dilaudid PCA, we'll see them in the morning.