The insanity of pain management in the ER

One of medicine’s ethical traditions is to relieve suffering whenever possible. I believe in this, and try to treat all of my patients as I myself would want to be treated under similar circumstances.

My dilemma is, even after practicing medicine for over 30 years, the definition of a “suffering patient” has become a moving target.

On the one hand, I hear arguments primarily from governmental agencies that presume to “advocate for patients in pain”, who say that we must take everyone at their word. If a person says his/her pain is a “10 out of 10”, then it is my ethical duty to employ immediately all medical interventions available to me to alleviate that suffering.

Unfortunately, our triage nurses almost never see a patient whose pain level is less than 10, and many are well over 10. Examples of “10 out of 10” pain in our ED in West Philadelphia include hangnails, paper cuts on fingers, and menstrual cramps.

We are also being told, by separate governmental agencies, that we are providing patients with far too many narcotic analgesics for their own good, and that we must do everything we can not to give potent pain medication to patients who do not obviously need them. It is often impossible to tell if a patient is really in pain, or is attempting to obtain narcotics fraudulently.

Let me tell you about a recent case in our ED. An adult female with chronic low back pain who claimed to be on daily Dilaudid oral tablets for pain management, presented to our community hospital when she ran out of her medication before her next pain management appointment. There was no acute injury, or any change in the nature of her chronic pain. Specifically, there were no new symptoms to suggest neurological impairment or infection. Of course, her pain level was a “10”, and she was placed in a holding bed in the hallway until she could be seen, due to the fact that the ED was extremely busy and there were no active treatment beds available. After waiting about an hour, our patient started complaining loudly that no one was paying attention to her. Even though we do not usually treat chronic pain in the ED, this patient was given a dose of IM Dilaudid and a prescription for a few tablets to last until she could contact her usual prescriber.

This patient registered a complaint with some agency of the state that sent an investigator to our hospital. The investigator was astonished that this patient was forced to wait until getting her medication, and gave our hospital a formal citation. We now have to comply with an action plan, with a goal of instituting meaningful symptom control for any patient with a pain level “7” and over, within an hour of the patient’s arrival to the ED. All of the nurses have to complete a course in “ED pain management”. Also, the triage nurse must inform the attending physician when a patient with a pain level over 6 is being placed in a room.

This is all insanity. True insanity. Our ED staff is intelligent, dedicated, and experienced. Regulation of this sort does nothing but nurture cynicism of the part of the staff. The nurses will follow the letter of the regulation, and the physicians will not be surprised if there are 20 people in the waiting area all with pain levels over 10, none of whom will die if not treated immediately. Nothing will have changed except we all will have been convinced of the unmitigated stupidity of our governmental agencies, and the tragic acquiescence of our hospital administrators.

Patients have learned that ED’s are basically the “corner market” for free narcotics, and there does not seem to be any legitimate will on the part of anybody to undo this, except the DEA that threatens us all with loss of licensure if we continue to do what we are told by other governmental agencies.

When will the insanity stop? Am I supposed to use my skill and judgment in prescribing narcotics, or do I respond robotically to the patient’s subjective statement? Legislative and bureaucratic micromanagement of medical practice is making it nearly impossible to treat patients in a rational manner.

I predict the Affordable Care Act will do nothing to make the problem of narcotic abuse and addiction better, and will likely make it worse. I hope against hope to be proven wrong, but I not holding my breath.

William Jantsch is an emergency physician.

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