I remember the first time I experienced the paradigm shift when it came to pain management. Sometime around the late nineties while I was on call, I received a phone call from a floor nurse stating that a patient that had their ankle operated on that day by another surgeon was having increased pain that was not controlled by the pain medication that had been ordered. As I had been doing for many years, I inquired as to what procedure was done, what pain meds were ordered, any allergies, any associated symptoms such as numbness or tingling and, most important, whether the patient had a splint on with tight bandages.
More often than not in the past, this simple inquiry revealed that there was an identifiable, correctable reason for the patient’s pain and the proper course of action would be to correct the problem — in this case to loosen the tight bandages. Just changing the pain medication was the last thing I did and for years it worked well, but this time it was different.
The nurse insisted on repeating to me that the patient’s pain was “10 out of 10.” I insisted that I understood that the patient was in pain but that it was necessary to “listen to the message not just shoot the messenger” and try to loosen the dressings first then call back if that did not work. Clearly annoyed, the nurse just hung up.
Several days later, I ran into the surgeon who was clearly upset. He told me that apparently instead of loosening the dressings the nurse called her supervisor who contacted the hospitalist who ordered stronger pain meds. The next day on rounds surgeon found the patient’s leg grossly swollen, dusky and almost developing a compartment syndrome, a very dangerous condition where the patient could have lost their leg. He then told me that what happened was that the hospital staff had been re-directed to be more aggressive in treating pain and that they were following new guidelines which included the “pain scales” and now labeling pain as a “fifth vital sign.” I thought he was kidding. How can be pain levels be considered a vital sign when there is no objective way to measure it like a heart rate or blood pressure? He just shrugged his shoulders.
At first, I thought this be an isolated incident but no. Everything changed afterwards, and a very uneasy balance between the hospital staff and administration was created, with the nursing staff caught in the middle. The administration said they had to do this because it was a new protocol they were being forced to follow. Also, it was around this time that I was first told about the concept of patient satisfaction which greatly aggravated the problem.
The first lawsuits for “undertreating pain” sent shock waves. I and many of the staff went so far as to order that no hospitalists were to write orders for my patients. The more experienced nurses realized the folly and were on our side, but the younger nurses were very frustrated receiving a lot of conflicting orders. This was one reason for a high rate of turnover in the nursing staff.
The disease quickly spread to the outpatient setting. Physicians writing prescriptions for narcotics for an arthritic knee when a simple injection would do. Physicians succumbing to the pressure to have high patient satisfaction scores by taking the easy road of just renewing narcotics. ERs who before would only give a couple of days of pain meds would now write for over a week which delayed the patient’s follow-up in our office making treatment that much more difficult.
The only ones that seemed to benefit were the physicians who developed the specialty of pain management, but one big reason why was that patients were being referred there first when they could have been referred to a physician who actually could find and correct the source of the pain.
One day, I saw two patients who were referred to me after being on narcotics for a very long time for conditions that could have been corrected early. By itself, this was not unusual and was occurring with increasing frequency but after offering every other reasonable treatment other than just renewing the meds these two patients left my office very angry and threatened my staff.
Now we are in the middle of what should have been a totally predictable “crisis.” Accusations and blame are swirling about but not correcting the problem.
I place the blame where it started. Those, no matter how well intended, who convinced themselves and had the power to pressure others that pain was a disease onto itself, not what it really is: a symptom. If health care has any hope of getting a handle on this crisis, then we have to go back to a time when physicians first determined why their patients have pain instead of just shooting the messenger. While we’re at it get rid of pain scales, fifth vital signs, and anonymous patient satisfaction scores. If we have not learned by now that these have caused more problems than they have solved, I don’t know what will.
Thomas D. Guastavino is an orthopedic surgeon.
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