Sometime during my medical training in the early 1980s, a wise, old attending orthopedist taught me this about pain management:
“Pain is a message that something is wrong, a red flag that corrective action is needed. Narcotics should only be used when the cause of the pain is determined and corrected (Post-op or post injury), all other pain management tools have been tried and failed, and it is determined that nothing more serious is going on”.
Wise words that physicians have followed for hundreds of years.
I used this quite successfully for the first 15 years of my practice, especially while being on call and covering for my own or my partner’s patients who I knew little about. Virtually every night, I would a call from a floor nurse stating that the patient was having “increased pain.” I would go down a checklist to make sure there was nothing more serious happening. Some of the better, more experienced nurses had that information at the ready without asking while other, less experienced nurses did not and at times seemed flustered that I even asked. Did they have surgery? What was the procedure? Any other problems like a fever or shortness of breath? Any numbness or tingling to the affected limb? Can they move their fingers or toes? Does it hurt to move them? Do they have a dressing on that is tight? Correcting one of these issues, especially loosening a tight dressing, usually worked. I would ask the nurse to do this and call back if there was a problem. 80 percent of the time, there was no problem.
That was until about the early 2000s — when we got the first in a series of talks at our medical staff meetings by “experts” in pain management. We learned about pain scales, fifth vital signs and — most significantly — that everything we were taught about pain was wrong. Pain needs to be treated aggressively; it is a disease onto itself. Overuse of narcotics was no big deal. Naturally, many of us were skeptical. Many questions were asked, and there was a general consensus on things like using narcotics for end-of-life care, but none of these so called “experts” seemed to able to make a distinction between acute and chronic pain, post-op vs. non-operative pain, or injury vs. non-injury pain. All pain was bad and needed to be eliminated. I said to myself that this was BS, decided to ignore it and continue to do what I was doing.
Later, I started to receive a different kind of call from the floor nurses. They started out by saying that they had a patient with increased pain. The more experienced nurses said, “I know this is BS, but I have to tell you that this patient’s pain level is now 10/10. I said, “That’s OK. Tell me what’s wrong,” and did what I did before without a problem. However, the less experienced nurses would say, “This patient’s pain is now 10/10.” When I started with my usual inquiry, the annoyance level was quite high. More often than not, I had to raise my voice and say something like, “I need you to loosen the dressings first before we just give more narcotics. It’s important to listen to the message, not just shoot the messenger.”
After several interactions like this, I started to receive calls from the nurse manager on call. Apparently, the floor nurses complained that I was “keeping the patients in pain.” Again, the more experienced nurse managers agreed with we and stepped in to solve the problem, but soon there were more nurse managers who took the side of the floor nurse where another argument ensued. I held my ground.
Now the problem got bumped upstairs to administration, where there was, to put it mildly, not a single experienced person. I got into yet another “yell-fest” with the hospital CEO that I was not following the new “pain guidelines, ” and I received the usual threats of expulsion from the staff or filing a complaint against my license. I explained that the hospital wished to override my decisions they had several options: A) Pay for my malpractice, B) Find another physician to take over the patients’ care C) Go medical school, get your own medical license, and take over the patients’ care. Not surprisingly, none of this was ever done, in large part because of a number of other physicians, especially the surgeons, had the same experience as I, complained about it and the hospital backed down. More proof that if physicians hang together, we won’t have to hang separately.
So here we are today, and the pendulum has swung completely in the other direction. Now I get as much grief wanting to give narcotics to the appropriate patient as I did trying to withhold them from the inappropriate patient 15 years ago. A real pain is just trying to treat pain. Outside interference has been attempted, and it has failed. We never seem to learn; we just try more outside interference. It is time to go back about 20 years and start over.
Thomas D. Guastavino is an orthopedic surgeon.
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