Nov 28, 2006

Patient advocated

Patient X:
A middle aged man comes with back pain. "Back Pain?" I thought "What middle aged person doesn't have Back pain?"

As it turns out this one broke his back a couple of years ago at work. Fixed by surgery, rods were put in. He became addicted to pain killers... and then other things.
Now he's in the hospital with an abscess in the soft tissues of his lumbar spine that won't heal. Because of his past and present addictions (he came in positive for 2 different types of drugs, nonRx) The doctors are serving up the pain relievers very sparingly.
So every 2 hours...on the dot...I went in with his meager 1/2 mg pain shot.
Every 2 hours, I called the MD and reminded him about how much pain our patient was in.How he yelled out for help, writhed in bed, had a constant sqinty eyed look, never watched TV, ate, or slept. (If my patient and I were going to suffer so was he)
The really sucky thing is his drug use became known to his family (By him) just recently. He won't be getting the emotional support he needs from them.

Patient Y:
I stopped a seizure dead in it's tracks today.(I used a vagal stimulator magnet thingy, which was so cool.) A seizure that causes a Post-Ictal Violent phase. So Violent that the seizures this patient has had since admission usually takes 6 staff members to restrain him after he throws several punches, kicks, bites. He'd been in restraints off and on since admission. He was as nice as the Pope himself when not seizing.

But no restraints from me. After this 4 minute Tonic Clonic seizure, I gave him the PRN Zyprexa. It worked! No violence, a bit lethargic but nobody got hurt. He was cooperative even. I passed the word on to his MDs and the night RN. Zyprexa, Zyprexa, Zyprexa. Miracle drug for this one. For some reason the nurses before me hadn't thought to give it. I was the first, even though it was ordered. He awaits placement in a home soon...his family can't handle his violence.


At 12:43, Anonymous Anonymous said...

Well, I don't know much about drug addiction, but this meager dosing of pain relief doesn't make sense to me. Surely you could give him however much he needs to be comfortable until the abcess heals and then deal with his addictions? Apart from anything else, it's been shown that adequate pain relief helps healing faster, hasn't it?

At 13:44, Blogger Jo said...

That's exactly my point Vasha. Unfortunately we nurses have to follow doctor's orders. And those were doctor's orders.

I made it crystal clear to the docs that it wasn't working.

Consequently, this patient later proved to have multiple abcesses and had to be rushed into surgery later and then on to ICU, due to the compression on his spine.

I think this was a case of Doctors being blinded by the addiction.

Thanks for reading!

At 15:21, Blogger The new Third Degree Nurse said...

Good post, Jo. And great job on the Zyprexa. I didn't realize it was given for seizures.

So sad about the back patient's addiction. I have a strong bias against back surgery myself...but even as a newbie student, I've seen the doctors "dismiss" patients whom they believe are drug seeking. And perhaps, in many cases, the opposite is true, too.

At 20:49, Anonymous Anonymous said...

Wow - you did a fantastic job of advocacy for the back pain patient.

I have never understood why, if you have had drug issues in the past, it means that you are meant to suffer for the rest of your life.

By all means wean the patient down if you must, but to give only 0.5 mg (and I hope you weren't talking morphine!) is cruel. Downright cruel in this situation.

At 22:12, Anonymous Anonymous said...

Great post. Found you through Change of Shift, will read more. Being a patient advocate is sometimes the hardest part of the job..and the most important...relieve the pain adequately so he can heal, rehab, and work on addiction issues as his back is healing..but if he's in severe pain, the only thing he gets from that is more shame! doesn't the facility's bill of patients' rights address this issue? is there an ombudsman or some other person who can intervene when this kind of situation comes up help you as a patient advocate...

At 23:17, Blogger Jo said...

3rd degree,
Good to see you again Girlie! In the long stretch yet?
Zyprexa didn't help with the seizures, it just helped with the Psychotic Post-Ictal phase he went through. Zyprexa is an anti-psychotic. I gave it IM.

Actually here's a Patient X update. It was found that it was not just one abcess but multiple abcesses all down his spine. Apparently was hard to see on the MRI in his soft tissues. He was sent to surgery immediately and then on ICU. There was an issue with spinal cord compression risk.
I'm sure the MDS are feeling pretty bad about underestimating his pain now. (It was the MD who filled me in on the development, they discovered over night shift) The MD did appear to feel bad about it.
He will be heavily sedated in ICU.

In any other case I would have gone from Resident to can't really go higher then him. With 5 doctors (attending and residents) agreeing, it's hard to seek action.

BTW: What's an Ombudsman?

At 07:03, Anonymous Anonymous said...

We had a patient about a month ago in the MICU who was having pain issues. I didn't know much about her, but was just covering her briefly while her nurse was busy. She was moaning and crying from her pain. I went to the resident, to try and get some more narcotics ordered. The resident told me that her nephrologist had mentioned that she might have some drug-seeking issues, so no more morphine.

So she continued to cry and moan all day long. She died two weeks later.

Just one more patient that we have failed to comfort in her time of death.

At 08:29, Anonymous Anonymous said...

oh, this kind of thing makes me so mad...I work in the VA, so I deal with a lot of dual/triple diagnosis folks (medical health condition, substance use and mental health -- often PTSD, sometimes just bipolar or schizophenia, and, of course, dementia) When someone who has a drug history has a medical problem that is *not* the time to deal with the substance issue. We're talking tolerance, here and the need for more, not less medication. So you use something like a fentanyl patch (I know, it takes a few days to get up to speed), and if they can take things P.O. an SA (sustained action) morphine, or even a PCA, without the bolus feature if you need do. Giving regular doses of medication does not give a rush or any other kind of high. And who knows, his non rx addiction may have come from his "self medicating" for his back pain. I've been known to get pretty much in the face of doctors when I think they're undertreating pain, but I work mostly hospice/palliative care, so I have a leg to stand on.

Glad he's going to get better control (or I hope so, and not just snowed with propofal

At 14:04, Blogger Lisa said...

I hope that doctor feels more than just a little bit badly for making patient X suffer. :(

I had a surgeon make me suffer in the hospital after surgery earlier this year. After having elevated cortisol for 20+ years and a pit tumor, I'm not sure why but I just do not respond to most opiods. :( That doesn't change the fact that I am in pain, however.

That poor man, I hope he recovers well.

At 21:19, Anonymous Anonymous said...

Sounds like you were working hard to try and get patient X comfortable. That's happened to me, too, when an MD wasn't aware (or has bias against) people who are used to a pharmacopia of narcs. It's a tough one.

Since I'm NOCs and not in the ER, I get to say to the MD: "So you're writing your phone number down so I can call you for more pain meds when patient X needs them, right?" Sometimes, this helps.
/jo (also)


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