This clinical rotation has been so full of “firsts.” I guess that makes perfect sense, but it just seems like every single thing is new to me, including pain assessment.

My patient was in his 90’s with multiple decubitus ulcers, and they were also trying to rule out some kind of spinal infection or osteomyelitis from a previous injury. He was supposed to have dressing changes twice a day by the wound care nurse, but the morning I worked with him, he was incontinent, and the dressings were soiled. Due to the fact that fecal matter can break down your skin (especially a 90-something’s who has also been on long-term corticosteroid treatment) in a matter of minutes, we didn’t have time to pre-medicate him before the dressing change.

We certainly paid dearly for that decision, and now I wonder if it was right thing to do. Should we have waited and gotten him some narcs, first? At the time, it seemed like we were doing the right thing, and I guess that’s all that matters. Regardless, Mr. X let us know that he was suffering. After yelling at us repeatedly to stop, get our hands off him, and leave us alone, he threatened to punch me in the face, and started pulling on my scrubs and poking me in the stomach. He was AOx1-2, and probably closer to 1 due to the level of pain he was experiencing. (I wasn’t in danger of being punched, by the way, despite what he was threatening.) At one point, Mr. X’s radio played the following song, and when he started reciting the words, through his intense pain, I almost had to leave the room.

You always hurt the one you love
The one you shouldn’t turn at all
You always take the sweetest rose
And crush it till the petals fall.

You always break the kindest heart
With hasty words you can’t recall
So if I broke your heart last night
It’s because I love you most of all…

As soon as the dressing change was fininshed, we gave Mr. X his pain meds: 1.0 mg of dilaudid IV push. So it’s supposed to take effect almost immediatly, right? Right. I came back after 10 minutes to make sure he was still breathing (I have a slight nervousness about the respiratory depression that narcotics can cause, especially in the extreme elderly) and while I was there, I asked about his pain. He responded that it hadn’t changed, and his wife said “maybe it hasn’t taken effect yet?”

I smiled weakly and ducked out of the room. Having recently had my own shot of dilaudid, and feeling the effects within seconds, I was having a hard time believing that Mr. X’s pain was still a 10/10 as he had previously described. Additionally, he was not grimacing or yelling as he was previously; in fact, he was dozing in and out of sleep. Yet he was still complaining of 10/10 pain. I kept coming back and asking. I checked at least four times to see if his pain level would drop with time, if we weren’t moving him or poking him, or if he would be able to fall asleep for a longer period of time. Nope. Each time I asked, he told me it was the same.

After hemming and hawing and talking with Mr. X’s nurse, we got him a one time order for more dilaudid. I gave it to him IV push again, this time just in time for the next dressing change. This time, there was a noticeable difference in his agitation. He was certainly not comfortable, and he did repeatly tell us to get out and stop touching him, but there were no threats, no grabbing or poking. It was a marked difference, and I told the wound nurse that despite his protests, he was ten times better than this morning. So the dilaudid was doing something. After the dressing change, I changed his gown and sheets, and just before I left, I asked him how his pain was. He smiled and said “Everything is fine.”

Lesson learned? It’s easy to project your own ideas (and those of society) of pain onto another patient. It’s easy to assume they are drug seeking, or that they are confused and angry at the nursing staff, but not really in pain. It’s more difficult to realize they’re actually in pain. Pain doesn’t have to look like tears, screaming, crying, grimacing, puking. Even 10/10 pain can be quiet and sleepy. Thank you, Mr. X, for teaching me this lesson. I can only apologize for not working faster to get you the relief you needed.

On a side note, Mr. X’s doctor appeared to be totally oblivious to his condition. Now listen here, I’m not trying to start a spitting war between doctors and nurses, as we’re a team, not a heirarchical organization. We each need each other, and I’m sure there’s an abundance of incompentance on both sides of the coin. Today, it just happened to fall more on the MD side. Tomorrow it could be my side. With that disclaimer out of the way, I will proceed.

I was kneeling on the floor, emptying Mr. X’s foley, when Dr. A walked in and proceeded to jabber away in medical jargon, not to me, but to Mr. X (who was on 2 mg of dilaudid and was AOx1-2 without the narcs.) At one point, he asked Mr. X if he needed to go to the bathroom. At that exact moment, I was standing up with a urinal full of bright yellow pee, and I almost dropped it on myself when I heard that question. Instead, though, I simply said “He has a foley. I just emptied it.” And left the room, snickering.  The whole situation represented, I think, a serious lack of “know thy patient.” Oh well. It was good for a laugh on my end. Now that I have bad karma, it’ll be me doing something that stupid. You have my permission to laugh!

That’s all for now. Next week I’ll be spending one day in the OR and one day in the ER…can’t wait!

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