So, first, blame where blame is due; the ACS (that's you guys) started the JCAHO. It's true! Your ancient surgical colleagues did it with the purest of motives, but since they didn't bring their anesthesiologists along... well, you see what happened. My smart co-author O'Connor (I'm the metaphysical one) would agree with you; it's the law of unintended consequences, and unproven policy. His post "everyone talks about it..." discusses misguided policy efforts. Actually, a third author Kofke, has written along with our old professor, Mike Rie, about the notion that administrative policy that affects care constitutes a violation of the Helsinki accords (I think it's Helsinki) since it constitutes experimentation on patients without their consent. This includes things like arbitrarily decreasing staffing ratios...
Early on there were problems with deaths attributed to mis-setting of the PCAs. There is no question that the PCA isolates the patient from the over-extended nursing staff; in some sense, that was its purpose-to decrease required nursing interventions. Incidentally, there is a cynical, hilarious post listed on one of my favorite blogs "anesthesioboist" from an ER doc in SF which addresses the 10 out of 10 complainers in the ER. What the world needs now is technology to reliably detect apnea/hypoxia with few false positives. In the meantime, I advise all families of major surgery patients to camp out in shifts in the room as monitors and advocates, just like they do in all Lesser developed countries. Seems extreme, but I would do it for my family members. Wouldn't you? Good post.
Sherman
Sorry, O'Connor's post is "Everyone does it, but nobody talks about it" I'd create a link here, but I don't think I have enough HTML access.
The site is looking cool again...
Oh, I agree --- the American College of Surgeons created this JCAHO monster. Unfortunately, despite the benefit of hindsight, they are hell bent on creating newer, worse programs that will do little to improve patient care and serve only to further the cause of bureaucracy (such as the SCIP program). Ugh.
What doctors and nurses are "trained to do?" I truly don't want to be rude or snarky, but this really worries me. When a GI specialist told me that all painkillers will do is "mask the symptoms" of inflammatory bowel disease in the middle of an active flare (which was of course being treated with appropriate therapies that take time to work), I could only assume that that represented the way he was trained to handle patients' pain. I've had IBD my whole life, and I spent a fair amount of that as a pediatric patient who was never offered pain relief of any sort to deal with a painful disease. Pain management was simply not part of treatment of an active IBD flare in a child, even when I was hospitalized for long periods and could have been medicated under close medical supervision. It wasn't until I became old enough to advocate for myself (and able to argue that the disease significantly interfered with my ability to work, etc) that I was able to get treatment for pain. At all. I don't think that treating pain according to patient self-report is some kind of perfect system- it has flaws. But I am a product of the bad old days when physicians didn't see pain treatment as necessary. Eventually, the disease would come under control, and then you wouldn't be in pain anymore! Maybe it's a product of just my bad experience, but I'm really, really scared of the idea that pain should be assessed and treated according to how bad your doctor or nurse thinks it is. I've been down that road.
As a pt. belive me, you can wake up from a profound sleep to a high pain level - pain is exhausting. But why wake a pt. to ask?
Nice blog. Thanks.
My experience has been in the ER. I have seen numerous near misses (patients needing reversal) and am aware of a few clean kills related to over aggressive pain management in a busy ED without the depth in Staffing to provide sufficient monitoring of the practice. I have seen numerous people who “Had a Ride” lie or sneak out and drive after being well medicated. I call in a report and turn in a DMV form when I see it happen. How do we measure how many people that has knocked off over the years on the roads by one of these Customers. Wont ever be measured and the reports will be anecdotal so it will be ignored in the pain management debate.
I see this problem as getting worse and now being driven by the desire to produce high patient satisfaction scores which is reflected by improper intervention in medical decisions by Hospital Administrators.
I was the nurse you guys would probably dislike who used to call the surgeon on every patient with the "IM only" post-op orders (so, in essence, every patient operated on by the group) and ask for the pain meds IV instead. These were mostly back surgery patients.
The patients all had IVs, and it just seemed unnecessarily cruel to give a painful IM injection when they already had an IV from surgery. Of course, the patients always asked why they had to have IMs when they had IVs as well. It really makes no sense to me.
After enough people bothered them with calls, they switched the standing orders to IV. I'd much rather give an extra IV shot or 2 than fewer IMs.
Now that's an interesting study!
Why hasn't it gotten more attention? Too new?
Pain as the 5th vital sign....pshaw!
Wow I never realized pain meds were such a pain. Maybe what people need sometimes is a someone to tell them everything will be ok and give them a pat on the back.
Mimi
i long for the IM days...in my experience it works so much better for people...maybe not as fast...but not as many complications...its about educating patients...but that takes more nursing time @@
I'm just a patient, and I have chronic pain due to Complex regional Pain Syndrome. I'm also visually impaired, and from what I know, unless you know me well, you won't be able to see my pain levels. I am great at suppressing "pain behaviors" because it is considered wrong for me to show them. I generally don't have any sedation from my medications, unless I have a change in medications, then, I'll be somewhat drowsy, but that's better than the 9/10 pain which makes it impossible to focus. I understand your concerns, and the dangers, but having nurses and doctors actually able and willing to address pain was a godsend after my last surgery. There's a downside, and an upside to everything.
I do appreciate your post, it helps me understand the fears my doctors and nurses deal with while treating pain.
I followed your path: I preferred IM shots, too, for the same reasons, but eventually got harassed into using the PCA. And I must say, I eventually became a believer, particularly with the addition of the "basal" mode. I also was pretty liberal with IV toradol given q6h: it seemed to decrease the amount of narcotic needed. Had to be careful with the dose, and to make it a stop order...
Ah yes, the good ol' days. I remember IM injections! The bruises were a sight to behold. And now, for the truly illiterate, we have created a picture menu of pain management. Isn't over-regulation grand?
Chronic pain patient here, due to on-the-job injury while an RN. I do see a pain specialist, and I can quite honestly say, it would pretty much be impossible to be a 10/10 on his scale. 10/10 means you're unconscious. 
I do like his scale, as it is numerical, but it writes out in detail what each number is, so it's fairly easy to say what your level is. I came into nursing just as the pain scales were invented, and they were VERY subjective, and we still gave some IM injections for pain relief, but then transitioned over to PCA's.
As a person who had a PCA after my Hyster last summer, docs, please, please put a little low, constant dose of medication along with the dose when you push the button. I had the exact problem you described where I would press the button, get some pain relief, fall asleep for a short time, then wake up and try to catch up on pain relief. Thankfully, that certainly wasn't my most painful surgery, but it wasn't pleasant having to play catch up on your pain relief. I also didn't care for the fact that some of the staff was satisfied with me having a 5/10 on the pain scale, and saying that since I was a chronic pain patient, that's the best it would probably be. Wrong! You don't tell a patient in post-op recovery that they have to suffer like that. I was breathing fine, my sats and vitals were fine. Give me the stinking pain meds!! BTW, when they got me up on the floor, and got me on the PCA, my pain got down to a 3/10.
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I didn't see this until now, but I can say that as a patient, I have disliked the pain scale a lot.
It has been described in several different ways, all seeming just really subjective and confusing to me.
So what is 10? The worst I've ever had, or the worst I can imagine? Uhmmm. I'm pretty healthy, so when I say 8 against the worst I've had... well, I myself don't think that is too bad. I can imagine being in a lot more pain. So then that makes it what, a 4? But I would prefer to not be in pain just now, so maybe... a 6?
In my opinion, pain is not the enemy. Fear of pain is far worse than pain itself. I think this over emphasis on being pain free and comfortable at all times isn't just bad in the hospitals, but has bled over into our everyday lives where if we feel the tiniest twinge we have to take something, now.
My opinions on this change a lot when someone is dying. At that point, I think we should be as comfortable as possible.
As an internist who sees post-op patients, my beef is with putting post op patients on clinical auto pilot with a PCA. Occasionally, even after very good surgery, bad things happen. The patient is the best early warning system for identifying and fixing many of these events. The chest pain of a post op MI can be a life saver. A nice quiet night on the pca can be great for patient, nurse and doc, but fatal for the patient with a new clinical event.
The pain scale is a tool which supports charting goals and not much else. The best pain assessment scale is the R.N. and her skill set. I have worked PACU for many years. Far be it from me to immediately medicate a patient who awakens to say pain is a "10" and then go right back to sleep to occlude their airway snoring loudly. They are usually medicated on their second enunciation of pain, not the first, if they are still obviously sedated.
Tammy
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