How to avoid a consult

This week I’m camping out at the hospital every night, covering the Acute Pain Service (post-surgical pain) and the Chronic Pain Service (all other kinds of complicated pain).  We have patients with complex oral regimens, standard intravenous Patient Controlled Analgesia (PCA), perineural catheters which infuse local anesthetics near a sensory nerve, epidurals, and even a gentlemen with metastatic cancer up in the ICU who has an intrathecal catheter (within the dural sac which surrounds the spinal cord) receiving intermittent doses of opiates.

I come in at 1900 and leave at 0800 Monday through Friday nights.  It’s great, because I can usually get at least six hours of sleep, so I feel like I’m having a miniature vacation here in the City.

Covering the pain services is also the rare time when we feel like true consultants.  Anesthesiologists fashion themselves to be consultants in perioperative medicine, which is true to an extent, but we really take on the patient and take care of every aspect of their physiology while the surgeons operate.  The pain services are more of a traditional consultative role.  As such, it’s nice to address the problems I know how to address, and leave the primary care team to deal with working up problems I’d rather not get involved with, as well as the painful aspects of coordinating care and planning discharges.

Sometimes nurses will try to consult us when their patients are in pain.  This is inappropriate.  A consultant comes when another physician calls, describes the patient, recounts what’s already been tried, and asks the consultant to address a specific problem.  “My patient’s in pain,” is not an appropriate way to get help.  A nurse would never call a cardiologist out of the blue and say, “Hi, yes, this is Nurse Williams.  Mr Jones on 8-South was having some chest pain.  I could have called the primary team first, but I thought it was probably his heart, so I called you to see about getting an EKG, an echo, and that sort of thing.”  Or the gastroenterologist, “Yes, Dr Smith, my patient just threw up and there were streaks of blood.  Could you come do an EGD?”  So why would they call the pain management physician and say, “My patient’s having pain”?

No.  The nurse should call the primary team, who then calls us.  And, young intern, there are certain things you should know when you call a consultant.  It doesn’t matter if you’re cross-covering so you don’t know the patient as well; it’s still your patient for the night.  Name. Medical Record Number. Location. Age. Pertinent medical history. Surgical history if applicable.  Surgical pain management.  Postoperative course.  Current problem–Where is the pain?  What is it like?  How has it changed?  What’s been done already to address that problem?

The reader with a keen eye for detail will notice that I bolded and italicized a sentence above.  This is because so many young doctors will call us, and they’ve done nothing yet.  I wouldn’t call a cardiologist until I’d interviewed the patient, done an exam, gotten an EKG, checked labs, and possibly floated a pulmonary-artery catheter.  I’d have the chart and data in front of me so that I can concisely tell the story.  But no.  We get calls, “The patient’s in pain.”  “What have you tried?”  “Well, we stopped his home medicines because we thought they were too much, and we started morphine 1mg subcutaneously Q3 hours prn, and now he’s having pain.” “Okay, so what did you do next?” “Well, that’s why we’re calling you.”

This example illustrates another point that many doctors misunderstand regarding chronic and acute pain.  A patient who has chronic pain well controlled on medicines, who then develops acute pain on top of that chronic pain, still needs to continue the chronic pain medications and get additional acute pain medications.  Many physicians will see a patient with not one, but two reasons to have pain, and will then give the patient less medicine rather than more.  Another basic skill that all physicians should have is a basic escalation in pain medicine.  If the patient’s on oral meds, try intravenous.  If the patient’s on morphine, try hydromorphone.

So, with that soapbox behind me, I’ll now relate the story of the nurse who called me.  “My patient’s in pain.”  I had to tease out of her the fact that she was a nurse, as well as the patient’s name, age, location, history, and story.  This patient was on a PCA.  “How frequently has he been using it?   Have you increased the demand dose as the orders permit you to?  Have you given a clinician bolus as the orders permit you?”  I don’t know, no, and no, were her answers.  My plan for her, over the phone, was simple: Give a clinician bolus as the orders already tell you to do.  Assess how frequently the patient is using the PCA.  If he’s not using it with appropriate frequency, then educate him that he can push the button every six minutes.  If he is using it frequently, then increase the demand dose as the orders already suggest you can do.

Problem solved.  Nurse gently educated.  Patient’s pain addressed.  Formal (and unnecessary) consult avoided.

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11 Comments

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11 responses to “How to avoid a consult

  1. mulberrystreet

    I mentioned this story to a colleague, and he brought up an appropriate point. As someone who doesn’t know and has not seen the patient, I shouldn’t direct the nurse to give an extra dose, but merely inform her that the dose is available. If the pain is expected after surgery and the pattern is one of inadequate opiate dosing, then an extra dose is appropriate. But if there’s a new problem developing, that’s something for the nurse to detect and for the primary team to evaluate.

  2. Yes, the nurses’ approach to pain meds sometimes puzzles me. They’ll call at midnight to say the patient is having pain, and will I do something about it. I look up the orders, and point out that in addition to the PCA, the patient is also ordered prn dilaudid and toradol, as well as tylenol for minor pain like a headache. And their response is, “Oh, I didn’t know I could give all of those.” Well, that is why they are all ordered. The worst is when I come to round in the morning, find the patient stoically biting back complaints of severe pain, and find out from the day nurse that the night nurse unilaterally decided not to use the pain meds that were ordered; and she’s not there any more for me to talk to. I hate that people are so scared of narcotics per se that they don’t use, or even ask about, all the prn meds that I’ve planned.

  3. Yes, the nurses’ approach to pain meds sometimes puzzles me. They’ll call at midnight to say the patient is having pain, and will I do something about it. I look up the orders, and point out that in addition to the PCA, the patient is also ordered prn dilaudid and toradol, as well as tylenol for minor pain like a headache. And their response is, “Oh, I didn’t know I could give all of those.” Well, that is why they are all ordered. The worst is when I come to round in the morning, find the patient stoically biting back complaints of severe pain, and find out from the day nurse that the night nurse unilaterally decided not to use the pain meds that were ordered; and she’s not there any more for me to talk to. I hate that people are so scared of narcotics per se that they don’t use, or even ask about, all the prn meds that I’ve planned.

  4. david

    I like how your “No” to begin the 5th paragraph serves not so much as an answer to a specific question, but rather more like a dam to hold back all the nonsense in the previous paragraph, to ensure it doesn’t spill over into the pure and noble ideals in the sentences that follow.

  5. David, your comment had me laughing out loud! I liked your literary criticism-imagery, and I think you’re right–the “no” doesn’t address any question in particular, but is meant to put a stop to “all the nonsense” that precedes.

  6. mg

    I also enjoyed David’s post…i’m assuming it’s DH and not DO??

    The more I read Jonathan’s MW posts the more I keep wondering….when, exactly, is he going to write a book??? I suppose the cumulative experiences represented on this blog could be a start……..

  7. mg

    Just curious….

    Does anyone else re-read their replies on this blog before submitting?

    I’ve become paranoid about my use (perhaps improper and inadequate) of the English language from reading this blog! Yes, I know that ….. is probably an unaccepted form of punctuation….

  8. You have no idea how many times I re-read something I’ve written and find several glaring misspellings and grammatical errors.

    Fear not, I’m a big fan of the ellipsis. (…)

    And it was DH.

  9. Why did it make a smiley face? I tried to put an ellipsis within paretheses.

  10. david

    I was curious who mg was, but then it came to me on a moment’s reflection. How’s your hebrew these days? Breshit bara elohim et h’shmaim v’et h’aretz…

  11. charity

    Jonny – that’s not a smiley face – it’s a winky face. perhaps your last period turned into a semi colon – thus creating the wink?
    testing: 😉

    I

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