Tag Archives: Pain Management

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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Well, if that’s how you feel…

Since the person who is covering the inpatient chronic pain service was post-call today, I rounded on the service.  Tomorrow I’ll go to my usual assignment of the week–pediatric pain.

The first patient I saw is being treated for cancer.  He looked fairly comfortable, sitting in bed, basking in the sunlight streaming in the window, listening to music through headphones.  In an instant, I thought he looked awake and alert and had a pleasant appearance.  These are all important things to notice when seeing patients with chronic pain.  The physical exam starts from the moment the doctor walks in the door.

As I walked in, I said, “Good morning Mr Jones, I’m Dr H with the Pain Management Service.” All the body language clues I’d already noted did not prepare me for the first words out of his mouth. “Here’s another doctor.  Good-bye!”

I must say, I was rather taken aback.  I’d tried to sound cheery and energetic, and his first words to me were blatantly sarcastic.  Trying not to be overcome by countertransference, I responded in a nonaccusatory and neutral tone.  “Well, Mr Jones, if you want me to leave now I will, but I was hoping to talk with you about your pain medicine.  Will you tell me how you feel?”

I found it confusing when he said in a puzzled tone, “No, I don’t want you to leave.  My pain is pretty well controlled on the medicines.”  He suddenly seemed very pleasant again.

It all came together when I realized that he wasn’t listening to music when I first came in; he was talking to his daughter on the phone with an earpiece, and he immediately hung up with her upon my entrance!

Later in the day, I found it particularly gratifying to evaluate a new consult for a patient with cancer with bony metastases.  The primary team had her on an odd jumble of multiple long and short acting medicines: fentanyl patches, extended-release oxycodone, immediate-release oxycodone as needed, hydromorphone intravenously as needed, and a lidocaine patch.

After doing a quick history in Spanish, I reviewed the current regimen and simplified it considerably in my recommendations: Continue the fentanyl patch for baseline pain control.  Start a hydromorphone PCA (Patient Controlled Analgesia) with an optional nursing bolus for uncontrolled pain.  Start scheduled acetaminophen to decrease opioid requirement.  Apply the lidocaine patch to most-affected area, 12 hours on, 12 hours off.

This way, we can measure how much hydromorphone she requires in a day (based on how much she doses herself) and later convert the medications to a combination of long-acting and short-acting oral medicines for a home regimen.  Pretty straightforward, but it’s nice knowing that she will likely be comfortable tonight in the hospital because of my recommendations.

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What happens in New Jersey…

Or, “There’s Never a Dull Day in Pain Clinic”

My attending: I’d like for you to try methadone.

Patient: Methadone???  I don’t like the sound of that!

My attending, matter of factly: Well, we could call it something different.  How about Dolophine?

* * * some time later, after my attending left the room * * *

Patient: So do you think that switching to methadone could be a good plan?

Jonathan: Hmmm, so you’re on Vicodin, Neurontin, Cymbalta, Klonopin, Valium, and Flexeril.  Yes, the methadone may help you to use less hydrocodone.  Plus, methadone may prevent you from building up as much tolerance.  But it’s still important to take a stool softener.

Patient: I see.  What about medicinal marijuana?  Do you ever use that in this clinic?

Jonathan: Well, that’s not legal in New York State.

Patient, enthusiastically: Oh, but I live in New Jersey!

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