Treating Pain ADEQUATELY, and Staying Safe… Patients and Physicians Alike: Cases from the Field - PowerPoint PPT Presentation

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Treating Pain ADEQUATELY, and Staying Safe… Patients and Physicians Alike: Cases from the Field

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Treating Pain ADEQUATELY, and Staying Safe Patients and Physicians Alike: Cases from the Field Laurie Lyckholm MD FACP Hematology/Oncology and Palliative Medicine – PowerPoint PPT presentation

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Title: Treating Pain ADEQUATELY, and Staying Safe… Patients and Physicians Alike: Cases from the Field


1
Treating Pain ADEQUATELY, and Staying
SafePatients and Physicians Alike Cases from
the Field
  • Laurie Lyckholm MD FACP
  • Hematology/Oncology and Palliative Medicine
  • Massey Cancer Center
  • Virginia Commonwealth University

2
Objectives
  • Examine cases in which pain management is a
    challenge.
  • Demonstrate how pain management may be applied
    safely and appropriately in any situation

3
Rob L.
  • 30 y/o healthy man admitted to the ED with crush
    injury of Lt leg
  • Ruptured popliteal artery
  • Bilateral compartment syndrome

4
Rob L.
  • Given enough IV pain meds in ED to take the edge
    off.
  • To OR for emergent fem-pop bypass, bilateral
    fasciotomies from ankles to thighs

5
Rob L.
  • Epidural for 24 hours after surgery fair pain
    control, then
  • Weaning beginshydromorphone PCA initially at 2
    mg every 6 minutes reduced to 1mg after 12 hours,
    despite pain scores 8-10.
  • Severe pain10/10 persists, even with patient
    using hydromorphone PCA regularly
  • Patient asking for more pain medicine regularly

6
Rob L.
  • 12 hours later, PCA discontinued and started on
    prn hydromorphone every 4-6 hours

7
Rob L.
  • He shouldnt be having that much pain.

8
Rob L.
  • 30 y/o usually very stoic, macho man crying
  • BEGGING for pain medicine every hour
  • Rates pain continuously as 10/10

9
Rob L.
  • Pain consult called after 3 days of intense
    untreated pain, pts mother insists
  • Full pain consult by trusted Pain/Palliative Care
    team
  • None of consultant recommendations followed

10
Rob L.
  • Pain continues
  • Nurses are distressed
  • Team refuses to increase pain medicine
  • he shouldnt be having that much pain
  • Pain team calls charge nurse first, who says his
    hands are tied
  • Pain team calls attending physician, who restarts
    PCA hydromorphone at appropriate dosing (1mg
    every 6 minutes and 4 mg bolus every hour) and
    patient becomes more comfortable

11
Rob L.
  • Over the course of the next few days, Robs
    condition improves and he is comfortable, using
    1mg IV dilaudid twice an hour on average, and 1-2
    4mg boluses/day.
  • Bolus before and during dressing changes, which
    involve peeling dressings off open fasciotomies.

12
Rob L.
  • Day of discharge. To have ongoing dressing
    changes and wound care by Home Health
  • PCA discontinued.
  • Prescription?

13
Rob L.
  • Dilaudid 2mg 1 tablet every 6 -8 hours for pain
    10
  • Appointment in 1 week.

14
What went wrong???
  • Undertreatment
  • WHY??
  • Assumptions
  • Biases
  • Fear
  • Lack of experience
  • Lack of education

15
How could it be done better?
16
Jenna T.
  • 35 y/o woman with metastatic breast cancer
  • Pain from primary breast lesion as well as
    sternal and left humerus pain from metastases.
  • Using MS Contin 120mg every 12 hours
  • MSIR 15-30 mg every 3-4 hours for breakthrough
    pain
  • Says pain fairly well controlled

17
Jenna T.
  • Calls clinic nurselost medications had purse
    stolen

18
Jenna T.
  • Calls the next week pain is worse needs more
    medications

19
Jenna T.
  • Calls the next week pain is worse needs more
    medications sister will pick up
  • Does not show up for next appointment
  • Calls the week after did not show needs more
    medications pain out of control.
  • Comes in for appointment. Clearly in pain, very
    quiet, furrowed brow. Winces with movement.
  • Calls the next week. Out of meds says they were
    stolen.

20
Jenna T.
  • Ways to help Jenna but stay safe
  • Drug Screen, but carefulknow your screens!
  • Weekly refills
  • Patient herself must come to pick up
  • Frequent brief appointments
  • Single pharmacy
  • Single physician writing meds
  • Talk with pharmacist directly to discuss plan
    (HIPAA okay)

21
Final Messages
  • Even the most difficult pain patients can be
    treated safely but must be collaborative and
    truthful
  • Burden of proof on the physician if they do not
    believe the patient
  • Dont make assumptions based on socioeconomic
    biases
  • Talk with your patient about concerns

22
Final Messages
  • Work with your pharmacist directly call before
    sending patient if very large number or unusual
    way of taking medication.
  • Telegraph messages on the rx pad
  • for cancer pain or for chronic back pain
  • Write out number prescribed 100 (one hundred)
  • .

23
Final Messages
  • DOCUMENT each visit and why pain medicines
    prescribed
  • If prescribing large doses, request frequent
    visits and/or phone calls if patient unable to
    transport easily, document phone calls in patient
    chart

24
Final Messages
  • DOCUMENT
  • DOCUMENT
  • DOCUMENT!!!

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