A Quieter Happier Place to Work by Al Sacchetti, M.D.
Saturday, July 18, 2009 
Al Sacchetti, M.D.I’m often amazed at how frequently emergency physicians work against their own best interests. I’ve observed many examples of this in my career but my all time favorite is the management of abdominal pain in the ED. Now anyone who has read anything at all about the treatment of abdominal pain in the last 2 decades knows that narcotic analgesics are perfectly safe in these patients. Not only don’t they mask clinical signs and symptoms, but they may actually improve diagnostic accuracy.
The problem comes when Emergency Physicians (EP) don’t take full advantage of these findings. Instead of a decent dose of morphine like 10 mg IV, they write for only 2 mg just in case all those article might be wrong after all. Now the problem with this approach is two fold. First, it is unfair to the patient. If they have pain they deserve to have it treated. Giving an inadequate dose of pain medications might make some physicians feel they have done their duty, but certainly the patient’s not going to think that way. Second and more to the point, it is unfair to the nurses caring for that patient and the other patients in the department. If you give inadequate pain medications, then patients are going to continue to experience pain and continue to demand the attention of staff and divert resources from other patients in the department.
Think about it. A patient comes in with abdominal pain, not severe writhing around the stretcher renal colic pain, just some moderate abdominal pain. After your exam, you decide that patient requires a CT scan and some lab studies. In the best of departments this is a 3-4 hours evaluation. You also realize that once you have ordered those tests there is little to no chance you are going to make a disposition decision on that patient until all the tests are back. Therefore, that patient is going to be occupying a stretcher in your department for the next 4 hours.
At this point you have one of two options. You can do the wrong thing and treat the patient with miserly doses of analgesics and leave them to harass, annoy and otherwise monopolize the time of the nurse assigned to that bed. Or you can do the right thing and narcotize the patient for the next 4 hours. Give them enough pain meds so that they blissfully lay on their stretcher in a light stupor. What you are aiming for is a state in which they won’t bother their nurse, hell when done correctly, they should’ even be able to pronounce the word nurse. The nurse is now more efficient and can care for other of her patients, you are more efficient because the nurse is no longer constantly bothering you about the patient with the abdominal pain and the department as a whole is a quieter happier place to work. I have on many occasions had nurses ask me why I’m giving a patient such a dose of narcotics, they obviously don’t warrant that much medicine. I explain that I understand that they are not in extremis and may in fact be malingering, but for the next 4 hours they are going to be in our department and during that time I don’t want them distracting any nurse, technician unit secretary or me from the care of other patients.
Now when their work up is complete all bets are off. They can have the undivided attention of every member of the department to expedite whatever is their determined disposition. It is interesting how once the nurses catch onto this approach they begin encouraging other physicians in the department to adopt the same philosophy for a quieter happier place to work.
Reader Comments (2)
It's not surprising that Al's blog would be right on target but the reasons he gives for giving a high dose of pain medication (rather than these ridiculous 2 and 4 mg doses of MS) misses the most important reason, which has nothing to do with making the nurses' life easier. I'll tell more in my upcoming blog but here's a hint: it both makes YOUR life easier and gives you clinical information which the low-dose strategy never does.
If it is difficult to get your staff to give an adequete amount of morphine (i.e. 10 mg) consider ordering Dilaudid where 1 mg is equivilant to 8 mg of morphine. Nurses who balk at 10 mg morphine never seem to flinch with 1 - 2 mg Dilaudid.