January 18, 2010, 12:58 pm

Anatomy of a Pain Shot

druggie:locThis has me stumped.

What on earth is she doing?

She is drawing something up from a spoon, I assume it is a medication.

But what?

I usually associate this sort of activity with heroin addicts, but obviously this is a clinical environment.

Okay, all you nursing historians out there…

What medication would need to be drawn up from a spoon instead of a vial or an ampule?

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Migraine.

Three days.

Out of pain medication and vomiting so you wouldn’t keep it down, anyway.

Agony.

Emergency department.

*****

You’re in luck – no one in triage!

A bed opens up, the nurse takes you straight to a room.

Gown, blanket.

And….

Two minutes later you send your cousin out to ask how long it will be until you get your pain med.

Excuse me?

*****

There is an unrealistic expectation of just how long it takes to get pain medication in an ER.

A few procedures that need to occur before that shot gets to its destination.

  • Registration – We must have the information. The admitting clerk is not trying to hassle by asking for your address and birthday and ID.? We need that information to officially identify our patients when we give medication.
  • Examination – There must be an evaluation by the physician or the nurse practitioner before medication can be given. There may be patients who arrived before you who have yet to be evaluated; there may be patients who arrived after you experiencing life-threatening issues. Either way, they will be seen first.
  • Orders – The physician/NP writes the order for your medication. Your nurse, also responsible for other patients, may be busy in another room. They will notice that medication has been ordered and take the chart to prepare the meds.
  • Medication Preparation - The nurse pulls the medications from the medication dispensing system. The medications are carefully drawn up and all syringes are labeled before they leave the med room. The nurse will bring them to your bedside.

And you get your shot.

It’s so basic, really. Organized. Logical.

But it is not instantaneous.

Nothing in the ER is instantaneous except CPR when you go into cardiopulmonary arrest.

So, understand that you will probably have to do a certain amount of waiting before you receive your pain medication. It’s okay to ask for an update if you aren’t sure of what is going on.

But at least let your cousin sit for longer than two minutes before you send him out to remind us that you are in pain.

We didn’t forget.

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12 Comments

  • storytellerdoc
    storytellerdoc

    January 18, 2010 at 1:31 pm

    LOL…great post. I really like the pic–I think she is heating up the lemon pudding two degrees to make her demanding patient more happy. Also, funny stuff with the pain med sequence. You always make me laugh. Well done.


  • atyourcervix
    atyourcervix

    January 18, 2010 at 2:01 pm

    Of course, on the floor, there are several more steps involved in that whole process.

    Fax order to pharmacy. Wait at least 20 minutes for pharmacy to review it, and enter it onto the patient profile. Oops! No height, weight or allergies entered yet. Pharmacy calls nurse to put those items into the system so they can “profile” the med. Med is profiled. Nurse removes from pyxis. Nurse compares written order to what is in the med administration system. Verifies med is correct. Scans pt’s bracelet, verifies all of the 5 rights again. Finally gives med. Charts med.


  • the Muse, RN
    the Muse, RN

    January 18, 2010 at 4:00 pm

    Hey! How’d our L/D Triage Patient get in your ER?? ….aaaaa, just medicate her and send her back, ok? Thanks so much! We appreciate the team work.


  • Jen C
    Jen C

    January 18, 2010 at 5:06 pm

    My mom has been a nurse since Florence (no really), one of my favorite stories is her doing exactly what that nurse is doing, making injectable morphine. It came from pharmacy in a powder form, needed to be mixed with water, briefly “cooked” over the unit bunsen burner then it could be drawn up in a glass syringe and injected with a reusable needle.
    Yep my mom made crack.
    42 years later she still can’t live it down!


  • Walt Trachim
    Walt Trachim

    January 18, 2010 at 7:22 pm

    About the only time that I know of – other than if they’re in cardiac arrest, as you said – that a patient gets in immediately is if I’m taking them to the Cath Lab. And that’s only if they have tombstones on their 12-lead and I’ve either hammered them with large doses of IV fluids (if it’s inferior wall) or I have a nitro drip hanging (if it’s anything else and they’ve got both pain and a raging BP).

    Otherwise, I think you nailed it rather succinctly… :)


  • maha
    maha

    January 18, 2010 at 8:28 pm

    Patience after all is a virtue, especially in an ER. Even more so if the emergency isn’t actually life threatening.


  • Annemiek
    Annemiek

    January 19, 2010 at 3:57 am

    As Jen says, it is morphine that that nurse is preparing. I had an elderly patient that was a nurse in the 40′s and told me all about it. Also about how they had to sterilize and sharpen the needles. Go figure how long it took to get a painshot back then.


  • Peggikaye
    Peggikaye

    January 19, 2010 at 1:00 pm

    I’ve had dibilitating migraines since early childhood. I never ever thought to go to the ER till my sister in law went ..and got help.

    So, one day, one hit and nothing helped. Since I knew there was an option to my 3 day cacoon, I went to the ER …and after waiting (not very long, but longer than I was comfortable with) the lights …the noise ..the chaos … I left … I’d rather spend 3 days in a dark room with a wet towel over my head than endure the 2 to 3 hour wait to get relief.

    In the grand scheme of things, that seems odd …but really …the ER made things soooo much worse .. I couldn’t endure it.

    Then my neuro learned I had migraines (was in patient, he came into my room to find me hiding from the lights/sounds) and he talked to me about options. Preventatives and abortive meds (used only tylenol before)

    Now, I take Topomax, and still get migraines, but they last a few hours instead of a few days …and while I can’t function with one, I don’t have to hide from the world.


  • NurseMe
    NurseMe

    January 20, 2010 at 4:24 pm

    Kim,

    I’ve tried to explain the system so many times. Waste of breath and time. I keep forgetting, because its an emergency to them, its an emergency to us! My ER has actually implemented a fairly efficient way to get meds from the pyxis prior to the patient being registered. Each pyxis has a blank sheet with predetermined codes that are entered as if its a patient. Then once the patient is registered we take a sticker and place it next to the code we used for that patient. Providing we remember. No way to get interns and residents to the bedside faster, though.

    Peggikaye, I agree the ERs are no place for migraine sufferers because of the lights, noise and constant activity. One of my friend’s has recently begun acupuncture for migraine management. She’s achieved pretty great results. Where she used to be incapacitated for 1-2 days, she now takes Excedrin and can go to work. It can be fairly expensive if you don’t have an insurance plan that covers acupuncture. Check it out.


  • Peggikaye
    Peggikaye

    January 20, 2010 at 7:13 pm

    Kim, you couldn’t pay me enough to do acupuncture. (I doubt it’s covered, either and no way for me to afford it anyway!).

    I’m so needle phobic I’d never be able to manage it. I know they claim it’s not the same but it LOOKS t he same and that’s all I need!

    My needle phobia is soooo severe… I had natural childbirth ..twice … knowing the second one was well over 9 lbs (they suspected closer to 10 than 9 and he split the difference at 9 lbs 8.75 oz) That was my SECOND child after having a child naturally already …why? I’m not some natural child birth advocate …they simply were not going to stick a needle into MY back to give an epidural! nuh huh ..wasn’t gonna happen!

    Acupuncture …nuh huh …ain’t gonna happen!


  • ER Nurse_JR
    ER Nurse_JR

    January 23, 2010 at 8:24 pm

    Kim,

    Great post about pain management in the ER and as much as I have tried to explain to my patients things take time in the emergency room, the patients expect instant results and relief. I have seen patients be pulled straight back from the registration chair, mostly for chest pains, but the occasional patient presenting with severe pain comes directly back. Everything needs a doctor’s order, but a good charge nurse or proactive nurse will approach the ER doctor & ask for morphine or dilaudid for a patient in severe pain (think gall bladder or kidney stone).

    Peggikaye & NurseMe,
    I completely agree that an ER is no place for a patient with a severe migraine, especially when the ER is packed, with wall-to-wall hall patients. I too get migraines (but have never gone to the ER for help) & always feel bad for the patients who come in with severe migraines & get placed in a hall bed. There is no way the noises, the lights, the talking/yelling helps a migraine. For those patients who are fortunate enough to get a room in the ER, I do see most get relief of their migraine with phenergan, toradol, and IV fluids (depending on the doctor, the phenergan may be reglan instead).


  • mersilkee
    mersilkee

    January 27, 2010 at 8:55 pm

    I have two chronic illnesses, one of them is a degenerative brain disease and the other one is a complex regional pain disorder. I have been on a heavy dose of narcotics for several years. When I have to go to the ER for some other condition such as when I had a huge DVT a few years ago, I came in through the ER.

    The nurse said, “Don’t worry dear, we’ll get you some pain medicine as soon as we can.”

    After an hour she brought in 5 mg. of Demerol. I was in a lot of pain but it was hard for me not to laugh. I am a really hard stick and they finally the doctor did a cut down, so I didn’t receive my 5 mg of Demerol until I had been there three hours.

    It is useless to try to talk to an emergency room doctor about how much pain medicine I require. After they find out how much I am taking they tell me they are afraid to give me anything more because I am on so much but they do not understand about opioid tolerance. I wish physicians were taught more about pain when they are in training.

    My pain management doctor is in a far away place. Good pain management doctors are hard to find these days. I tried taking a “note from my doctor” with me to the ER and a card from my doctor but that didn’t help so I just started feeling silly and very frustrated doing that.

    Now, when I go to the ER, my husband explains my pain medication situation to the doctor as soon as she or he walks in the room. He asks permission for me to take my own meds and they usually agree especially now that I have a terminal illness.

    If they don’t agree, I take my own pain medication anyway because I am not going to remain for hours in pain.

    I have extensively researched my condition and the effects of pain medicine and I know more than they do about what I need to take.

    I have abdominal migraines and the ER is no place to be for those either. Now I tough it out at home. That way I don’t get overdosed with anti-emetics. After I found out what was going on re. my abdominal migraines, I tried going to the ER and telling them what they needed to do but that didn’t go over too well.

    One ER doctor told me once, “Look what we do here is trauma, that is what we know, that is what we are good at.”

    One thing they are not “good at” is pain management.


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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