Strategies for Pain Management in the Cath Lab
Are you ready for a non-data driven lecture? I think it is important to take a look at the topic of pain management from a different perspective, and review how we take care of our patients. You do need the hard data; I am not downplaying its importance. You need to be able to understand that doctors make decisions with their patients’ best interests in mind, rather than basing these decisions on which vendors bring the best bagels. The point I am making is that pain management in the cath lab is about more than drugs. It is about the fact that our patients come to us and expect us to relieve their pain. They expect it, but they don’t get it. After this lecture, I want you to come away understanding that we have to do better and we can do better.
Patients are petrified that we will not take away their pain. We must approach pain management with the knowledge that it is not just about chemistry; there is a human being underneath the chemistry, and we can offer correct pain management if we realize this fact. An easy way to remember this fact is to pretend that the patient is your own mother.
Let’s start with the basics. How many of you just walk into the room and automatically start to turn over the room covering up the patient, straightening the sheets, straightening the lines. Do you remember to introduce yourself? Hi, I’m Marsha. My job is to make sure that you’re comfortable, and I’m pretty good at it. These words go a long way to reassure the patient. It’s just a few words, but they connect you with your patient, who is feeling disconnected from reality at this point. Let the person know that there is a single person who is going to take care of their pain and their fear. While you do that, reach for a warm blanket.
Pain management is a patient control measure, not a staff control measure. I know that sounds kind of light, but if you know that you always give fentanyl and versed to every patient, you are not giving adequate pain control. You have to understand that some patient populations are stoic. How many of you have had a patient on the table with ST elevations that get worse and worse, and they never flinch? In some cultures and/or religions, people believe that it is their duty or penance to deal with their pain. Some may believe that the more pain they deal with on earth, the less they have to deal with in heaven. You have to be aware that the rising heart rate and ST elevations can be treated, but the patient isn’t going to ask for it.
On the flip side, how many of you have had a patient on the table that starts screaming the minute you touch them? This patient population belongs to a culture that believes that if they share their pain with everyone, and loudly, the pain will be dispersed through the surrounding people. Your heart is pounding, but they feel better.
Remember, your job is to adjust your pain management to your patient’s needs. Be aware of the subtle things that will show that they are in pain.
Tell your patients when it will hurt. Don’t tell them after the doctor has already stuck the leg with the needle to deliver the lidocaine. Use your finger, touch the place and show them where the needle is going. Say, This is where it is going to hurt. By the time I finish banging on your leg, it will be numb. As long as they are aware what is going to happen, they can handle anything. However, if you sucker-punch one of your patients, you’ve just wiped out your ability to relieve their pain. Their catecholamines have gone up and you’re fighting a losing battle, because they don’t trust you anymore. Tell your patient everything that is going to happen.
Have you ever heard the thought that telling the patient that it might hurt will have them expecting it to hurt? Personally, I think this is hogwash. We are taking care of people, and our patients need and expect to be treated with respect.
Your patients can handle anything if they are told what to expect. If the patient knows that you can take care of the pain, they will go through the procedure with flying colors. Again, the message is collaboration working with patients to help them get through the procedure with the least amount of pain and anxiety.
In the meantime, ask the patient what type of music they enjoy. If you asked me to tell you one thing about the practice at Washington Hospital Center, for example, I would say that they look at every possible way to make the patient experience better. If the patient likes jazz music, they put on jazz music. If the patient wants earphones, they will give them earphones, but if the patient doesn’t want them, the music is put on for the entire staff to hear. They wrap the patients in warm blankets. They set the mood with guided imagery, which is a way for the patient to control their fears. For example, the patient will be instructed to think of a calm, happy place where he would like to go when he is really afraid. The mood is set. If the patient asks you for jazz, do not put on country music. (Unless you are laughing together and have the time to make a little joke before the procedure. Remember to put on the music they asked for before you leave the room.)
There are some things about drugs we need to understand. Pharmacology and pharmacology competencies are part of everybody’s orientation program. I am not here to talk about them. I will discuss them briefly, but I am not here to tell you specific amounts of the specific drugs. You will find that in any of your programs. I am here to talk about the practice of pain management, not the science. I am talking about the heart of your patient. I am talking about making them feel comfortable enough so that you can fix their pain with the least amount of emotional trauma. When you are going to use drugs, use the good drugs, and use a lot of the good drugs. Medications in the cath lab are given in addition to good patient care. You cannot give any medication that is going to work if your patient is cold and frightened, and you put on country music when he likes classical.
The technologists at my lab have taught me one caveat. In the state of Maryland, the x-ray technologists are allowed to give medications. I have never seen one of them give a drug without first asking if the patient was allergic to anything. They ask every single patient, every single time.
Remember your elders. Just as there are cultural differences among patients that must be addressed, we must realize that our patient population is getting older. You are going to have patients in their 70s and 80s, and the older they get, the less muscle mass they have. This is going to skew your drug administration and it is also going to skew your lab values. You have to consider that the nurse who failed to give 10 mg of valium in pre-op did so for a reason. She did it because she didn’t want this elderly woman on the table an hour later who hasn’t had anything to drink for the last 12 hours, is now scared to death and the drug hit her too hard, and she now has to reverse it. Remember to approach the elderly just a little differently than you would somebody in their 20s. That doesn’t mean you don’t have to treat them; it just means you have to be careful.
Pain medication begins in the pre-op area. How many of your patients have told you that they were given medication in the pre-op or trans-care area, but it’s not working? Do you tell them that it’s not supposed to, so they don’t think they are taking pills for nothing? Tell them it’s going to work after you’re finished; after they are so happy that we didn’t knock them off doing the procedure that they can relax and the medications will work. We give them medications in their intravenous lines, and that’s what works. This brings us to the following point: make sure your IVs work.
Everybody uses drug cocktails. No matter which lab you ask, they will tell you that they use fentanyl and versed. In some cases, labs will use demerol; the problem with demerol is that it has a metabolic breakdown that is different, but it is a very good drug when people come in with a broken arm. You can still use fentanyl and versed; they’re short-acting.
How many of you have ever had to take care of one of your friends or colleagues? They know what you’re going to do, and you’re trying really hard to be cool so that they can relax. Tell them right up front that they’re too awake, know too much and that you’re going to put them to sleep and wake them up when it’s over. People in our profession know what to expect, and that sometimes increases their pain and anxiety.
How many of you do electrophysiology? How many of you give EP patients enough drugs to knock out your whole cath lab and they’re still talking to you? The EP doctors can’t tell you why this is so. They’ll tell you that the patients are young. Oh, really? When I go into the EP lab, I see patients who are just as old as we see in the cath lab. They’re not that much younger. They’ll tell you that their patients don’t have all of the other diseases that our patients tend to have. Oh really? How do you think they got the patients? They got them after we took care of them in the cath lab.
Again, I think it is common sense. If I stuck my finger into an electrical socket, I would have a stress reaction. What do you think they are doing in the EP lab? Zing, zing, zing. I’ve never had to reverse a patient in the EP lab. It is amazing to me that these people can tolerate this much medicine. Catecholamines are wonderful.
Let’s talk about overdosing, which is rare, but does happen. How many times have you actually had to reverse fentanyl and versed? It doesn’t happen that often. Why do we really need to reverse? In those rare cases where there is respiratory depression, you may need to reverse. It is easier to reverse a bit of the medicine than intubate for an hour. Give your patient a little bit, and see how well they recover. The reversal agents only last an hour. Cath lab drugs last 2“4 hours. Give them the pain management medications on the lighter side and a little bit more frequently, and you won’t have to reverse. It’s common sense. Pretend it’s your mother.
How many of you have consistent documentation? How many of you have gone through JCAHO this year? Did they look for consistent documentation of conscious sedation? (Same place, same form, same way, no matter what unit you’re on, from door to door.) That’s what JCAHO is going to do. They’re going to say, Are you using the same Aldretti scale when you’re doing conscious sedation? Are you using the same pain management scale? It doesn’t matter which scale your hospital uses (e.g., the little cookie faces with smileys and frowns, etc.) as long as it’s a standard that is recognized and consistently documented.
Congress considers lack of pain control to be a violent act to your patients. Now, we all know what violence is. If you don’t relieve your patient’s pain, Congress has decided that you are behaving violently and inhumanely toward your patients. This puts it in a totally different perspective, doesn’t it? Pain management no longer becomes a generous thing to do. It becomes something that we need to do because we are human beings, and we have concerns about whether our patients are scared and hurting.
Pain management is a mandate. It is something that JCAHO is looking to see in your facility. They have actually called this the decade of pain management and wrote standards that were published in 2001. The standards start out with the given that all patients have the right to have their pain controlled. It is a written mandate, and it is in your standards of care. It’s the patient’s right and your responsibility to educate your patients about their rights. Not only do you have to relieve their pain, you have to tell them that you are going to relieve it, and it is expected that you will do so.
Throughout the world, we are not controlling pain. Throughout the world, patients are complaining that those of us in the medical field are not controlling their pain. We can do better.