Cath Lab Digest

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.)