Monday, July 23, 2007

The downside of the "5th Vital Sign"

I have been called a sadist. No, really, a sadist. At least that is what some would call me, a person who willingly inflicts pain upon others, at their request! How can I be seen any differently?

In fact, pretty much everything I do is accompanied by some degree of pain. In many cases, what I do to patients hurts a lot. Thankfully, in the 21st century we have the advantage of readily available narcotics, as well as a variety of non-narcotic pain relievers. We also have more advanced forms of narcotic delivery, such as PCA pumps and transdermal iontophoresis. And, generally, we surgeons are pretty good guys about dispensing pain meds ---- after all, I have had six operations myself, and know that a little morphine can be a good thing!

I also know that a lot of morphine can be a bad thing.

If we take a trip in the wayback machine to the time I first hit the hospital wards as a third year medical student, postoperative pain management for the majority of general surgical patients involved intramuscular administration of narcotics until the patient could take oral medications. An "IM injection" is simply a euphemism for a shot in the rear, which many patients understandably don't care for and often avoided. But they work, and provide a fairly sustained release of medication for a few hours to allow a reasonable period of pain relief.

Because some patients didn't respond terribly well to, or avoided altogether, a "shot in the rear," intravenous narcotic use became more prevalent over the past 20 years. This was particularly aided by the development of the PCA (patient-controlled analgesia) pump. These little doodads are nice, allowing patients to get a consistent, small dose of narcotic by pressing a button; a lockout feature prevents the pump from giving too much in too short of a time span. So, in the ideal situation, the patient simply can dose himself whenever he is uncomfortable, without having to call for a nurse to give him a shot, as Forrest Gump would say, "in the buttocks."

There are a few problems with PCA pumps, however. It is not uncommon for a patient to get enough medication to allow them to sleep....but only for a short while, and they have to play "catch up" with the medication to get back to a reasonable state of comfort. Some physicians add a continuous low dose of narcotic to be given along with the "demand" doses in order to counter this issue. The pumps are mechanical devices, and can malfunction and not deliver the medication appropriately. And some patients are simply incapable of using PCA pumps due to other underlying medical or psychological problems. However, all in all, if used properly, PCA pumps can be an excellent component of a clinician's toolbox to treat postoperative pain.

However, the PCA pump era soon was accompanied by two unintended close followers: decreasing nurse-to-patient ratios and an ever-increasing emphasis on treating pain as something that can (and should always) be completely eliminated. In that milieu, a physician who prefers to prescribe IM narcotics can be accosted for using up valuable nursing resources, and assailed for not being sensitive enough to patients' pain. Of course, given that scenario, it was only a matter of time before some self-important regulatory agency got involved in the business of pain management.

Fast forward a few years to 2001, when the Death Star of American Medicine decides it should be the arbiter of all things pain-related --- JCAHO published its report on Pain Management Standards. Basically, it mandated that hospitals establish policies for assessing and treating pain, particularly postoperative pain. In fact, the push was on to mandate that pain assessment be viewed as a "fifth vital sign," given the same importance as heart rate, blood pressure, temperature and oxygen saturation. Because the path of least resistance to complying with these sorts of mandates generally involves a simple-but-poorly-thought-out solution, all across the country hospitals implemented scales (visual or number) to rate patients' pain levels. However, in each of these scales, it is the patient, not the caregiver (nurse or physician) who is rating the pain. I know this sounds cruel, but, well, that's what nurses caring for postop patients are trained to do.....and patients sometimes don't have a realistic understanding of what their pain level is.
Couple that issue with the militant attitude of JACHO ----there shall be no pain!!--- whose guidelines insisted that anyone with a pain score greater than 5 must be reassessed. In the real world, unless a nurse wants to go through the headache of extra paperwork, reassessment means "remedicate." And, of course, there is the all-too-frequent patient who describes pain as being "10 out of 10" as soon as he is arouse from a profoundly deep, narcotic induced sleep; how does one truly rate him with JCAHO's mandates in mind?

And that, my friends, is how we have gotten into the pickle of potentially overmedicating, overnarcotizing, and oversedating patients sometimes to dangerous levels. That doesn't just lead to sleepy can lead to death. Don't take my word for it; there's a nice article that actually details a higher mortality rate in the era following this pain assessment effort (2000-2004) as compared to the era just preceding it (1994-1998). The study, entitled Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign should really be read as a wakeup call to nursing administrators, surgeons, and anesthesiologists who run postop pain services.

Pain management is important and merciful in the postoperative setting --- but it is important to be aware that our desire to be kind can inflict a greater danger to the patient than their pain represents. Hopefully, the pendulum can swing a bit back towards a more judicious approach. I would also recommend that we teach patients about those pain scales before they ever hit the OR --- and I would start by saying that a "10" on a scale of 10 would be akin to being doused with gasoline and lit on fire. Then we can at least work backwards from a mutually visible reference point. Any thoughts from the anesthesia caucus?