Sunday, October 14, 2012

Listening without judgment an important component of pain management - The Clinical Advisor

For as long as I've been in the medical field, I've heard the phrase, "Pain is what the patient says it is." Nurses are taught to assess pain as the fifth vital sign, and have multiple ways to assess a pain level as accurately as possible, from number scales to pictures. But as providers, are we really listening when patients complain of pain?

Most of us have patients who always seem to be complaining about some ache or pain. There are those patients who keep coming back time and again with the same pain, despite our best efforts to help them. This can be frustrating for the patient and the provider. I know many providers who "tune out" when these patients start discussing their pain.

I've been thinking about people's perception of pain all week. I had some minor cartilage repair in my wrist that turned out to be a more extensive surgery than anticipated. I've had great pain control post-operatively, but it reminded me that this isn't always the case.

Seven years ago, I had laproscopic surgery and was in excruciating agony when I came out of anesthesia. I was reporting a 10 out of 10 on the pain scale during recovery, but the nurses just brushed me off, telling me that I had no pain tolerance and to go home and take my painkillers. "Don't tell a woman who has given birth without pain medication or an epidural that she has no pain tolerance," I thought.

Eighteen awful hours later I had a huge hematoma. It looked like a bikini bottom made from bruising. When I saw the surgeon, he was appalled that no one had called him about my unusual pain. If they had alerted him, he might have been able to stop the internal bleeding and prevent the hematoma from growing so large.

Managing pain is a huge part of my profession, and I see such extremes in the way people respond to pain. I've seen women roll onto the labor floor laughing and chatting. "Well, we know she's not in labor," says the nurse. And the nurse is right, most of the time. But every now and then we are wrong, and the mom is in active labor with advanced cervical dilatation.

More often we see the moaning, cursing, writhing women, not in active labor yet, but in obvious pain. The puzzle, as an obstetric provider, is how to best get her comfortable before active labor starts. Who am I to say that a patient's early labor pain isn't as intense as another's active labor pain? A patient's pain is what she says it is.

I also see many women complaining of chronic dysmenorrhea or dyspareunia, often complex and difficult to manage disorders. Typical pain management strategies can be ineffective for these women and they are often frustrated, having been written off by practitioners as hypochondriacs or drug seekers. Sometimes patients complaining of chronic pain are drug seeking, but isn't addiction a form of pain as well?

I try to keep listening when my patients tell my about their pain, then work on developing a plan with the patient to best meet their needs and get them out of pain as quickly as possible. This may include referral to a specialist or to pain management.

Pain can be debilitating and can be a cause, as well as an effect, of depression. In my experience, pain is usually a sign that something is wrong, somewhere. If we listen well, ignoring our own judgments and preconceived notions, we may actually be able help relieve the pain.

Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.