The Young Patient
I had a young patient on Thursday - he was 15 years old. Apparently he has an irregular heart beat and he had a few episodes of fainting, so he came in for an electrophysiology study and got a Reveal implant. This is a device implanted under the skin in the chest that monitors and records the heartbeat. If you have any episodes of dangerous heart rhythms, the doctor can see exactly what happened, when, and for how long.
This kid was screwed up in a strange way. His history included ADD and other psych problems. He was on several drugs for ADD and anxiety. When you see this as a nurse, you think "Oh no. Meds aren't going to touch him." So it was with him. During the procedure, he was very difficult to sedate, and his pain was unmanageable. When he came back from procedure, I learned that they had given him benadryl IV in addition to the normal sedation - you know they can't knock him out when they pull out the Benadryl!!
All day, there was nothing I could do to satisfy him - in fact, there was nothing anyone could do to satisfy him. It was a losing battle....and unfortunately for me, he had the call light, and he knew how to use it.
He had sheaths in when he returned from procedure. He was not knocked out from procedure....the sheaths were ready to pull, and we did. I medicated him with everything I was allowed to use - 7.5 mg of valium, 4 mg morphine. Even with this, and the lingering effects of the sedation during procedure, when we pulled the lines, he reacted like we were amputating his leg. Moaning, wailing, writhing.
Aside: the doctor didn't even write for any pain management or relaxation medicine. What a dope. I had to hunt him down and tell him what medications to order, write it down, and get it signed. Sheesh. The doctor knew what kind of kid he was dealing with!!!
Once I gave him all the medication I could, I had nothing else to offer. So I had to stay there during the sheath removal procedure, and report his pain was 10 out of 10 or 9 out of 10. This so-called level of pain never dipped be low a 9 all day. 4 percocets and 12.5 mg of promethazine did not help.
Nevertheless, despite this "excruciating" pain, he was able to converse with his family in a calm, rational manner, and he was able to doze off several times. He could readjust his position, and scratch an itch. His blood pressure did not skyrocket, nor did his breathing rate or heart rate increase. In fact, his irregular heartbeat normalized after the procedure, and he was in normal sinus rhythm all afternoon.
I found it difficult to believe that his pain was so intense. Personally, I think this kid knew how play the system and for whatever reason, played it like a violin.
My Philosophy on Patients' Pain
I respect people's pain. I am not in the patient's body and I wouldn't presume to know what they are feeling and going through. Therefore, in most, most cases, when they say 7/10, it's a 7/10 and I address it as appropriate and within my scope of practice.
I am conservative with pain medication because I have a limit to how much I can give and I want to keep my tools available. Pain medication is not candy, so I would like to give a patient as little as possible that effectively manages their pain. I don't want them in pain.
Then there are the outliers and this kid was one of them, in my opinion. These patients can't handle pain, any little bit. To them, there are two levels of pain - 0 and 10. In my limited experience, these patients typically have some kind of psychological issue in the mix. They somehow believe that they should not ever have any pain, and any pain at all is a cause for emergency and drama! The world is ending!! I'm gonna die! Oh, the agony!!
A Note on Promethazine
It's an anti-emetic. It has a reliable side effect of making people go to sleep. I really, really don't like to use it to knock people out. It's not what it's for, and it's also pretty nasty chemical. It irritates veins, burns when it's administered, and can cause dire complications if it infiltrates tissue. I had nothing else to offer this kid, so I tried it - he kept asking for something to make him sleep. And sure enough, it didn't do a thing.
And sure enough, he let me know it didn't do a thing. Over and over. And over.
Heh. At least he didn't barf.
My Philosophy on this Kid
This is really sad. I think this young man has been raised all his life to be the sick kid. It sounds like he's been in and out of the hospital a lot for various episodes of this or that. He has been given every reason to develop and nurture his anxieties, therefore they are present in him. He mentioned at one point that all of his friends are other sick kids- kids with cancer, chronic blood disorders, etc. All he knows is how to behave like a sick kid and his environment reinforces it. And, as an experienced patient, he has learned how to play the system. He knows well how to be the victim.
In fact, that's probably the only way he knows to live.
Another odd thing about him is that he could take multiple pills in one swallow. That's weird for a 15 year old. When I was 15, it was all I could do to take an adult aspirin without gagging!!
It's so sad. It will take years for him to change his reality, if it ever does happen. Who will love him, besides his mother? He'll end up being disabled for something exacerbated by his worry and poor coping mechanisms, and we will all get to pay for his life via our taxes. What a pathetic future!!
Conclusion
I try very hard not to let patients suck me into their lives' dramas. I am a service provider not a player in their lives, and as a matter of self-preservation, I can't get involved. In most cases, keeping healthy distance is not that difficult. Most people have that similar expectation, and things go along smoothly.
Every once in a while there's one that pushes my buttons. It happens because I'm human, too. I start to reflect their anxiety and internalize it...not good! I'm getting to the point where I can recognize it's happening before I get too deep, and I usually can use my coping tools to handle it. As you can see, though, it still breaks through - after all, I'm writing about this a week later!
This blog is one of my coping tools. I hope I have exorcised this demon now.
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