Tuesday, September 26, 2006

Pain from the pain team

I’ve not posted anything here for a while. The government are intent on morphing the medical profession into their own image –a grotesque parody of consultants formed under the Modernising Medical Careers (MMC) Farce.

More on this later.

SM has now moved hospitals and is back doing Anaesthetics, following a spell in Intensive Care. I’m genuinely enjoying my job, with one exception –the pain team.

Several years ago it was realised that post-op pain is not well managed, patients were often sore and this delayed recovery as well as being unpleasant for the patients. Anaesthetists, as those with a wide experience of managing analgesia (pain relief) started setting up ‘acute pain services’. Realising that much of the work was routine and fairly repetitive they rapidly got a lot of nurse specialists to do the work for them.

Now these nice ladies (and a few gents) walk about the hospital, Monday to Friday, 9-5 dealing with pain issues. Outside of this time the on-call anaesthetist gets called. About everything. Junior Doctors are no longer deemed capable of running basic devices like morphine pumps, or capable of being educated about epidurals –mostly because the pain nurses give the impression that what they do is highly complex and when they are unsure the Junior doc would clearly be out of their depth –‘Send for the Gasman’ goes out the cry.

But now it seems that even I’m not capable of dealing with these complexities, despite several years of training and the medical degree to boot. Why, because what I suggest is ‘not protocol’.

An example – I went to see a patient who was sore. Simple post op wound pain with nothing else funny going on. He can’t take oral meds because he is feeling sick. He can’t take morphine because it makes him hallucinate. So I suggest an alternative opiate given under the skin. The ward nurses are not happy because this is not ‘the protocol’ and the pain team (i.e. more nurses) don’t do it that way. No amount of explaining by me as to the safety and efficacy of this drug by this route will swing them, I even end up offering to give the injections myself and teach to Junior doc how to do them –but no. Up against the implacable wall ‘its not protocol’.

Sadly many patients do not fit neatly into protocols, and what is best for them has to be judged on an individual basis. Nursing, with its strict rules and protocols, does not have the flexibility to alter this. Medicine, when practiced by doctors, does. This does of course give me the ability to do great harm if I screw up –but that’s what the last 9 years of education have been about trying to prevent.


Blogger Dr John Crippen said...


I sent a punter with intractable back pain (done the rounds of the surgeons) to the pain clinic. He was not seen by the anaesthetist consultant, who is good, but by the Nurse Practitioner, indeed on this occasion, the Oxymoron (Consultant Nurse)

She told him he could take 2 paracetamol on a "time contingent basis". As I said elsewhere, I don't speak "Nurse" but i think this means 2 paracetamol every four hours as necessary"


12:12 pm  
Blogger Dr Sandman said...

sadly all too familiar. Chronic pain is a particularly difficult specialty, and one where nurse specialists may have a role following up the punters and talking to them (something I think nurses are often quite good at).

But, they need to be seen by a doctor with expertise in this are first, who needs to plan proper treatment which may, or may not, involve medication, psychology etc... To abdicate this responsabiltiy to a nurse is scandalous.

12:54 pm  

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