Tuesday, 30 March 2010

Pain thresholds

Day shift: Four calls; two by ambulance; two by car.

Stats: 1 Chest pain; 1 Abdo pain; 1 Back pain; 1? # Humerus.

A late start and a 35 year-old man with chest pain in a Government building. He had no medical history and there was no family cardiac history but his pain was the ‘tightening band’ kind and it started when he was at rest - always a suspicious event. He’d walked from the underground station to work and had let the pain ‘settle’ before calling an ambulance an hour later because it hadn’t quite gone away. This was a risky strategy but one I fully understand as this is probably how I’d behave if I got pain like that. No healthy person wants to admit that they may be having a heart attack.

His ECG had several anomalies on it – an inversion in one of the leads that should have been positive and, despite two printouts to rule out vibration, his P waves were multiple and possibly suggestive of an AV block but, until he’d gone to hospital and had a more thorough check, there was no way of telling one way or the other whether he was in trouble.

Ovarian cysts are painful and I fully appreciate the struggle women have with this condition if not dealt with definitively, so my next patient, a 24 year-old, who was rolling about on the floor of her office while her two extremely concerned and often slightly obstructive colleagues looked on, made for a challenging scenario. She was three floors up with no lift available and I had to manage her, her two companions and the possibility of walking her down those steps to the car, without losing control of the situation.

Apart from the pain, there was no need for this call to be more than a simple in-car transfer but the young woman made life very hard for me. She wouldn’t communicate, insisting only that she would be ‘fine’ and she attempted to pass out several times, in between bouts of thrashing and rolling. Getting obs was all but impossible and I gave her Entonox but she wouldn’t use it properly. Her friends were too close and too involved and had to be told several times to let me do my job. Granted they had probably never seen someone in such pain before but physically getting in the way and verbally interrupting wasn’t helping at all.

A crew turned up because this was given a Red category (breathing difficulties), so I got help when I had her at the top of the second flight of stairs. If she’d dramatically collapsed she may have taken me with her when she tumbled but, with encouragement and a few reminders to stay upright, we got her into the ambulance. She proved just as difficult for the crew when she threw herself to the floor of the vehicle and delayed the journey to hospital even more. Meanwhile, outside, her two friends huddled the back doors and became a real problem – the traffic (including buses and lorries) was slowly edging past the ambulance in a very narrow street and they were at risk. They had to be told to move out of the way of danger several times before they got the hint.

I left the crew to it as they tried to get the woman to sit on a chair for the trip and I told the pair what they obviously didn’t want to hear. The woman in pain did not want them to travel with her. No doubt my strict attitude to controlling the situation and this announcement from their stricken colleague will earn me a complaint but this is something the public need to understand – we are there to do a job and we need to feel safe while doing it; removing any risk or possibility of risk to ourselves, the patient and others is of primary importance, even if that means a sterner attitude. Not rude - stern.

Another pain that can be unbearable is that which is generated by damage to the spine, the cord or the muscles around the vertebrae. A 31 year-old man slumped awkwardly in his chair at work as I administered (or he administered) Entonox to reduce the agony he was suffering after a diagnosis of ‘back problems – unknown aetiology’ was given by his doctor - and then he was left to cope with tablet analgesia and the promise of physiotherapy. He’s on a waiting list.

His problems started with a bout of Epididymitis and, after a check for other problems, he was told that this was probably to blame for his backache. It wasn’t, so now he has to get by when it strikes. Today, however, he couldn’t even stand up and it took a lot of gas and air to get him moving to the car. Neurologically he was fine but he needed something done to help him and that’s why he went to A&E. Unfortunately he was then sent to the waiting area and I had to take my Entonox away from him. Poor guy.

Breaking your ‘funny bone’ isn’t funny at all – I’ve yet to see someone laughing their heads off after doing it, unless they have been given Entonox and Morphine. A call to a GP surgery for a 74 year-old man with heart problems (currently being dealt with by said GP), left me a little annoyed because the gentleman had fallen on the steps outside the surgery after having just seen his doctor and all they did was take him in, sit him down and call an ambulance for a ‘possible broken shoulder’. I arrived to find him on his own and with nobody around initially to tell me what was going on. There were no notes with him until I asked for them and the Receptionist wasn’t interested.

This man had been left sitting in pain, unable to move his arm and with no examination having been done to ensure that an open fracture hadn’t occurred or that neurological or circulatory damage hadn’t taken place as a result of his injury. He’s had three heart attacks, so I am surprised that no basic obs were carried out prior to my arrival. I think there was a duty of care in this instance and it was left to me to do everything possible to ease his pain and protect his broken limb. All it took was an arm sling – a basic first aid skill.

Be safe.


Anonymous said...

Further to an accident in the car park of my gp's surgery. Without boring you with details no gp/nurse anyone would have anything to do with hurt person who was pregnant also and an ambulance was called due to potential 'litigation'!! How about basic human kindness.

The trouble with pain I think is that sometimes it gets all complicated and fear, embarrassment etc. stop the patient behaving who would otherwise be compliant.

Occassionally with my Ehlers Danlos I have had to attend A & E and always try really hard to be obliging and helpful regardless of severity of issue. Fell over banged my head once and got concussion that didn't really feel like it hurt but boy the head injury made me rude as hell!

Feel sorry for the lady with the ovarian cyst probably she should have called in sick that morning but possibly had already had time off or had not been performing well at work and needed them to see her pain was real. She is possibly at the end of her tether. Not using the entonox could have been pain related also sometimes the simplest of tasks when stressed or in pain can seem impossible. Perhaps like you she was worried about falling down the stairs and wanted to keep her wits about her!

Sometimes I wonder if all people who rang 999 were told to wait and ring NHS direct and get the treatment they dish out over the phone whether you could put your feet up. Imagine all the pretend eplileptics, drunks, immigrants, women and other irritating members of the public who would simply disappear leaving you free to turn your attention to those who are in genuine need.

Although the way things are going nowadays if some manager decided to cut the service altogether on the grounds it wasn't cost effective it would statistically prove a worthy saving.

Having read your blog for a long time now I am not sure I would ever have the bottle to ring 999 for me personally on the premise that if I could speak I probably wasn't worthy of the attention.

Xf said...


I sincerely hope that I don't give the impression that if a patient can speak they are not worthy of attention. Our attention should always and ONLY be focussed on those in genuine need.

Lynne said...

A 74-year-old with a history of heart problems gets seriously hurt in front of his GP's surgery and they don't even do basic obs and first aid?????!

That is just effing shameful. I wish there were some way to name and shame them for such appalling indifference, or have them put on notice about needing to improve.