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Pain Management in Otolaryngology. The PA’s Perspective. Marie Gilbert, PA-C 4/15/12. The PA’s Role in Pain Control. Primary Focus is always on the welfare of the patient. Keep the patient comfortable, safe, and informed.
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Pain Management in Otolaryngology The PA’s Perspective Marie Gilbert, PA-C 4/15/12
The PA’s Role in Pain Control • Primary Focus is always on the welfare of the patient. Keep the patient comfortable, safe, and informed. • Organize/coordinate care so that steps in care are not reduplicated or forgotten. • Plan for problems. • Recognize when problems are escalating, and when to “circle the wagons.”
For Patients Already Under A Pain Management Provider • Preoperative communication with Pain Manager is best. Keep written record of their instructions for “break-through” pain, for your own records as well as for the patient, and of who can prescribe them. • If the Pain Manager wants all pain prescriptions coming from that office, make sure all your staff can see that order documented in the chart (to avoid extra Rxs being given). • If the Pain Manager wants all pain prescriptions coming from that office, make sure the patient is aware of that, with a clear understanding that you don’t wish them to be uncomfortable after surgery but need them to be able to keep their contract with the Pain Manager.
Preoperative management • Complete H&P is needed, with special attention to patient’s medication list, allergies, and other significant medical or social history. • For example, avoid excessive sedation in a patient with COPD who will have nasal packing. • Give post-op prescriptions at H&P if possible and as authorized by physician. (Keep clear communication so that both PA and MD do not Rx.) • Have protocol (written if possible) on which pain meds, length of supply, number of refills, etc. so that others covering the case or covering your vacation will have the same instructions.
Discharging Patients • If you write Rxs for the patient at discharge, make sure to document that, not only the hospital chart, but in your office chart, to facilitate post-op care. • Have a plan understood from the physician about how long Rxs should be extended, i.e., until the next office appointment, 1 week with a refill, etc.)
Helpful Patient Instructions: Pedi • Liquid narcotics can sting, and they are bitter. Suggest to Parents to mix it with Hershey’s Chocolate Syrup, or to have the pharmacist flavor it. Also, liquid pain meds taste better when cool. • Remind parents that narcotics may cause constipation, already a common problem especially with tonsillectomy and other procedures prompting poor p.o. intake, so they may want to offer foods like applesauce or oatmeal for fiber while patient is on pain meds. • It is not uncommon for parents to fear the child may become “addicted” and reduce dosage or withhold pain medication prematurely. Please reassure parents their child will need pain control, especially after tonsillectomy, and the duration of need will not prompt addiction. • Remind parents NOT to substitute with Ibuprofen or Aspirin due to risk of bleeding.
Helpful Patient Instructions: Adults • As with children’s preparations, adult liquid pain meds can be bitter and sting. They do taste better when cool and mixed with chocolate syrup. • Adults should take extra fiber or a product like Colace to avoid constipation, and remind them that straining can cause bleeding. • Ask patients to watch supplies well enough that they do not end up asking a person covering call on a weekend to give refills. They may end up being refused or sent to the ED. • Remind adult patients not to substitute Rx pain meds with aspirin or ibuprofen until instructed to do so. • Acetominophen is okay in limited amounts unless there is liver disease , significant ETOH use, or other co-morbidities. Remind patients not to take acetominophen along with their prescriptions that also contain it. (Oxycodone is available without acetominophen.) • As with any other anatomical involvement, shingles of the Head & Neck can be excruciating, so prescribe accordingly, and prepare the patient for the likelihood of prolonged duration.
Summary • Know your patient. • Know your patient’s potential pain management needs. • Have a plan with some built-in flexibility for medication intolerance, inadequacy, and allergy. • Know when to defer back to the supervising physician or Pain Management Practice.
References • www.pain-topics.org • http://pain-topics.org/pdf/OxycodoneRxSafety.pdf • http://www.nlm.nih.gov/medlineplus/pain.html
