Most trauma professionals worry about over-prescribing
pain medication. But under-prescribing can create problems as well.
Uncontrolled pain is a huge patient dissatisfier, and can lead to unwelcome
complications as well (think pneumonia after rib fractures). Always do the math
and make sure you are sending the right drug in the right amount home with your
patient. If the patient’s needs are outside the usual range, work with their primary
provider or a pain clinic to help optimize their care.
care during an emergency
This situation can occur in the emergency
department when the emergency physician calls a specialist to assist with
management. If the specialist insists on the emergency physician providing care
because they do not want to come to the hospital, the specialist opens themselves up to major problems if any actual or perceived problem occurs
afterwards. The emergency physician should be sure to convey their concerns
very clearly, tell the specialist that the conversation will be documented
carefully, and then do so. Specialists, make sure you understand the emergency
physician’s concerns and clearly explain why you think you don’t need to see
the patient in person. And if there is any doubt, always go see the patient.
Failure to get informed consent
In emergency situations, this is generally not
an issue. Attempts should be made to communicate with the patient or their
surrogate to explain what needs to happen. However, life or limb saving
procedures must not be delayed if informed consent cannot be obtained. Be sure
to fill out a consent as soon as practical, and document any attempts that were
made to obtain it. In urgent or elective situations, always discuss the
procedure completely, and provide realistic information on expected outcomes
and possible complications. Make sure all is documented well on the consent or
in the EHR. And realize that if you utilize your surrogates to get the consent
(midlevel providers, residents), you are increasing the likelihood that some of
the information has not been conveyed as you would like.
Letting noncompliant patients take charge
Some patients are noncompliant by nature, some are
noncompliant because they are not competent (intoxicated, head injured). You
must use your judgment to discern the difference between the two. Always try to
act in the best interest of your patient. Document your decisions thoroughly,
and don’t hesitate to involve your legal / psych / social work teams.