Wednesday, August 01, 2007

Attention to the fifth vital sign may adversely affect the other four!

The DocSurg is aggravated by the fifth vital sign. So am I. In his July 23 post DocSurg recounts the rise of pain management dogma this decade, focusing on Joint Commission’s mandate and the notion of the fifth vital sign. (By the way, check out his 2005 rant about Joint Commission!). He notes:

And that, my friends, is how we have gotten into the pickle of potentially overmedicating, overnarcotizing, and oversedating patients sometimes to dangerous levels. That doesn't just lead to sleepy can lead to death.

He then goes on to cite this paper from the Journal of the American College of Surgeons. The investigators set out to test the premise that present day use of unscientific pain scales causes injury and death from overmedication by comparing adverse events in time periods before and after the promulgation of pain rating scales and other pain management dogmas (1994-1998 and 2000-2004, respectively). The study showed an increase in the rate of deaths due to overmedication in the 2000-2004 period and concluded:

The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.

These unintended consequences were not unanticipated. But as the pain management initiatives were rolled out 8 years ago practicing doctors’ safety concerns were largely ignored.

1 comment:

Anonymous said...

When I was hospitalized a little over a year ago for trauma surgery it was my first adult hospitalization and I had not even visited anyone in the hospital for many years. After the surgery I mostly slept, waking when someone came into the room and responding to them.

I do remember being asked at times to 'rate' something, one to ten, and because the nurse was so kind I tried to come up with a number and tried to vary it. At no time, once I got to the hospital was I ever in pain, and did not realize the number asked referred to pain level. It might be a good idea for medical staff to first ask if the patient is in pain and THEN ask them to rate it.

I got wonderful care throughout and am very grateful to Salem Hospital in Salem, Oregon and to the surgeon, Dr. Steven Beranek. And of course, completely recovered!