By Colleen Morley DNP RN CCM CMAC CMCN ACM-RN
I recently had the experience of having outpatient surgery on my dominant hand. Trigger finger release on the middle finger. Surgery went fine, tendon released and immediate return of range of motion with the affected finger. YEAH!
I had attended a pre-surgical consultation the week prior, completed a stack of papers including health history, allergies, etc. When I arrived the morning of the surgery, the staff repeatedly asked me to verify the information and confirmed that it was in my chart. The APN visited me prior to my departure to clear me for discharge and handed me my discharge instructions and pain management prescription.
That’s when the story stopped being the “perfect outpatient surgery experience”. You see, I am allergic to opioids. Horribly, horribly allergic. Hives, projectile vomiting and in one previous post-operative event, an acute unresponsive episode. After the birth of my youngest son via C-Section (2001), I was given IV Demerol (even though I had an allergy band on noting this allergy). This was not an experience I wanted to go through again. Similarly, after another major surgery in 2014, the physician overrode my stated desires to manage pain with Toradol (‘could cause GI Bleeding’) and placed me on a Morphine PCA pump. The first 24 hours were a nightmare. I never touched the PCA button, but the automatic basal rate dose would administer the Morphine, and it would start the whole reaction every time. The MD transitioned me to Toradol after the first 24 hours when she saw me; in pain, no sleep and lucky her, she caught the basal show.
So, imagine my surprise when the APN at the Surgery Center handed me a prescription for Tylenol #3 with Codeine. I told her that I couldn’t take this. She suggested Norco. Again, I refused. Her response…” well, I don’t know what to do for you then”. I mentioned Ketoprofen (Toradol with Ibuprofen) or Ketorolac (Toradol). She was unfamiliar with either drug. She called in a prescription to my local pharmacy for the Ketoprofen, stating that she didn’t feel I would get good relief with it.
The pharmacy could not locate the medication in their network (took over 24 hours to determine that), so I called back to the APN who called in a prescription for Toradol after confirming that they carried it. By this time, I was 36 hours post-operative with insufficient pain relief. As a patient, this was horrible. As a case manager, this was unacceptable.
5 days later, I was back in the office, after 2 sutures “popped” and the wound started open. Sitting in the Physician Assistant’s (PA) office as he added a layer of Steri-Strips to bring the wound back together and rewrapped my hand to resemble a mummy, I had the opportunity to watch him do the electronic prescription for the antibiotic he was sending in for prophylaxis. He tried submitting 2 different antibiotics, only for the system to stop the process as it noted a conflict with my antibiotic allergies documented in the chart. So, how would the Tylenol #3 or Norco requests have gone through?
So, what is my point? We, as a healthcare community, must do a better job of listening to our patients, in advocating for shared decision-making. We must develop alternative plans of care for those who cannot follow the “usual path”. The PA had no problem going down a list of antibiotic alternatives, but no one had a plan for not using opioids for pain management during all my healthcare experiences over the past 20 YEARS!! As professional case managers, we must educate ourselves on alternatives, listen to our patients, research the options they present and advocate for them and their needs/desires.
Have you read CMSA's Opioid Use Disorder Case Management Guide? Members receive a free digital copy HERE
Does your organization have structures in place to involve the patient in the process?