Thread by @grimalkinrn

I'm going to talk about a Black woman under my care for the course of two nights. Most information will be changed to protect patient privacy.

So I'll call my patient Mary and I'm Nurse Jo. Mary has had a pretty big abdominal surgery. She can't eat but she can have swabs. She is on a dilaudid (a strong IV narcotic) pain pump. She is miserable.

I call the doctor. My first suspicion (after checking her IV site to make sure it was good) was that she was on too low of a dose. Mary was about my side. Mary just told me "it's okay, honey, I know they aren't going to believe you."

The doctor gives me a very liberal protocol because he knows me. Basically I can now give Mary enough dilaudid that I could kill a horse. If Mary were a horse. On the comfort level, I've got ice packs to her incisions, I've made her a neck rest because I noticed she had apnea.

And to try to make her miserable night better I even put some crystal light powder on her ice chips.

Then I give her larger and larger amounts of dilaudid over the course of the hour. Still. 10/10 pain. It's fucked up. She's not even a little sleepy.

By now, all of the numbing medicine they did before surgery has worn off. Mary can barely hold still. I have nearly gone through a 6 mg PCA syringe trying to get her pain under control. So I think on it and hatch a plan.

My plan: Add IV tylenol every six hours to be alternated with IV toradol (kidneys were fine, I checked) every 6 hours. The doctor agreed and I added these things to Mary's regimen. She feels a little better and tells me it's okay, she's used to being in pain.

The intern comes up to my desk and I immediately make a beeline. I would like to give Mary a test dose of 2 mg of Morphine because my theory is that the dilaudid just isn't being processed at all. He goes and examines Mary, who doesn't want to be a problem. "She's fine" he says.

Mary is not fine. Her blood pressure is through the roof. She's at risk to tear an incision or her skin from writhing in the bed. What's more, we've gotten to the point where I have 6 patients (I've gotten 2 more admits from the ED) and now I have less time.

So I argue with the intern, a very bright young white man with enough cologne to knock me and Mary to the last decade. He refuses to give me ONE FUCKING DOSE OF MORPHINE. I talk to Mary about what I want to do. She's on board. The intern refuses.

I call the midlevel. I review Mary's blood pressure, inability to walk or rest, and the ineffectiveness of the dilaudid pump. I want to give a 2 mg test dose of morphine and if that works, switch the pump. This is something I've done many times for tons of white patients.

Midlevel says they'll discuss it at rounds, which is six hours away. I say "If this is the answer you're giving me, then I will need to call the chief resident." He says "go ahead, they'll say the same thing." And the chief resident said the same thing.

I knew what I was doing.

See.. Mary wasn't stupid. She was a well informed patient. And she had found the only Black woman surgeon in her insurance group to do her surgery.

I call the chief resident who has already been briefed. I don't have to brief the charge because that night, I was in charge. With 6 patients. God bless the other 5 and the CNA. The chief resident refuses me the morphine. I tell him I am going to wake the attending. He hung up.

All along this way, I've heard microagressions from the residents and I'm sure Mary has, too. She just wants to be a good patient so she gets the care she needs. Something else is happening to, though. Mary is seeing how hard I am fighting for her and trust begins to build.

The tylenol/toradol rotation meant she was getting something for pain that worked (just not enough) every 3 hours. So I call the attending. The only Black surgeon, the only Black woman surgeon, in my hospital.

"Dr ________, I am caring for your patient Mary, who is not getting adequate pain control.

We have added in tylenol and toradol, she has received bolus (extra) doses, and her pain is still 7/10. I would like to give her a test dose of 2 mg of Morphine, monitor her closely +

And if the morphine works, I would like to switch over her pain pump. She has had 5.4 MG of IV dilaudid over 5 hours with no effect. Her blood pressure is elevated and she is in so much pain she cannot walk or lie still.

Dr: "That sounds like an excellent plan, Jo. Go ahead and do that. Give me the names of the residents you spoke to."
(I should note I had also alerted the house supervisor and had a round robin with the other floor nurses for ideas on how to help Mary.)

Finally, I had what I wanted. I took that precious 2 mg dose of morphine into Mary's room and she said "I'm scared it won't work." And I say "we can call Dr _____ back and at the least you are getting a pain consult at 7 AM.

I check Mary's vitals, check her oxygen tubing, push the morphine and then empty her foley bag so if she does fall asleep I don't have to wake her. I surround her with pillows and refresh the ice pack on her belly.

The morphine worked. The lines of tension on Mary's face were gone. She was smiling. She said "you did it!! Thank you so much for listening to me and believing me." And I told her it was my pleasure to be her nurse, which it was.

Then Mary dropped a bomb.

Mary is a nurse at a nearby hospital. She had come to ours after a bad experience at her own hospital and a lot of gossip with people saying she was a drug seeker, etc. People had always jumped straight to dilaudid with her and it turned out I was right +

When I left to go home and sleep, Mary was walking the unit with the day shift CNA and waved as I left. I'd been able to take out her catheter because she could get out of bed now that her pain was controlled. She was walking, the best way to prevent blood clots and muscle loss.

I came back that night and now, Mary was off the PCA. But I had thoroughly documented exactly what Mary needed for pain control and to avoid Hydrocodone, which is synthesized in the liver into dilaudid, and to go straight for tramadol or percocet. +

When she was ready to leave, the next morning, her family was there super early to pack her things. She called me in to tell them I was the best nurse she'd ever had. And a young man said "No, momma, you're the best nurse ever."

What a compliment. It meant so much. What meant more was the trust Mary and I developed that first night. She knew I was doing everything I could and by morning she was feeling so much better. We exchanged a loving, GENTLE hug because she still had a giant incision.

I wish I could say that Mary was the only Black patient I'd met that had problems with pain medication but that was not the case. I've seen so many excuses for not giving post op patients adequate pain control, even though many of them are recovering from cancer.

I didn't know it but that night, I learned what it meant to truly advocate for a patient and to truly go the distance but I hate to think that if her attending had been white and not a Black woman, knowing what another Black woman was dealing with.

After that, I got a reputation as someone who was great with pain. I took extra classes on acute on chronic pain and how dosages should be incrementally changed. I volunteered for patients on the toughest pain protocols. I offered to take care of people in for heroin withdrawal.

But I have never received a compliment so great as that patient, that NURSE, telling me I was the best nurse she'd ever met, and thanking me for believing her. We both cried a little. I went through that nurse feeling that you want to take the patient home (it's a thing).

I'm just one nurse though. Mary was just one patient. We as medical providers must continue to do our best to weave traditional and non traditional methods for adequate pain relief. It can be done. If you relax a patient with lavender they might not need a big dose of meds.

But that's the story of Mary and Jo, two nurses, and a long, painful night that thankfully, was over by the time the sun rose.

I want to add that I don't feel this situation would have been so bad if Mary had arrived during the day when the pain management team was there. Because the OR had been delayed, Mary hit the floor right at shift change. The most dangerous time for a patient.

And I don't want anyone to think of me as a "white savior" in all of this. I listened to what my patient told me, watched her vital signs, and believed her. This should be a simple thing to do.