Pain.com Interviews Major Donald Stracener, RN

MAJ Stracener, welcome to Pain.com.

MAJ. Stracener: Thanks for this opportunity to contribute and educate your readers. The work you are doing  to further the education and insight of healthcare providers ultimately benefits patients- and meeting patients needs and assuring their comfort are what all healthcare providers, including myself, aim to do. Thank you for your work and forum.

Pain.com: Can you provide our readers some insight as to your background?

MAJ. Stracener: I am a registered nurse. I attended my nursing school at Northwestern State University and earned my BSN in 1993. I have practiced and continue to practice in both military and civilian facilities. I will address both career paths. My military career started in 1990 as an enlisted cargo handler in the Army national guard. This helped fund my last 3 years of college. After graduation, I accepted a full time direct commission as 2ND Lieutenant in the US Army. I initially served at Ft Polk, LA and then went to Wuerzburg, Germany for a little over 3 years. I deployed twice while in Germany to the Baltics in support of Operation Joint Endeavor. Like the vast majority of my career, I treated patients in the emergency department and critical care areas. I especially enjoy trauma and critical care. The sicker/ more injured the patient- the better. I hate to see anyone in a bad situation but enjoy the privilege and challenge of keeping them comfortable and making them better. I left the Active Army in 1999 and returned to my home state of Louisiana with my family in 1999. I remained in the Army reserves until 2001 where I had more of an instructor/leader role as a "weekend warrior". In 2001, right around 9/11, I transferred to the Active Air Force and relocated to my new home here in San Antonio. At Wilford Hall Medical Center, I had the opportunity to work in their Emergency department- A Level I Trauma Center. I was there for 3 years and was one of the Charge Nurses. While at Willford Hall, I deployed to Iraq in 2003 to Iraqi Freedom. In 2004, I returned to the Air Force Reserves and started working full time for Methodist Healthcare here in town. I currently hold the rank of Major and have 19.5 years of military service. I have learned so much and thoroughly enjoy my military service.

As a civilian nurse, I worked in the ICU and Emergency Department at Christus St Frances Cabrini Hospital in Alexandria, La for about 2 years. Here in San Antonio, I have been working with Methodist Hospital since 2004 on various units. I currently work as an Admissions Nurse in the Emergency Department and fill in as part time Nurse Administrator. As Admissions Nurse, I complete as many admission assessments as possible for patients being admitted to the hospital. Also included in this position is a resource person for critical care issues. I respond to all Rapid Response situations and all Code Blue situations. This position has enabled me to help my peers in many ways. As an admit nurse, I can complete a process for the patient in the ER in under an haour that will take 2-3 hours on the admitting floor. A rapid response situation is one where a patient is beginning to deteriorate and the nursing floor asks for an ICU nurse evaluation and assist to prevent the worsening situation from getting worse. A code blue situation is actual or imminent cardiac or respiratory arrest. My other role as Nurse Administrator involves overseeing all aspects of nursing care and ensuring the nursing units have the resources they need to provide high quality care for our patients.

Pain.com: What makes an ICU nurse different from a regular nurse?

First of all, all ICU nurses are "regular nurses" to start. All nurses have been trained to deal with patients with a variety of conditions and, to some extent, how to deal with emergencies. ICU nurses receive additional training via classroom study and on-the-job training to take care of the sickest of the sick. ICU nurses care for patients on "life support" , such as patients on mechanical ventilation, blood pressure and heart rate (vaso-active)meds that are adjusted or titrated, or with special circumstances such as those recovering from major surgeries or trauma. The standard of care is different between a "floor nurse" and a critical care RN. For example, say a patient on a med-surg floor has a temp. The nurse calls the MD for guidance before administering any medication. Conversely, if an ICU patient has a fever and the nurse calls the MD, the MD will ask what the labs and chest x-ray look like; the ICU RN is expected to have already done the workup and share those results with the doctor when she calls him or her. An ICU nurse must be highly autonomous because an ICU nurse must be able to make on-the-spot decisions that floor nurses would never be asked to make, from diagnostics to giving meds. Being able to make those crucial decisions and see the immediate response of my patients is one of my favorite aspects of my job.

Pain.com: Do you have specific training to deal with death?

MAJ. Stracener: Unfortunately, death is a reality in what I do for a living. Death is also an area where very little training is provided to help medical professionals deal with this reality. The mentality still exists among the medical profession that we are going to save everyone, so death as a training topic is hardly ever mentioned and is more of an afterthought. Most nurses learn how to deal with death on the job and it really is never easy.

As you mature in the profession, you do come to realize two facts that help you cope: First, we all, at some point, are going to die. Death is a part of life and those of us who are nurses have to deal with that reality every day. Secondly, there are things in life that are worse than death. You have to consider quality of life vs. quantity of life. Any nurse with, say, more than five years of experience could tell you horror stories of poor patients who were in absolute misery and had no chance of recovery, and when you see that, you just know that there are situations worse than death. The nurse's primary responsibility when a patient is in a death or dying situation is to provide aggressive pain management within established guidelines and to support the patient and family through a dignified end of life.

Pain.com: That brings me to another question: With so many states approving PAD (physician assisted death/suicide), does the military apply the state law where the hospital is located, or does it apply federal law, or is there a special military medical code of ethics that one must adhere to?

MAJ. Stracener: I am not a big fan of physician-assisted suicide. I am a big proponent of aggressive pain management and anxiety relief in an end-of-life patient. I believe you can keep a patient very comfortable with generous amounts of properly titrated pain and anti-anxiety meds and not have to intentionally kill him or her. I also don’t believe a nurse or any other person has the right to intentionally take a life except to defend their own.

As far as your question about military law, I would have to defer that to an attorney for a certain answer and I will do so. My best guess at this point would be that federal law would trump state law just as it does with all other aspects of military medicine.

Pain.com: Since this is Pain.com, what are the major issues you see when trying to alleviate pain?

MAJ. Stracener: Allow my military candor to come out with this one. Frankly, we suck at pain management. Physicians are often scared to write for enough medicine to relieve severe pain and, when you accidently find one with the stones to do so, the nurses are scared to give the medicines to relieve the pain. We tend to fear the "what if’s" and lawyers and those of us who are medical professionals still tend to over-estimate the possibility of chemical dependency. I have at various points done individual study on this subject and there is NO literature anywhere that states proper management of pain results in addiction. Also of note is that opiates and benzodiazepines, the two key cornerstones of serious pain relief, have reversal agents that can quickly reverse the effects of the drugs in case a patient gets too sedated. As long as a patient is in pain, you are not going to have the respiratory depression so many providers fear. Most of the opiates and benzodiazepines we use have NO upper limit dose range, and there is a reason for that: a patient should be given what they need to alleviate their pain in small incremental doses until their pain relief objective is met. We as a profession are scared to do this. I may at some point blog on this topic separately if you like because it is so important and has been a source of several recent court cases. Documentation is the key to distinguish between an effort at pain relief versus a rogue effort at assisted suicide.

Pain.com: Is it difficult to tell a person in pain that you cannot remove all pain, that you are just looking for a tolerable level of pain management?

MAJ. Stracener: Well, as you know, I have a little chronic pain issue myself with a military related injury. I can tell you, good communication is the key. Using a pain scale of 1 to 10 with 1 being very little pain and 10 being the worst ever pain, a good provider will discuss with the patient what is an acceptable pain level for them. As a general rule, a pain score of 1-2 would be best described as an ache you know is there but in no way limits your function or quality of life--that is where I stay. When pain creeps up to a 3-4, I take a dose of medicine to alleviate my symptoms. Patients do not, for the most part, want to be stoned on meds, so that’s really not an issue, but they do want relief for their pain. What I do see is not nearly enough time is being spent on the education portion of pain management. I can't tell you how many times I have educated patients about pain and discovered that they had no clue about their own condition even though they had been in the hospital for days. An informed patient is a patient in control and that in and of itself is a strong mechanism for pain management.

Thanks again for the opportunity to contribute to your site.