By HANS DUVEFELT
A “frozen shoulder” can be manipulated to move freely again under general anesthesia. The medications we use to put patients to sleep for such procedures work on the brain and don’t concentrate in the shoulder joints at all.
An ingrown toenail can be removed or an arthritic knee can be replaced by injecting a local anesthetic – at the base of the toe or into the spine – interrupting the connection between the body and the brain.
An arthritic knuckle can stop hurting and move more freely after a steroid injection that dramatically reduces inflammation, giving lasting relief long after any local anesthetic used for the injection has worn off.
The experience of pain involves a stimulus, nerve signaling and conscious interpretation.
Our brains not only register the neurological messages from our sore knees, shoulders, snake bites or whatever ails us. We also interpret the context or significance of these pain signals. Giving birth to a long awaited first baby has a very different emotional significance from passing a kidney stone, for example.
I have written before about how we introduce the topic of pain to our chronic pain patients in Bucksport. Professor Lorimer Moseley speaks entertainingly of he role of interpretation in acute pain and also explains the biochemical mechanisms behind chronic pain.
TREATING PAIN WITH ANALGESICS
Even when we are awake, we can reduce orthopedic pains with medications that work on the brain and not really in our joints. A common type of arthritis, such as that of the knees, is often treated with acetaminophen (paracetamol), nonsteroidal anti-inflammatory drugs (NSAIDS) like ibuprofen or even opioids.
During a move necessitated 20+ years ago by my change from a “private practice of medicine” life to a “back to school” life, I decided to undertake the move on my own using a rented van. I also had to affix a small trailer packed with furniture to the van. As I lifted the not so heavy trailer to the hitch, one of my children ran toward the trailer. I stopped my child’s progress with a holler and an out-stretched hand. As I did that, a disc in my back popped and dropped me to the ground. I have had back pain every day since. I have managed my back pain on my own. But, I now think it is time to start using my medical insurance to pay for the care of my back pain. So, fellow insured, you owe me a BMW.
Yes, a BMW. I know that my back pain is a subjective complaint and you can’t prove or disprove that I have it. I also know that there is no measure of my back pain; I can grade it on a scale from 0-10, as some do, but that is such a difficult task that I can’t internally come up with a number. I am sure, though, that the number changes daily. Even if I could assign a number to my pain, there is no guarantee that you would assign the same number should you suffer the exact pain as me, or that you could assign a number to my complaint better than I could. The pain is there, though. I feel it and alter my activities to not exacerbate.
Recently, a friend gave me a ride in his BMW. The seats fit my back to a t and as I sat there, my pain abated. I asked him to turn on the heated seats. Even more remarkable pain relief followed. In fact, after the ride in his car, I had no back pain for over 3 weeks, the first 3-week, pain-free stretch of time in over 20 years. So, since insurance plans often pay for some types of interventions such as heaters, buzzers, or needles, as examples, to help people with their back pain, so, then, shouldn’t insurance pay for a BMW for me? I think so.
Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.
The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several different categories. By understanding and thinking about these categories, physicians can begin to identify the root of the anger and take measures to address it. This exercise might seem simplistic at first. However, you’ll be amazed by how powerful the results can be.
Why do patients become angry? What are the common “root” causes?
Medical illness is often accompanied by pain, so much so that pain is often considered the fifth vital sign. Assessment and treatment of pain is an important factor for all medically ill patients. Anger is a common emotion in patients with pain, especially chronic pain. It is thought that the presence of significant anger may in fact further aggravate the feeling of pain. Physicians must not only be able to assess pain, but also to weigh the benefits and the risks in prescribing analgesics. When any patient appears to be “angry,” the presence of pain, especially untreated/undertreated pain, must be considered and rectified as a matter of urgency.
2. Fear and worry
Being medically ill, especially if one is hospitalized, can be an intensely destabilizing experience for both the patient and his or her caregivers. In some cases, an unknown prognosis, the occurrence of complications or the impact of the illness on their independence, can make patients fearful about the future. This worry can manifest as anger, and since patients cannot direct their worry or anger toward their illness, this anger may be displaced onto people around them, including hospital workers. Attempting to recognize, and where possible alleviate, their worries is often very helpful.
3. Feeling unheard or uninvolved
Any patient who displays anger in a hospital setting is guaranteed to attract attention. For some patients the expression of anger may actually suggest that they feel “unheard” in the medical setting. They may feel that they do not have enough information about their condition or their concerns have not been addressed. The question then arises, how do we make them feel heard? Do they understand why they are in the hospital? Do they understand what their treatment options are? Do they feel they have been part of the decision-making process? Ensuring that patients feel they are involved in their care can reduce the anger that can arise out of being “unheard” in a hospital.
The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.
The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.
If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.
Consider this recent article in The New Republic: ”Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction.
As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.
But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital.
The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.
Now hospital payments are at risk too.
I am so tired of seeing statements like these:
– Nutrition is not taught in medical school.
– Pain management is not taught in medical school.
– Practice management is not taught in medical school.
All three of those statements, and the vast majority of others bemoaning the shortcomings of medical education just because “XYZ isn’t taught in medical school” are right, but oh so wrong.
“Nutrition” is not taught in medical school. What we learn is biochemistry, metabolism, gastrointestinal and endocrine anatomy and physiology. We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.
“Pain management” is not taught in medical school. What we learn is neuroanatomy, pharmacology, behavioral psychology, and neurophysiology, so that we have the basic knowledge to understand pain management. Narcotics dosing, epidural steroid injection techniques, rehab protocols and so on are learned in residency. I agree that pain is often not well managed, but not because “it’s not taught in medical school.”Continue reading…
Today a dear friend of mine told me a horror story about her recent trip to a hospital ER. She has kidney stones, with rare bouts of excruciating pain when they decide to break off from their renal resting place and scrape their way down her ureters.
My friend is a stoic person who also doesn’t like to cause trouble for others – so when she was awoken at 4am with that same familiar pain, she decided not to call an ambulance but rather drive herself to the ER. She also chose not to call her doctor out of consideration for his sleep needs.
She managed to make it to the triage desk at her local hospital and was relieved to see that the ER was quite empty. There were no ambulances in the docks, no one in the waiting area, and no sign of any trauma or resuscitations in the trauma bay. She approached the desk trembling in pain and put her health insurance card, driver’s license, and hospital card on the desk and let the clerk know that she was in incredible pain.
Shiri Sandler was diagnosed with RSD, (Reflex Sympathetic Dystrophy or Complex Regional Pain Syndrome), after surgery on a broken bone in her foot at the age of 20. Years later she faces severe chronic pain that has spread throughout her body and requires regular treatment with powerful painkilling drugs to control.
In this segment, she discusses the challenge of coping and how she use uses ReliefInsite, an online pain diary, to help manage her condition. She also talks about the stigma those with chronic pain can face when they seek treatment.
“I went to a GP in my neighborhood. And I said I have RSD. And he said. ‘Well, what does that mean?’ Well I have a lot of burning pain in my foot. And he looked down at my foot and said. You wear the wrong shoes. You’re making this up. And He kept going. You’re too young for this. You’re a hypochondriac. These drugs are going to kill you. That was my personal favorite. And he yelled at me for an hour and a half. And I sat there crying. Because you never feel you have to yell back at a doctor. Being told that what you’re feeling is in your head is terrible … ”