Tuesday, January 29, 2008

Trust in Pain

A comment recently received caught my attention. And not so for it’s questioning of my patient attitudeness, but more for this first portion:

I think it is interesting that you have chosen anesthesia as your specialty - the management of pain issues being one of the few areas of medicine where the physician has to simply trust the patient to report their pain since there is no objective test to prove it. Have you thought about how you will manage when a patient reports pain (and i'm not speaking of one of the flat out easy to spot drug seekers) but you feel you have treated them adequately? If you, using your prior experience and all of your knowledge don't feel they need more meds despite what they are telling you - what will you do?

Fortunately I received a great lecture on this topic early in my 3rd year that has stuck with me. Yes, there are those people out there who abuse the system and want to have narcs up the wazoo just because they want to get high. However, in anesthesia we do have to be more receptive to the idea that someone’s pain is a 10/10 even though they are sleepy.

The lecture to which I referred earlier was by a doctor who worked with the old and terminally ill. She often gave dosages of pain killers that many other doctors thought would surely kill the patient. Her advice was that pain should never be uncontrolled just to remain within the “standards” of the pharmacopeia.

“The patient will let you know when they’ve received enough. You just titrate out the amount until they are pain free or close to sleep. Then you’re at your boundary.”

In most patient encounters this wouldn’t work too well – not enough staff to watch carefully over the patient as the drugs reach their peak effect. However, in the PACU, where we have nurses who carefully observe and manage patients, we can adjust more readily. They are given orders for pain management by the anesthesiologist, who, by way of observing the patient’s narcotic need intraoperatively, will have a better understanding of how tolerant or labile the patient is towards pain control measures. These can then be adjusted based on pain scales and overall patient physical characteristics.

Addressing the notion that we lack objective tests, certainly during the operation there are physiological parameters that anesthesiologists look for when controlling pain: increases in blood pressure, heart rate, breathing, perspiration, etc. are all items that alert them to a need for increased pain management (this being said, it is important to realize that even though the “body” is responding by reflexive physiological measures, the patient very rarely has any recall). This is a form of acute pain control, often a direct result of a noxious stimulus. Many patients present with similar findings, even when conscious, and allow for more visual confirmation of pain. While easier to understand and treat, we still have people with chronic pain, vague and mysterious, that's often at the heart of these controversies between physician and patient.

Rather than label a patient as a "malingerer" or "druggie" who presents multiple times for low back pain, neuropathic pain, or "flares" we must trust them. And that’s were the catch comes. That’s were so many healthcare providers, who entered medicine wanting to help only to be burned time and again, are now skeptical of most pain complaints. The abuse they've seen and endured, at the hands of addicts and malingerers, hurts more than just the patient - we all suffer to some degree.

Considering the notion that people report pain even after receiving large amounts of highly potent narcotics, you can easily expect providers to write the patient off as an addict. Unfortunately, while true in many cases, some pain cannot be well controlled with medications or is completely untouchable. This leaves the sufferer searching for assistance, help, and relief from the constant agony. Pain specialists are often useful for these kinds of patients, using advanced pain management, through invasive procedures, to help in these cases. A rather lucrative field, I personally have no desire to entertain such thoughts, as pain patients are some of the hardest people to treat, having been "mistreated" so many times.

Many forms of pain are hard to diagnose, treat, or even moderately control regardless of level of therapy. Asking for a quantification (the best known is the 0-10 scale) is often hard to deem accurate as pain is patient specific, based on psychological, emotional, and environmental cues. Someone claiming 10/10 pain may actually have the worst pain they've ever experienced. Just because we've seen people in worse situations shouldn't cause us to feel they're lying to us - it's completely subjective.

A theory postulated by some neurologists and others has suggested that the brain “makes up” pain in order to elicit stress responses that were once normally found – we’ve just become too comfortable and it’s a fall-back mechanism gone awry, kind of like the increased incidence of allergies. I kinda like that idea and understand it – after all, many of the harder to “trust” diseases like Fibromyalgia are more receptive towards medications targeting brain chemistry and function*. Whether I believe it to be a real disease is not the question, the patient believes it and therefore they suffer from it. We need to understand that more.

I honestly feel that we must listen to a patient and assess them truthfully while at the same time the patient must also listen and adhere to physician advice. An overdose of pain medications results in decreases in many aspects important for body funtions, including breathing and cerebral consciousness. If patients are found to be sleepy, lethargic, hard to arouse, disoriented, or having some trouble breathing at a normal rate they shouldn’t receive anything more - regardless of additional complaints. That's were the education comes into play. The physician must acknowledge the limit and be in control of the situation, without allowing emotions or a concern for legal action to influence their decision.

Despite the fact that there is some evidence that pain exists regardless of conscious level (i.e a sleepy patient can still have 7/10 pain) we need to accept that the limits have been met or breached and inform the patient as best as possible. I might still trust that the patient has pain, but my ability to help with more narcotics has been limited. My hands are tied.

*Is it just me, or do those commercials have the crazy patient look down? I look at those ladies, talking about their pain, and just shudder.


Bostonian in NY said...

I'm being forced to precept in oncology this semester for my physical diagnosis class and it's amazing how many of these folks come in with either completely inadequate pain management or who have not even had their pain acknowledged as a symptom that needs addressing. Now that I think about it, pretty much every CC that I've written up has been pain thus far. Seeing what these patients are going through will definitely make me consider pain as one of the first orders of business when I'm assessing.

Student Doctor said...

Great Post. As a first year interested in anesthesia, it's easy to just think of the field as perioperative and forget about everything else involved.

Good luck in the match....although your list hardly includes the most appealing locations! (Shouldn't you have ranked a program in Miami or L.A. just in case? :)

MSG said...

Appealing locations depends on what you're after. I hate - HATE - large cities and hot, humid weather. Some really terrific programs are in these cities, but I would rather not even pretend. That being said the programs I've looked at are, for the most part, quite excellent and work a lot harder (I think) than those in big places with big names.

Anesthesia should remain on your list as you go through the next few years. Consider some other options as well, but I think this is one of the best specialties out there.

Margaret said...

I know that your post is about extreme pain, chronic pain and I'm happy that you are sympathetic and helpful to the sufferers.

But what about the lesser pain that arises from long-term physical habits such as bad posture or lack of appropriate regular exercise? That too, becomes chronic. I'm always surprised to hear people complain about not being able to get pain killers for this sort of pain. It is 'good pain' in my opinion, your body letting you know you need to DO something, yourself, not seek meds that will make your body just shut up the complaining.