Continuing the pain diaries

More to and fro between this establishment and the Harrumpher, who recounted his late experiences in the demimonde of emergency rooms. I have the sort of job that allows me to say yea or nay to various hospital actions (as in yea you can do that; nay, we won't pay you what you want) I have to have more than a passing acquaintance with evidence-based medicine to do this. A number of medical actions or phenomena have passed across Mr. H's bows in the last fortnight, seeming strange or indefensible, as no doubt they do to most medical consumers. On the other hand I see them almost every week, I don't know nuthin' 'bout birthin' no babies, but I see a fair amount of orthopaedics in action.

Patients are likely to lose a lot of weight after trauma, mainly because the body is set up to repair major injuries as well and as quickly as possible. You’re in metabolic warp drive; the repair functions make very high demands on your resources. There is related evidence that otherwise healthy people may suffer from malnutrition during recovery from physical trauma, perhaps because the demands of the repair functions are so far ahead of supply.

Hospitals give patients (especially fracture patients) Tums or the like for a couple of reasons. Acid stomach from the meds is one of them, for sure. Another is that the repair function is diving deeply into your calcium resources, and Tums are a good, cheap and readily absorbable source of calcium. Blood loss and replenishment can also throw your calcium balance out of whack. One thing that can happen if your calcium is low is acid stomach; another is that you’ll sneeze a lot. Believe me, H, someone with broken ribs does not want to do that. I deal with the blood part of the business every three weeks when I donate platelets. The Red Cross wants its donors comfortable. It also doesn't want them having paroxysmal sneezes whilst their entire blood supply is being pumped in and out of them.

Hospitals administer laxatives because opiates, even in small amounts, slow or stop the wave action (called peristalsis) that moves food and waste through the gut. This contributes to lack of appetite, but it also causes constipation, and constipation from this cause can lead to impaction and more serious problems. Those of a certain age will remember getting tincture of paregoric for diarrhea as a kid: it's the same principle, and the opiate content of paregoric is low compared to some of the opiates bandied about today.

Relations between patients and clinicians would be far better if the latter would explain why patients should do this or that. Unfortunately, both time pressure and a clubbiness that goes with medical training usually preclude that. The lack of communication has many regrettable consequences.

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Pain dynamics, like those of waves at sea, ought to include duration. Many of us with trigeminal neuralgia (TN) live sizeable parts of our lives with little or no pain. We learn to focus on those times, because it helps us to endure the times when the Beast comes to call. Also, most TN patients have a unilateral condition, affecting one side of the brain. It is possible, even in a severe breakthrough, to perform a sort of meditation in which one retreats to the unaffected hemisphere of the brain and dwells there until the breakthrough episode subsides. It doesn't eliminate pain: it just makes endurable the unendurable. Clinical knowledge also helps. In my safe hemisphere I can note the manifestations of the episode as they happen and so concentrate on something besides the pain.

People getting through such things as orthopaedic trauma, heart surgery or cancer treatment are hard put to find such a "happy place." These conditions affect everything one does. In addition to pain, these patients have to put up with roadblocks to almost every activity of daily living: to such an extent that the roadblocks can equal the pain as a challenge.

Every working day, I deal with providers who seem to miss this point, and devote large parts of their treatment plan to throwing opiates at their patients.
The study I cited recently would be especially helpful if it put the brakes on providers who do this, and motivated them to more holistic treatment.

Don't forget: when it comes to dealing with pain, we are all wusses, compared to the generations who lived before anaesthesia and analgesics. Not everyone was heroic, of course, but there was a deeper acceptance of pain, perhaps because there wasn't much choice. One of my favourite reminders (and the historical record is full of them) is the story of a British officer wounded at the Battle of Waterloo. Needing his arm amputated, he endured the operation (they lasted 30-45 seconds) without a sound. At the end, all he said was "bring my arm back. There's a ring my wife gave me on the finger."

I could not do that: could you?