LEGACIES AND LOLLIPOPS 16
by MAGDALA
Part Sixteen - FIRST DRAFT
"Pain is a more terrible lord of mankind than even death itself." Dr. Albert Schweitzer.
Julian was in the foyer when I got back to the hotel. I started into a flustered explanation of where I had been when he cut me short.
"Greg called us." Julian said, smiling. "Join us for breakfast."
The diminutive Tink was in the middle of a breakfast, which would have satisfied the driver of a monster truck. She nodded hello as she finished her mouthful.
"Grotesque isn't it?" observed Julian. "But at least it stops her from devouring fools in the lecture hall. What are you having?"
"Coffee will be fine."
"Coffee will not be fine. Greg said we were to ensure you had something substantial." said Tink gathering another huge portion onto her fork.
I looked blankly at the menu and the waitress appeared to take my order. Julian could see I was getting nowhere and took the menu from me.
"She'll have the continently breakfast, a fruit plate, coffee with half and half. Okay?" He asked me.
"Yes." I said. "Thank you."
"Greg said he had a painfree night and tolerated the anti-convulsants." Said Tink.
"I'm sorry I shouldn't have stayed." I was embarrassed and guilty.
"Nonsense," said Tink. "Don't you know how badly he needs to be held?"
I didn't know and didn't fully understand what she meant until later that morning.
Lisa Cuddy had outdone herself the lecture hall was packed. Every seat was full and there were many students standing or sitting in the aisles. Cameras were rolling for closed circuit and a full record and Tink was wired up with a lapel mike as was I.
Tink had briefly covered the various types of pain when she asked.
"Why do you need to touch the pain patient?"
Several hands went up. Tink pointed at a very self-assured looking young man.
"To see if they're jonesing?" There was the odd giggle from his support group.
"Is that your first thought when someone complains of pain?" Tink snapped back.
"A lot of drug seeking behavior happens in this country."
"'In this country.' I see you, being American and living in New Jersey, are the recognized expert on patients who display symptoms of pain. Well please come up here and stand beside me."
The student did not move.
"Come on ... come on.," she said. As the student went up the steps to the stage I was really glad Tink had eaten a good breakfast. She quickly wrote PAINBASE in descending order on the white board.
P
A
I
N
B
A
SE
She then handed the marker to the student. "Now you fill in the mnemonic while I carry on."
"Okay anyone else got any idea of why we touch the patient when they are clearly in pain?" I was impressed that more hands went up than before and realized what had happened. Tink had neutralized and isolated the bully.
Tink smiled and nodded at a girl in the second row.
"To determine the location and extent of the pain if it is likely to be referred pain and what level of touch aggravates the pain."
"Very good." She looked back at the white board and the red faced student. "Now you have heard your colleagues answer you can fill in the first three. 'P is for Place' giving the location of pain' ... 'A is for amount' giving the severity of pain ... 'I is for interactions' and helps us to find out what aggravates the pain." She turned back to the audience.
"You also need to touch the patient so that you can advise their loved ones how to touch them without causing them further pain. Sometimes a person suffering terrible pain needs to be held this is not the place of a doctor but it is the place of their closest friends or loved one. But it is the place of the doctor to find out what they need, how they need it and from whom they need it. Do you think you should listen to the patient?"
"Everybody lies" stated one wag who was rewarded by a chorus of laughter.
"Do not just pick up on Dr House's quotable quotes listen to what he means. He is one of the finest diagnosticians in the world when he says he does not want to talk to patients he is being quite truthful. But he does listen to them. He listens to them carefully. If he didn't he would not save so many lives." It was obvious they wanted to know more.
"I know you are aware that Dr House is currently a patient in this hospital. You are also aware that he suffers from chronic pain. This does not give you permission to speak to him on the subject of chronic pain unless he specifically allows you to do so at a time of his choosing."
"The torturous element of chronic pain is that very often the sufferer though in agony has trouble describing what is happening as the sensation falls outside the normal vocabulary they associate with pain. This is because in the case of neuropathic pain sensory input is abnormally processed by the peripheral and central nervous system. This is often the main indicator in the process of the development of chronic pain."
"The problem with dysesthesia and allodynia." Again she turned to the student at the white board who was still struggling with A the second letter of the mnemonic. "While you are working on the white board could you please put up a column headed SYMPTOMS and below that write dysesthesia and allodynia.
"Sometimes the pain as burning, at first there is often a feeling of pins and needles, or a strange altered sensation. It can be a shooting, or lancinating. The best description I have ever heard was from a very small child at Great Ormonde Street Children's Hospital. She said 'A nasty person has moved into my leg and they are setting fire to it...' She was talking about pain.
"Albert Schweitzer said 'When I hear a baby's cry of pain change to a normal cry of hunger, to my ears, that is the most beautiful music.' Yes it is music. And when you can alleviate the pain of an adult and you hear them laugh for the first time that too is music." She looked over at me and I knew she was talking about Greg.
"Luckily we were able to treat the neuropathic pain in time."
She pointed to a student at the back. "Yes red blouse. Blond hair. Don't look worried. "Can you tell me why it was lucky we were able to treat the child's pain in time?"
"I ...I don't know." she answered.
"And that is better than a guess and much better than 'I don't care.' Can anyone else answer this?"
A dozen hands shot up. Tink pointed at a student about half way back.
"Neuropathic pain is an important symptom to recognize, because delayed or otherwise ineffective treatment can result in chronicity and in permanent change in the nervous system."
"What percentage of chronic pain is caused by undertreatment of initial pain or failure to diagnose the onset of such pain?"
Even more hands went up. Tink picked the student who had been longing to answer.
"Would it be over 85?"
"Yes sadly it would be well over that. Of course we doctors don't like to be wrong. So one of the worst things a pain patient suffers is humiliation at the hands of the medical profession."
Tink turned and walked over to the student at the white board. He had hardly touched it unable to go past the first two letters in the mnemonic and had only got as far as the heading of symptoms. "I think you have experienced enough humiliation to understand a little more about pain." She turned to the audience. "Don't make fun of your colleague as he returns to his seat. He behaved exactly as many eminent physicians behave when they confront a patient experiencing severe pain."
"Are you alright now." She asked the student. He nodded. "But you are not. You are hurt and you are embarrassed. But you have learnt something today and next time you see someone in pain you may just save a life."
"Okay now all of you call out with the answers to the mnemonic and I will fill it in." They got very few wrong and soon it was complete.
Place/location of pain
Amount/severity of pain
Interactions: What aggravates the pain?
Neutralizers: What alleviates the pain?
Breakthrough pain: How often?
Activities: Are they limited by pain?
Side Effects: constipation, nausea, dizziness, sedation, dry mouth?
"Wow that was so good" She smiled at them like a proud mother. "Would you like to give the dysfunctional D's a whirl now?"
'Yes they chorused' ... Hands went up.
Distress: anxiety, conflictual feelings, anger, hostility, resentment, and alienation
Depression
Deficits in the following: impulse control, assertiveness, attention, concentration, memory, and judgment
Disturbed sleep resulting from pain or from other pain-related distress
Disability
Deconditioning.
Tink applauded the students and they applauded her.
"I think it is time we took a fifteen minute break. After the break we will discuss the possibilities of addiction to pain medication and the legal responsibilities of the medical practitioner treating pain patients.
Tink and l left the stage and went out through the doors where Julian was waiting. Tink fell into his arms and for the first time I could see she was shaking. "Was it okay, darling?"
"You were wonderful, darling."
"Got them in the palm of your hand." It was Greg fully dressed but seated in a wheelchair.
I was amazed. Tink was so pleased to see him.
"You are the one who should be speaking, Greg," she said.
"Julian told me that was your view." said Greg, "Will it mess up your feminist thingee if I take Dr Cameron's place."
Tink kissed him on both cheeks and then looked at him seriously "How's the pain?"
"Covered," he smiled "I wasn't planning any practical demonstrations."