Wednesday, February 27, 2008

"My Worst Nightmare"

Recently I have had to deal with a patient who refers to herself as my "worst nightmare". I knew she would be difficult before I ever did her surgery. She had warned me that she always had a lot of pain and it was difficult to control. I knew she would need more TLC than most patients.

I always call outpatients the night of surgery. It helps me sleep better and hopefully them/their families too. The night of her surgery (and I have learned to double check phone numbers where they will be), I called three separate times over a 2 hour period to two numbers. No one answered any of them. I left a message that "If there are any problems tonight, please, have me paged through the Medical Exchange at ****. I will check on you again in the morning." That night it was quiet.

I called her the next morning and this time she answered.

"I'm in so much pain."

After going through a list of questions to make sure there were no other issues (no undue swelling, no fever, etc), "Have you tried taking the Xanax with the Percocet?"

"No. I didn't know I could do that."

I had written the Xanax prescription after seeing how she dealt with the pain in the recovery room. Nothing we tried had seemed to make her comfortable until we tried it. I mean nothing including morphine. And physically she appeared okay.

I explained that she could. That the Xanax would help her nerves and help her rest. "So why don't you try that. I'll call you again tonight." She agreed.

I called back that night (Friday). Things seemed to be better. Saturday was quiet. Sunday, just past noon, the pager goes off. I called the number.

"Dr. Bates, it's your worst nightmare. The pain is horrible and I don't have any pain medicine left."

I go through the same list. No undue swelling, no fever, etc. So I offer to call in some Darvocet (and do so). I don't offer to meet her and write a new script for the Percocet. I don't suggest that she go to the ER. Two hours later, the pager goes off again. Same patient.

"Dr. Bates, I'm so sorry. It's your worst nightmare again. I don't know what to do. The pain is so bad."

This time I firmly tell her that she will have to tough it out until tomorrow (Monday) as I can't phone anything stronger in for her. She will have to make due with the Darvocet. (By my count, the Percocet should have lasted her until Monday or Tuesday).

Nothing more from her until first thing Monday morning when she calls the office. "Dr. Bates, it's your worst nightmare. I am in so much pain."

"You are no where near my worst nightmare, but we won't go there. Why don't you come into the office so I can see you. You will have to come into the office before I give you anything more for pain."

She comes in. Her exam is benign. She is healing as expected. I touch the operative area gently--she flinches. I leave it and keep talking to her. She visibly relaxes, as the time passes. I keep up a constant patter. I remove her stitches and tape the incision. I deliberately touch the area again with slightly more pressure. This time there is less flinching. I keep talking to her. Then one more time palpate the area. This time pointing out how she allows me to do so.

I give her one more script for Percocet and Xanax. I caution her to take them as prescribed, not more often. I bring up the young actor, Heath Ledger, who recently "overdosed" on prescription medications. She says she didn't realize you could take too many. She did fine from that visit on.

So for her I think that much of her pain was in her head. I think she "thought" she hurt more than she "actually physically" did. I don't mean to belittle her pain, but she had had a few bad experiences with pain, so she ANTICIPATED that each new event would be as bad or worst. I think that "fear" adds to her pain.

I try to get patients to realize that there will be pain, but that each day will get a little better. I don't try to make "light" of it, but to get them to distract themselves. Or to "reassure" themselves that it is not a permanent state. Postoperative pain (I know there are exceptions) is not a permanent state. It will go away.

As far as being my worst nightmare--not even close. Some of my "worst" nightmares would include an abdominoplasty patient dying of a pulmonary embolism (PE) 2-4 weeks after surgery, any patient getting toxic shock (was consulted after the fact on a patient once who needed a gastrocnemius flap to cover her knee joint after surviving TSS post-knee surgery), or this.

Or if we're talking non-patient related then this (snakes wrapped around you).

10 comments:

Femail doc said...

You have an admirable well of patience. Nicely handled!

mark's tails said...

Nice post. Reminds me a bit of the discussions I have with my patients regarding the difference between dyspnea and hypoxia.

rlbates said...

Femail Doc, thanks. I hope my patients see that "patience". I try, but not sure I always manage it.

Mark, thanks. I think each area of medicine has one of those "discussion topics".

Take care.

Dreaming again said...

I wish I'd read this earlier today.

My perspective is a bit different. I'd heard about docs Rxing xanax to help the pain killers.

I have xanax for panic attacks and nightmares as well as a specific anxiety (food related)

I was out, with a friend and my pain became unbearable (stupid health issues)

I went to take a darvocet ...and shocked myelf by not having any ... I'm not supposed to leave home without them or my Mestinon ..neither were in my purse! Can we say oops.

All I had was the xanax. Well ... I'd read a few things about the combo ...so I took it ...in hopes it would help.

Nope ... not at all (although, lunch was easier to eat ;) ... remarkable ..that actually worked like my psych said it would!!!)

Now, reading this, I realize it's more for anxiety that comes with pain (been there, done that ..especially after surgery)

Did nada for the lupus pain. *rolling eyes*

rlbates said...

Pk, well put comment. Thanks

Enrico said...

You are a gem of a physician, RLB. Willing to be the primary rx for anxiolytics in the outpatient setting post-operatively specifically as an adjunct to pain control is not an easy find these days. To boot, you employed some sneaky cognitive therapy, having her face her fears "rationally," employing a two-pronged approach. Brava!

rlbates said...

Enrico, I think you give me too much credit, but thank you.

Doctor David said...

Nice post. I work with many surgeons, and I'm not sure most of them (even the ones I like very much) have as much patience as you do.

What I truly found interesting was the concept of anticipatory pain. I hadn't encountered that before, but it doesn't surprise me since I routinely deal with anticipatory nausea. My chemo patients often (and this is a particular problem in teenagers) are so sure they are going to be nauseated and vomit that they become physically ill before I even give them chemo. Sometimes before they even leave home to come to the clinic. I had one teenaged patient once who needed Ativan just to get into the car to drive to clinic on a chemo day. Other days, he was fine.

rlbates said...

Dr David, what about the anxiety of it hurting to put in an IV? Though I guess most of yours have a port.

I see it with suture removal too. Some patient's are so sure it will hurt when you remove the stitches, they keep putting their hands in the way or take a pain pill before they come (even though the surgery pain is gone). Most of them (most) don't even feel the removal and are surprised when I tell them I am done.

Doctor David said...

Most of my patients do have ports, so we don't have to deal with too much iv anxiety. Although a port (as opposed to a Broviac or Hickman central line) still requires a needle stick. This can be awful for the little kids, but most older kids learn to deal with it pretty quickly. Much better than the anticipatory nausea.