Pain

Pain
2 a : usu. localized physical suffering associated with bodily disorder (as a disease or an injury); also : a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action b : acute mental or emotional distress or suffering : grief
(from Merriam-Webster online)

For me, pain has to be one of the most frustrating aspects of going in to the medical field. It seems that everyone happens to know off hand when their Lortab is due for a refill or has some allergy to codeine and every other narcotic except oxy or lortab. How do you manage a patient with pain?

When I was on palliative medicine, we didn't concern ourselves with addiction or DEA stuff. We manage the pain, we make sure our patients our comfortable at the end of their lives. It seems so simple, so straightforward. We take an oath to do no harm and comfort measures fulfills this, yes.

But what about the guy who says he can't spend time with his family, that his pain is 10/10 but yet I can take his shoes off without him flinching. Later my attending asks what I noticed about his shirt? He was drenched in sweat. I also noticed the dilated pupils and the tremor... the man was more than likely having withdrawals...

How about the lady who explains that she can't work because she's in so much pain and because she can't work, she can't get money to pay for physical rehab that might attenuate her pain. She claims she has a family history of arthritis and that "everyone" takes Lortab.

"Do no harm"
How about when we can't avoid harming our patients?

Just the other day, I was "recruited" to do a urethral swab on a patient who wished to be checked for STDs. Everyone could hear him moan and OH OH and OWWWWW and EFFF in the hall as I attempted to get the best possible specimen I could.


Then there's emotional pain, the pain of loss:

My very first trauma case involved a child that was run over by a parent accidentally. The child was without substantial brain function on arrival. At one point, the team wanted to allow the father an opportunity to see his child, say goodbye. The whole team looked on as they saw a father ask his child to pull through to come back to him. The look of sadness on each of our faces, the ache in our hearts was one sort of pain. The pain of looking at your lifeless child on a trauma bay stretcher was another.

But yet we, we being future doctors, are trained to suppress emotions and to act in the face of uncertainty. I read about this study a year or two back:

http://www.news-medical.net/news/2007/09/27/30497.aspx
"Without some regulatory mechanism, it is very likely that medical practioners would experience personal distress and anxiety that would interfere with their ability to heal,” the researchers write."


So as a student doctor, doctor in training, medical student, how do I cope with these issue of mortality. Well, principally there's God. For many of my peers and myself, the concept of mortality and the peace we must seek with the fact that we can't prevent all outcomes is rooted in our spirituality.

“I have found the paradox, that if you love until it hurts, there can be no more hurt, only more love.”
Mother Teresa

rosary

the man in nine
with his rosary
clung to life
alone , was he

words we spoke,
not for him
but for us;
his time grows thin

death isn't clear
like red and green
the man in the bed
somewhere between

here we are
there he lay
the end of his time on earth
might be today



This week which isn't over quite yet but deserves and early entry, has been the most interesting and different week. It's still part of family med, which I've learned can be quite the model of inefficiency and prolongation but the palliative and transitions team is something special and unique. They are the doctors, NPs, PAs, nurses and all staff who help care for those people who are nearing death and their family/friends. they are among the most humble people and really there is not other way to approach it. here, medical professionals admit medicine has failed and that a patient will likely get worse or pass or remain in some kind of poor state. here, we rationalize and plead with families to consider code statuses and try to prepare them for the end, or perhaps the beginning, death.

My first day, I quip was the day I donned a black robe and scythe. For one reason or another, 5 patients passed on the team I was on. Just that morning, I went with the NP to go and try to have the family consider changing code status and help them help their loved one. Something divine occured as a code was called for a man who I can only describe as being totally intractable to pressors , very hypotensive. I remained in the room in the code and was told to glove up for compressions and before I could rotate in, death was pronounced at 1023a, monday morning. It was the first time that I saw someone pass , in front of me and somewhat dramatically. Sure , I've been in traumas where someone has passed but on that service, it's almost like the actual passing occurs outside the sight and interest of the the team. Here, death is very much part of your day. Then as that family was consoled, there was a weaning of a vent in another room with a man with cancer history and he passed shortly. A very different, accepting family had said their goodbyes and allowed us to do his final examination. To actually appreciate that this man has no pulse, no heartbeat, no respirations, no response to pain... and only has agonal gasps.. really is humbling....

Yesterday wasn't as eventful which is both good and bad. In medicine, uneventful might equal a slow long day but it also means people are living. This again.. can launch a whole conversation on "living". I would venture to argue , to say.. that not a whole lot of people are "living" very well in the hospital. It really is a bad place for a lot of people. Today, I prayed with the Palliative team for a lady whose family was changing her code status to DNR and basic comfort measure. Per the family, I learned of a charming wizened lady who was in her yard , planting trees only days ago and was highly independent. It's not unusual to see your own family members in these families and to feel close to them. Again, at one point the family laughed at the idea that I would get hit by the door as they awaited another brother and then we held hands minutes later.

I suppose I've learned that not everything can be fixed, contrary to what a surgeon might tell you.. haha. Healthcare workers are mortals but we also can work in concert with God's will... it's unique to be on the Palliative team....

-Robert

Family Med Week 2

So week 2 of family medicine started out super lame. I mean, we can't write notes and I don't know.. my partner Matt said it well "Family Medicine In Service is like the bastard child of internal medicine". It's just odd because family medicine basically admits and takes care of anyone who has some relationship with family medicine.

So that means we take care of chest pain, whatever pain, pancreatitis, psych issues, etc. The thing is , I feel like we are the epitome of inefficiency and I guess alot of that comes from coming of a surgical team. It doesn't help that sometimes the team gets kind of giggly. I'll just say this much, our head resident/chief is this really cute Indian girl but sometimes she just gets all giggly and I just..have a hard time taking that seriously

Night call was all right. It was my first time partnering it up. Matt and I each took an admission and then we helped our resident. She let us peace out at 1130p.. so I got 5-6 hours of sleep but call beds are remarkably stiff and horrible for sleeping.

Things that I saw that were interesting.. a lady with a possible C1-INH deficiency .. so weird.


Umm.. a pretty good week. My weekend has been great so far. I actually got up from morning prayers, today, Saturday which doesn't happen often. Then my pops and I got some coffee and then went to go help clean up a Masjid that we go to.

It's weird, that supposedly religious people neglect the most basic aspects of cleanliness. We spent time cleaning up all kinds of trash and packing up wood and whatnot. Then we washed out all these dirty pots that were stinking to high heaven. I mean, a masjid is a House of God, not just the inside but the outside as well. This isn't the first time my Dad and I did this kind of work only to have people come by, Muslims that is, look and walk away or comment on the good work and walk away. I mean.. why is it that people view this work as being below them.

A good weekend. My cocky surgery attitude is wearing off and being replaced by corny, lovable me.. this was bolused by seeing Forrest Gump, one of my all time favorite movies.