Wednesday, May 31, 2006

Pain vs Harm

There is one thing, I think most of us would agree is tough to deal with- pain.  Although in medicine we say it is the 5th vital sign, it remains largely a mystery.  What makes it so difficult is it's subjective nature.  Doctors like objective findings; tests, numbers, X-rays.  When we must trust the experience of the patient only, it is uncomfortable.

There is however, a certain attitude we Americans have adopted about pain that I'm not sure I agree with.  Like our demand for immediate gratification, and sense of entitlement, somewhere along the way we've decided that we cannot experience pain.

There are ramifications to this mind set that ricochet thru every aspect of society. I saw it last month in OB, and I've seen it this week hourly in my orthopedics rotation. In an argument with a patient who is trying to get disability status from the back pain she's incurred over years of working with heavy machinery, the doctor I was working with said simply. "Look, your back condition is painful, but it is not dangerous.  Going back to work will not harm you" This patient could not separate the two - pain from harm.  In her mind to have pain was to have injury.  But in fact, it's not the same-

This is where society has erred- to link these concepts together.  IF we assume pain is damaging, and injurious, we avoid it at all costs, and will not tolerate it.  Thus our tendency to self medicate and avoid pain - with alcohol, drugs, and other bad habits.
One huge problem with the idea that pain must be avoided - is the impossibility of this. Thus, one is already doomed to failure in pursuit of never experiencing pain. There is something necessary about pain as well --it teaches. Child psychologists remind us to let infants stumble into tables and touch a flame- because guess what, they learn not to do it again.

All that said, should pain be treated? Of course. The caveat is that a residual amount of pain is okay, and expected.  Once my chronic pain patients with arthritis, injuries, etc realize that we can't take away the pain, just make it bearable - they do great.  It's those who continue to strive for a pain free existence that fail, and live out miserable lives.

Pain won't kill us.  It sounds harsh, but it's true. I'll continue to try and minimize pain for my patients, and myself.  But I also want to adjust mind sets, and separate pain from injury. The two may both occur in an event, but pain itself does not injure. Finally, pain is allowed, and will occur simply because we are human beings. So, pass the word along: PAIN HAPPENS


Saturday, May 20, 2006

OB stories

My month at the army base is nearing a close. Unlike first thought, I don't have even xanga access while I'm there. Thus the long entry.

My call on Thursday was a day of highs and lows. In the morning we had a 41 year old woman pregnant for her 9th time. She had 7 children already at home.  Although she was at her due date, the baby was still lying sideways. This was just too dangerous to allow to continue, so she was able to choose either a c-section or a "version" (AKA we attempt to turn baby from the outside).  She choose the version.  So, with about 10 people on hand, outside the hospital room, ready for an emergency c-section, another doctor and I went in to try this procedure.

At the bedside was an ultra sound machine and heart monitor. We lathered up her belly with gel. I then felt for the feet and rear end and pushed counter clockwise as the other doctor found the head and pushed down/counter clockwise.  With all our might we pushed, as the patient moaned from the pain.  The room was silent and all waited with heightened anticipation. After about 30 seconds there was a shift, we paused and took the US probe to check. The baby had moved quite easily! "We're done" we announced, as the room exploded in applause and excitement.  It was much too easy - and not supposed to go so smoothly. 

We immediately started the induction, and a few hours later, very naturally, I delivered a 10lb 6 ounce baby from mom, who choose the hand/knee position to deliver. I had just cleaned up mom, and was leaving when the nurses told me about the next room I was to go see.

A 20 year old male was in the ER that morning, and had just been diagnosed with renal cancer. It had spread to his liver and bile duct, and looked very, very bad. They had decided to fly him out to Walter Reed in Washington DC the very next morning. All this was coming so fast, and with less than a day left, the ER docs asked what were some requests he had. 

"I have two requests" he uttered, "to see my unborn child, and have one last home cooked meal". 

My role was to perform the ultrasound for his wife, him mother and himself so that they could see their child for the first and maybe last time.

As you can imagine, a completely different environment from the one I was leaving. The new diagnosis was heavy in the room, but the excitement to see their little child was competing for space. Ironically the wife was exactly as far along as me - the images for them, so similar to the images I had done on myself. They couldn't soak up enough of their little one's movements; kicking legs and arms, twisting and turning.  We printed some pictures for him to take with him.

I prayed silently that he'd be able to see his child in person in November. Until then he'll have these movie like images in mind.

It was hard to quit the ultrasound, but the nurses informed me there were other patients waiting. Puts everything into perspective, moments like this.


Saturday, May 6, 2006

Delivery methods

There is definitely a wide range of possibilities when delivering a baby.  I am working with both nurse midwives and doctors old enough to be archives.

I tend to enjoy the philosophy of the midwives...which value natural vs sterile.  As an example - and these are extremes: One of the nurse midwives just uses the hospital bed - doesn't put up stirrups or anything. She puts on a pair of gloves, but no gown.  She sits on the end of the bed and after the babies head is delivered, she has the mom reach down and help pull out their own baby straight up onto their stomach.  This is in sharp contrast to one of the old time doctors. He not only uses the stirrups- but places drapes over everything for "cleanliness", over legs, stomach, everywhere.  There is a bright surgery light that comes down from the ceiling that he uses and what really makes me laugh is that he goes to scrub before the delivery.  Scrubbing is what surgeons do before surgery - it requires special soap and about 5 minutes of sudsy scrubbing. He gowns and gloves up then, including a big mask, as if it was surgery.

The ironic thing is that a vaginal birth is anything but clean. Imagine having just swam through a sewer canal underground...how important to your health is what's beyond the canal opening?  Not too important when you are already covered in grime. 

I'd say my technique is mid ground. I haven't asked any moms to reach down and grab their babies yet... but i do like delivering into the bed.  I imagine back in the time of home deliveries and around the world, this is how they do it.