Aches and Pains

Because most people with minor injuries don't go to the doctor, physicians don't spend a lot of time learning about common transient illnesses. My knowledge of bruises, ankle sprains, and shin splints is probably comparable to anyone who has had them. As a doctor, when I come across these common minor complaints, my priority is to exclude something more serious. When I think of illnesses like asthma, migraines, or heartburn, I think of the severe end of the spectrum, not the mild end that most of my friends experience. I know a lot of friends with heartburn managed by diet modification (no more raw onions) but when I think of the disease in the context of medicine, my mind jumps to medications. Much as my friends like to query me about their symptoms, I'm usually not the right person.

In the same vein, I began having a muscle ache recently, and I have no idea what it is. IT band syndrome? A ligament tear in my knee? A muscle contusion from trauma I don't remember? Like most things, I'm just relying on common sense and hoping it gets better.

Bedside Manners

On this rotation, I've learned a lot of medicine, procedures, and medical decision making, but one of the most salient lessons is one in bedside manners. On seeing us, chronic pain patients can have a lot of different, understandable emotions. As we struggle to get their symptoms under control and improve their function, they go through periods of frustration, anger, distress, despair, and anxiety. One of my attendings here was a real role-model for me because of the way he managed these tough emotional responses. His soft demeanor, his body language, the tone of his voice, his empathy, the way he listens, and his validation of the patient's symptoms all put the patient at ease, encouraged her to open up and share, and engaged her as part of the team. Equally importantly, he managed these visits efficiently; it's easy for a visit to take twice its scheduled time if the patient is crying, but somehow, he magically smoothed things along and kept everything going. He also did not yield on principles he felt strongly about. If the patient wanted more opiates but medically did not warrant it, he comforted, acknowledged, and took care of the patient without pulling out the prescription pad.

The beginning of anesthesia residency is about learning procedures: placing the IV, the arterial line, the endotracheal tube, the central line. But in a way, the clinical interaction with a frustrated, distressed, angry, upset, or suffering patient is an equally challenging procedure. There is a learning curve to this; it's not just about "being nice." I'm glad I was able to work with this attending because it taught me a lot about something I don't think about often.

The Unfortunate Truth about Chronic Pain

The unfortunate truth, the thing no one wants to hear, the words all patients dread, is that chronic pain is like any other chronic disease - diabetes, hypertension, COPD, hepatitis, depression, epilepsy. With few exceptions, it something someone has to live with for the rest of her life. Although patients with low back pain, sciatic radiculopathy, undiagnosed abdominal discomfort, chronic regional pain syndrome, fibromyalgia, migraines, metastatic cancer, and other pain syndromes come to pain clinic hoping for a magic silver bullet, we don't have one, not even close. That's hard news. It's frustrating, disappointing, aggravating, and scary.

Because many types of chronic pain are lifelong conditions, the treatment isn't cure. We call ourselves pain management, not pain cure clinic. And the management of pain means setting expectations, creating goals, changing beliefs, and modifying lifestyles. In the same way that a diabetic can no longer binge on ice cream and cookies, in the same way a patient with hepatitis must get routine liver ultrasounds, in the same way an epileptic needs to watch stress and sleep, a chronic pain patient has to learn to live with her hurt. We make it manageable with our medications and interventions, but it's a partnership where the patient has to learn to cope, continue to exercise, and brace for the long run.

Here's the other awful truth: our interventions aren't great. Whether it is gabapentin for neuropathy or botulinum toxin injections for migraines or intrathecal pumps for metastatic cancer, our response rates aren't stellar. Pain is so diverse, so subjective, so complex that we're shooting in the dark a lot of the time. We can't explain why one treatment works for one patient but not for another. There are millions of dollars of research going into understanding pain networks, but for now, this is the reality.

Chronic Pain, Litigation, and Worker's Comp

There is a fascinating and tricky relationship between chronic pain and legal matters. When we see a patient who has chronic pain from a car accident, for example, one of the biggest predictors of the severity of her symptoms and her response to treatment is whether there is ongoing litigation. In the same way, if an injury is work-related, patients tend to do more poorly. Why is this?

The easy conclusion is that the patient has secondary gain, that they have an incentive to malinger, to play the sick role. And when talking about an accident or injury causing chronic back pain, limiting the ability to work, and dramatically reducing the quality of life, we're looking at hefty sums of money. But I wouldn't accuse a patient of dramatizing symptoms for financial gain. When we look under the surface, subjective feelings, behaviors, motivations, and emotions interact in complex and unpredictable fashions.

I saw a patient recently who lost most of her family in a car accident. Subsequently, she coped by immersing herself in her job. She worked a hundred hours a week, nonstop, because if her mind wasn't occupied with her job, it was occupied with her lost family. She then sustained a work-related injury which became so severe she can no longer work. Now, she sits at home ruminating, drinking, thinking of dying. Her pain is a morass of physical injury, maladaptive behaviors, depression, substance abuse, lack of social support, and inability to cope. Her treatment plan is extremely challenging, one that employs a psychiatrist, counselor, addictionologist, physical therapist, and pain specialist.

Another patient was involved in a car accident when a texting driver hit him from behind. After he was treated for multiple fractures in the emergency department, he started to develop chronic whole body pain. As a result of his injuries, he could no longer work. As he went from surgeon to surgeon, doctor to doctor, he started to accumulate bills he could not pay. His ongoing litigation was going nowhere; two years later and he was still calling his lawyer to move things forward. He began to despair, saying things like "if anything could go wrong, it would happen to me" and "I have nothing to live for now." He could not participate in physical therapy, could not afford a psychologist, and became dependent on opiate medications. Addressing these issues is not easy.

It's helpful for us to note whether an injury is work-related or has pending litigation. This affects the psychological and coping skills of the patient, their expectations of the future, and their ability to move on. We aren't primarily concerned with whether these patients have secondary gain; rather, we need to understand the social context of their pain so that we can address all the contributing factors.

Complex Regional Pain Syndrome

One of the more striking disease entities we see is complex regional pain syndrome, a name that always frustrated me because it seems to describe the disease but doesn't really say that much. Although some cases of CRPS have a clear inciting event, many don't even have an identified trigger. All of a sudden, the nociceptive and sympathetic nerves to a limb go wild, wreaking havoc. Because of nerve injury or inflammation or dysregulation or changes in sensitization, the normal pain pathways become completely disfigured. Touching a leg may cause excruciating pain. An area that feels numb may simultaneously burn and throb. The leg swells and becomes red. It sweats. The difference between the limbs is remarkable, as shown in the picture above. And because everything's gone haywire, there's no healing. The picture above is six months after an injury, and the left leg has gotten worse and worse in the absence of any ongoing injury. Seeing a few cases of CRPS really taught me how important nerves are. Even though we think of them as tiny wires relaying information, when they get out of control, they can take over a leg and ruin someone's quality of life.

Image shown under GNU Free Documentation License, from Wikipedia.

Pain Management versus Addiction Medicine

Sometimes pain management gets confused with addiction medicine. Although the medications, principles, and clinical situations are often similar, they are two distinct fields. We see a lot of patients with high opiate requirements and we manage opiate tapers, but we enlist our colleagues who are addiction specialists in the appropriate clinical situations. Many of our patients are tolerant to opiates, using whopping doses of morphine, methadone, or oxycontin to manage their chronic pain, but addiction is a separate phenomenon. Addiction is a behavioral pattern with craving, compulsive use, loss of control, and continued use despite harm to themselves or those around them. Working with these patients requires an extended skill set, one that psychiatrists often use. These patients split, become aggressive, deny use, and distrust physicians. Building the therapeutic relationship is a real challenge. I saw a patient recently who showed some hallmarks of addiction. He used compulsively, filling his prescriptions early, seeing multiple providers, using many pharmacies, going to the emergency department frequently. He had completely lost control, and this was impacting his personal relationships, his ability to take care of himself, and his work. We had an opiate contract with him, but because he continued to break it, we had to require him to see an addictionologist to get his refills. This is really tough because he will likely not follow up and may go through opiate withdrawal, a very uncomfortable but not medically dangerous process. This is a challenging clinical scenario for us, and unfortunately, this is not an uncommon occurrence in pain clinic.

Interventions

The last part of pain management is the procedures and interventions. For anesthesia residents, this is one of the more exciting facets of pain medicine. We can target peripheral nerves with anesthetic, steroid, or radiofrequency modulation. From intercostal nerves to pudendal nerves to spinal nerves, we can get to most targets with a good knowledge of anatomy and an ultrasound machine or C-arm X-ray. Sometimes, we target complexes of nerves called ganglia; we can ablate the celiac plexus, lumbar sympathetic plexus, and Gasserian ganglia. We also perform procedures on or near the spine; epidural steroid injections are a mainstay of therapy as well as the placement of intrathecal catheters and pumps.

The procedures are quite enjoyable and educational. We perform epidurals on obstetric patients all the time, but here, we guide it with X-rays and fluoroscopy. This allows us to really understand the anatomy, see pathologic variants, and become fluent with how to address problems. Comparing three dimensional models to our two dimensional X-rays challenges us to visualize the anatomy of nerves and surrounding structures. For the most part these procedures are fast, so we do many each day, allowing us to see a range of different disease states.

Image shown under GNU Free Documentation License, from Wikipedia.

Complementary and Alternative Medicines

We don't talk or think about it a lot, but there are many other approaches to pain management besides Western medicine. From acupuncture to Ayurvedic medicine to herbal supplements to energy therapies, there's a lot that Western doctors ignore (or are ignorant about). Few of these interventions have been studied so there's a lot of skepticism among us. Nevertheless, when someone has chronic pain that interferes with her life, activities, well-being, and happiness, keeping an open mind is important. As long as it is safe, we encourage our patients to try holistic approaches to mind-body wellness. We send patients to acupuncture, have a specialist that understands herbal supplements, and encourage yoga, meditation, and guided imagery. Some of our patients swear by it; others find no difference. But it emphasizes our philosophy that management of pain happens at many different levels with many different tools.

Image of acupuncture is in the public domain, from Wikipedia.

Medications

All physicians know how to treat pain, but the management of chronic pain and pain medications is far more complex than most physicians realize or want to deal with. Many patients sent to the pain clinic are either on whopping high doses of opioids or can't tolerate the side effects. Coming up with an appropriate regimen, tapering someone off, or escalating to treat cancer pain are all routine clinic visits. Luckily, pain signaling in the body is a complex dance involving molecules, neurons, and interneuron communication. Our armamentarium of non-opioid pain medications includes calcium channel modulators, sodium channel blockers, serotonin and norepinephrine reuptake inhibitors, NMDA receptor antagonists, and alpha-2 adrenergic receptor drugs. We target peripheral neurons, the spinal cord, and the brain. Despite all these options, our understanding of pain states is still quite limited. Sometimes I feel like I'm banging a hammer at tiny targets. Occasionally, the drug we select is the miracle pill, but more often than not, we spend months finessing the drug, balancing it with its side effects, tempering it to the circumstance. This is the art of pain management.

Image of harvesting the opium plant is in the public domain, from Wikipedia.

Physical Therapy

At our chronic pain clinic, we approach patients with fibromyalgia, chronic regional pain syndrome, low back pain, headache, and other complaints with a multidisciplinary manner. I think this is absolutely essential. Especially for patients who have seen so many physicians including other pain doctors, there is no single therapy that will solve everything. It's hard for patients to accept that we have no silver bullet, but when we explain the multi-pronged attack to control symptoms and help someone manage their pain, we get a lot of buy-in.

Along with pain psychology, we like to involve our physical therapists. Physical therapists know so much about body mechanics that doctors don't understand. Even though an orthopedic surgeon may know how a joint should move and a physical medicine and rehabilitation physician understands how muscle groups interact, a physical therapist puts it all together. They have the time, the patience, and the tools to encourage a patient to use that limb that hurts or overcome their fatigue and exercise. And for some diseases like fibromyalgia, this is the most important thing. When we have our multidisciplinary conferences, we pay attention to the pain psychologist and the physical therapist because their assessment and recommendations are just as important as the medications we prescribe or the needles we wield.

Back in the Day

This is a whimsical post. I might be too young to start stories with "back in the day..." - especially since I did my acute pain rotation only a year and a half ago. But back in my day on the acute pain consultation service, we easily saw forty to fifty patients divided between two residents. Now that I'm on my chronic pain rotation, we cover calls for the acute pain service. After feedback from when I did the rotation, the workload has really come down; now the acute pain service tops out at about thirty patients divided over three people. I'm a little jealous because back in the day, acute pain was a terribly busy and stressful rotation.

Pain Psychology

I spent a day with a pain psychologist. In most cases, the management of chronic pain requires attention to the psychological aspects of the illness. This is not to say that people with chronic pain have psychiatric disease, but rather that there are psychological tools that patients in pain should use to manage their symptoms. This is not surprising. The patients we see are so debilitated that they cannot sleep, have a poor diet, hurt when they exercise, cannot hold a job, and feel like no relief is in sight. This prospect is scary, anxiety-provoking, and depressing. Sometimes they feel that their physicians aren't taking them seriously or have tried everything with little success. Sometimes, they just want someone to listen.

And that's what we do. Working with a psychologist reminds me that the non-medical history, the social history, can be incredibly rich. We draw out the childhood history, think about interactions with parents or siblings, look at a patient's educational history. Some have had traumatic childhoods, gone through the correctional system or foster homes, and this makes a big difference in their coping mechanisms and outlook. We examine a patient's employment history, see how job and financial stressors play a role in their life. We ask about marriages and divorces, children and pets. We go beyond the usual "alcohol, smoking, drugs" and look at caffeine use, attempts at detox, attitudes about opiates. We take a detailed psychiatric history. All of this gives us the background picture, the milieu, that stews and exacerbates the patient's chronic pain. It is the stuff that gets in the way of effective treatment. It helps us anticipate the obstacles a patient must overcome.

In this rotation, I have become more and more convinced that the mind and the body are incredibly co-dependent. Medications alone cannot cure chronic pain. So we try to identify and give patients the tools and coping strategies to deal with what is likely a life-long condition. Though it is easy to dismiss this stuff as "fuzzy" and "imprecise," it is the art that complements the science of treatment.

Crisis Management

When I wrote about the plane crash in the last post, I was thinking of my experience, a single responder with a specific skill set and role. But as we talk and think about mass casualties, I begin to recognize more and more the challenge for and remarkable response by the higher level administration, both at SFO and at Stanford. From a hospital standpoint, a situation of this magnitude puts into play so many different things. We have to communicate with the disaster site to assist them with deciding who goes where. Any single hospital could get quickly overwhelmed, but by sending patients to nine different Bay Area hospitals, we did not inundate any one hospital's resources. Upon activating a code triage, the emergency department has to be cleared out and additional space set up. If dozens of critically ill patients arrive, we cannot have the ED filled with nonurgent cases. I talked a little about how additional physicians responded including multiple trauma and perioperative teams, but we also have to call in extra nurses, technicians, and other staff. If a patient needs to be transported to the OR or ICU, we have to have people on standby just for that job. We have to open up ICU and hospital beds, no easy feat when hospitals run near full capacity. And we have to handle a dozen other tasks: talking to media, predicting needs for the next 24-48 hours, identifying names of the victims, maintaining infrastructure. I know the hospital does a lot of simulation exercises to prepare for such situations, and the fact that this went so smoothly is a testament to the systems and preparation set in place.

Plane Crash

I was in the hospital rounding on pain service patients when I got a page: "Code Triage - Major." I hadn't seen this code before, but the page followed with an explanation: "Mass casualties. Plane crash at SFO." I hurried over to the OR, switched into scrubs, and set up an operating room. Anesthesiologists rushed in. Many were in house - ICU, cardiac, pediatric, liver, and obstetric teams - and others came in from home.

We got the story in bits and pieces. A Boeing 777 passenger jet flying from South Korea crashed on landing at San Francisco International Airport. Two people were killed, over 180 injured. Most were going to SFGH and other hospitals, but many were coming to Stanford. I was astounded by the rapid spread of information; Twitter feeds chattered, and I even saw a Youtube video of the plane billowing smoke. We heard the tail ripped off, an engine was destroyed, fire engulfed the plane, and even that the plane rolled over.

As I was setting up, our first patient rolled into the operating room. With burns on the arms and legs, a large bleeding scalp laceration, and little time to prepare, I had to make quick decisions about the anesthetic. After asking the patient some basic questions, I prepared a rapid sequence induction and intubated the patient. On intubation, I saw soot and erythema suggesting inhalation of smoke and hot gases. The rest of the anesthetic was resuscitation, warming, and access. Burn injuries cause rapid loss of heat and water, and falling behind can have severe consequences. We also kept the patient intubated post-operatively because inhalation injuries can have severe airway swelling.

I learned a lot from this incident. In a mass casualty situation, call all your resources early. Even though I wasn't supposed to be in the OR, my skills were needed and I had no hesitation to take care of someone sick and injured. Plan as much as you can early but expect that you will not anticipate everything. Anything could have come in, from burns to chest trauma to arterial bleeding to children. At this time, my place is at the front line, taking care of the individual patient, but I am starting to get a sense of what it's like to coordinate a potential multiple patient disaster. Communicate in the operating room; too much commotion or too little discussion, and no one knows what's happening. The surgeon knows the injuries and what he wants to do. The anesthesiologist knows the access, airway, blood pressure, temperature, and fluid management. The nurses handle the equipment, the post-operative disposition, and the medications from pharmacy. The front desk knows how many more people may be coming up and how much time we have before a critically ill patient sucks away resources. And debrief at the end. I made some anesthetic decisions that worked, but were they optimal?

Image shown under Fair Use, from New York Times.

Chronic Pain

I started my chronic pain rotation this month. Pain is truly a multidisciplinary field. Although anesthesiologists bring certain skills like regional nerve blocks, epidural and spinal interventions, and knowledge of pain medication pharmacology, there are many aspects of chronic pain outside our scope. For example, pain and psychological conditions often go hand in hand, headaches are a common chronic condition that doesn't respond well to our normal armamentarium, and diagnosis of musculoskeletal complaints often requires examination skills and tests perfected by physical medicine and rehabilitation doctors. Thus, it is truly a multidisciplinary gathering where each specialist brings something to the table and where residents and fellows try to shore up our weaknesses.

Chronic pain is a clinic based rotation, which is also very different from an anesthesiologist's usual setting. Stanford's pain clinic is located in a beautiful new facility with floor to ceiling windows, plenty well-designed examination rooms, a procedure area, and computers for patients while waiting. I'm slowly getting used to the tie and white coat rather than my usual scrubs. The fellows and attendings are from many different backgrounds; some have been surgeons, internal medicine physicians, traditional Chinese medicine doctors. Patients have often seen pain physicians in the past, so cases can be particularly complex. As residents, we rotate through the clinic, the procedures, and a few psychiatric and private practice settings. Clinic is not my usual habitat and chronic pain patients aren't my usual crowd, so we'll see how this month goes.

Paradox of Price

As health care consumes a larger and larger percentage of the GDP, one might assume that things are getting more expensive. We assume that brand-name medications, emergency department visits, hospitalizations, intensive care, advanced scans, and cutting-edge technologies cost more and more, but that might not be true. I was talking to some friends recently about personal genomics and testing services that market directly to the consumer. As sequencing technology becomes more efficient and cheaper, it has become possible for an individual to send in a DNA sample (like saliva) and for a company to analyze around a million genetic polymorphisms. To put this in perspective, the Human Genome Project took 13 years and around 3 billion dollars to sequence the genome, which is a little different than identifying genetic polymorphisms, but yields similar clinical information. When the company 23andMe started in 2007, the cost of the test was $999. Today, it costs $99.

Why the 10 fold cost reduction in six years? Because the company markets directly to the consumer (no need of any physicians or insurers to muddle the picture) and faces competitors, it has a huge incentive to use the rapidly progressing technologies to make its process more efficient and cheaper. And it's worked. Shouldn't the rest of health care follow this trend? Wouldn't physicians, insurers, and patients want market pressures for companies to make their tests, scanners, drugs, and treatments cheaper? How do we encourage healthy competition to make more efficient and innovative processes, technologies, and products?

Tragedies

We encounter a lot of awful things as doctors: failed treatments, metastatic cancer, injuries from abuse, accidents, drug overdoses. As we see these patients and situations, we sometimes have to reflect on them in order for us to tend to our own well-being; after being surrounded by tragedy, it is important for us not to get sucked in as well. 

One of the instances that bothers me most is the preventable tragedy. A child in an inappropriate seat without a seat belt sustains severe head injury when the vehicle rolls over at highway speeds. Although he is rushed to the hospital, we could not resuscitate him; his injuries were nonsurvivable. Most providers were shocked to hear that he was unrestrained and not in a car seat. No one could say whether any precautions may have changed the outcome, but I was really affected by this death of a child. Debriefing the case was incredibly important to me to come to terms with the fact that his prehospital injuries were terminal and we could not have salvaged him. It was important to me to reflect, discuss, and conclude that at some level, the laws made to protect kids in cars failed, and this contributed to the death of a child. Of course, this was a problem at the level of the parents, but it is also something that as a society, we can improve. We have to protect our children; we cannot make exceptions to child passenger safety laws. The most tragic incidents are those that feel like they could have been prevented.