Tuesday, November 18, 2014

Pain

The man in the scrubs looming over me on the examining table had a youngish, open face, framed by a baby blue surgical cap. He told me in a soft, even voice that he was going to numb my chest with a local anesthetic, and promised me it wouldn’t hurt. It didn’t. Then he reached down and came up with what looked almost exactly like the old bit brace manual hand drill my father had hanging over his tool bench back in Huntington Park. My eyes got wide.

Leaning over me and placing the drill point in the middle of my chest, he told me he was going to extract some bone marrow from my sternum, and leaning hard into my chest, he began turning the drill. I gritted my teeth and tried not to think about the possibility of the drill bit piercing the sternum and plunging into my heart. He finally stopped drilling and changed out the bit brace for some other tool that looked nothing like what my father had at his tool bench. He told me something like “this might hurt a little,” and then pulled a plunger up and sucked bone marrow out of my sternum. It felt like he was pulling major arteries out of my chest. The pain was astounding, but it was over quickly, to be replaced by a dull ache.

The bone marrow extraction was done fifty years ago as part of the work up that was done to determine the cause of my recurrent pericarditis. There were many, many other tests and procedures done over the course of two years before my military doctors gave up their detective work and simply removed my pericardium. But I’ll always remember vividly the bone marrow extraction. It’s a reference point for me on how to measure pain.

With rare exceptions, and those involve research rather than practice, pain is measured subjectively by observing and/or interrogating the patient. The most common measurement technique is the use of the ‘faces’ self-rating scale. Donna Wong, a pediatric nurse consultant, and Connie Morain Baker, a child life specialist, developed this scale in 1981. I’d venture to say we’ve all seen it at one time or another. When stuff hurts, we start pointing to the ‘frowny faces.’


But what we’re conveying is only one pain dimension -- severity, i.e., our subjective judgment of how intense is the pain we're experiencing. However, pain is multidimensional and doctors need additional information in order to better identify the source and cause of the pain. Without such information, treatment progresses by trial and error, at best. One of the tools that's been designed to capture additional dimensions of pain is the McGill Pain Questionnaire, shown below.
The McGill Pain Questionnaire
A multidimensional approach to the assessment of pain considers:
  • Chronicity
  • Severity
  • Quality
  • Contributing and/or associated factors
  • Location and distribution or etiology of pain, if identifiable
  • Mechanism of injury, if applicable
  • Barriers to pain assessment
The McGill Pain Questionnaire (MPC) attempts to get at chronicity, i.e., when the pain occurs and how it changes over time; its severity; the quality of the pain, e.g., sharp, stabbing, burning, aching, etc.; and the location of the pain, including its distribution or how it radiates from its primary source.
The doctor or pain management specialist will ask the patient to elaborate on his/her MPQ answers, and in addition, will ask about what may have caused the pain. The doctor will also assess the patient's ability to understand the questions and answer appropriately -- an important judgment when patients are impaired mentally due to age or physical/mental condition.

It is possible to describe different types of pain, or its etiology. The history and physical examination help to identify the etiology, which is critical, because different types of pain tend to respond to different treatments. Pain etiology can be:
The pain I felt in my chest when my pericardium was inflamed was "referred." The pain I felt recently when I wrenched my back was "radicular," and it was excruciating!

Radicular pain is a type of pain that radiates into the lower extremity directly along the course of a spinal nerve root.  In my case it was due to the impingement on the sciactic nerve by a lumbar herniated disk. This turns out to be the most common symptom of radicular pain and is usually called "sciatica" or sometimes radiculopathy, which is pain that radiates along the sciatic nerve down the back of the thigh and sometimes into the calf and foot. Radicular pain can sometimes be treated effectively with conservative (non-surgical) means, including physical therapy, medications, and epidural injections.

The onset of my sciatica or radiculopathy put me in the emergency room at 0200 one cold Friday morning. I was given something to boost my heart rate, which had dropped precipitously, pumped full of pain killers, and sent home with a prescription for hydrocodone, a muscle relaxant, and a referral to a pain management specialist.

After trying several injections, including nerve blocks and piriformis muscle injections, I was given an epidural. My pain gradually subsided after the epidural, which included a corticosteroid.

My point in this is to qualify the pain I've experienced in my long and eventful life. The most severe pain was an injection into my heel when I was five years old. It's about the only thing I remember from that period in my life. I even remember the tongue depressor the pediatrician put in my mouth to bite down on before he struck that needle in. That pain lasted a few seconds. The ice cream I got afterwards made it go away.

I've been knocked unconscious several times in my life and as I remember, the immediate pain wasn't bad -- and then I was unconscious! I don't remember what I felt like when I came to, but presumably I didn't suffer too much. I don't rate being knocked unconscious high on the severity or quality scale.

I've also had the breath knocked out of my on several occasions. This was a painful and quite distressing experience. Not being able to intake air is an awful feeling. But the severity of the pain upon having my breath knocked out of me was not that high. I rate this painful experience moderate on severity, but somewhat higher on quality.

The pain I experienced as a result of my chronic pericarditis varied considerably, but because my bouts with the disease lasted for five years, and involved tests like the above described bone marrow extraction, and because the constrictive nature of the disease was life threatening, I rate the experience one of the more painful and distressing of my life ('knock on wood'). That being said, one must rate pericardial pain in association with the onset and progress of a particular episode or attack, not with the overall course of the disease and its ups and downs. At the height of my pericarditis, the pain I felt (a referred pain from the inflamed pericardium rubbing against its inner and outer membranes) was stabbing, burning, aching, crushing, suffocating, and terrifying. And during these attacks, the pain was more or less (depending on how medicated I was) constant. So, this was the worst pain I've experienced.

But there's nothing like back pain for severity. I've had instances of back pain that are so excruciating that they incapacitate me. I've been collapsed on the floor unable to raise my head to drink the water my wife is offering me to help swallow the pill she is putting in my mouth. The onset of my sciatica was so painful that I became nauseous and faint. My heart rate dropped and I broke out in a cold sweat. The EMTs had a hard time finding a vein to start an IV. And after I was stabilized and released, I had many days of severe, debilitating pain, that required more narcotic pain killers than I care to think about. So on the severity scale, I rate sciatica at the top. We'll see how things develop. I hate to think this painful experience will ultimately take over first place on my PPQ -- personal pain questionnaire.

1 comment:

Richard Badalamente said...
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