Naked Science Forum
Life Sciences => Physiology & Medicine => Topic started by: PmbPhy on 09/12/2014 17:20:25
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I'd like to open up a discussion about the ethical behavior of Physicians since I've run into so many of them over the last 15 years. If you've never had medical problems then, of course, you're quite fortunate. If you have and they've been problems with chronic pain then I know what you've been through. The unethical behavior shows its ugly head when the doctor refuses to give their patient anything for their pain, even when the pain is horrendous. And believe me. The pain could be a 10 out of a scale of 1 to 10 and some of them would refuse to help you and not blink and eye. To these doctors it's simply not their problem. They consider themselves under no obligation to do anything to help you. Some of them won't even suggest a pain clinic and some of the pain clinics won't help you if you've done recreational drugs in your past. This fact should not be considered at all since a nurse can control the medication by keeping it in a safe at your house and give you one days worth of medication each day. She could even come twice a day and watch you take it to make sure you don't abuse it. Of course you could always get drunk and do drugs otherwise but that means nothing since it's dangerous to do that anyway and narcotics is just another drug. So although some might abuse it, lumping them all into a single category is unethical in itself. Especially since these same doctors will tell you to go to AA or NA for help and then they themselves will ignore the literature they hand out about medication where AA/NA says that it's unethical to hold back such medication for that reason.
So what can be done about such a situation? What does one do when they can't get help because of what other people do and what other people abuse? As I've said, I've been there and know what its like. It's like being tortured for a decade and I promise you that it's no different then being tortured since the level of pain is extremely high and rarely, if ever, lets up on its own.
Thoughts please?
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Doctors won't be able to ignore a patient's pain, once the use of fMRIs to measure it goes mainstream.
You can read more about what I'm talking about here:
http://io9.com/scientists-succeed-in-objectively-measuring-pain-472456061
For those that din't read it in it's entirety, they could tell the difference between emotional pain, and physical pain.
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Ethics is a slippery subject. When asked to deliver an ethical judgement my response is to consider what the Man in the Street would consider reasonable if he understood the science and epidemiology behind the question. The answer will always have a strong societal content and be based in most cases on statistics rather than individual presentations. Consequently it is much more satisfying to deal with heroic interventions on a small number of acutely sick patients with a rare disease than to waffle on about "treatment policies", and whilst those patients for whom the approved heroic intervention failed tend not to complain, there will always be people who fall outside the scope of a general policy and grumble about not being heard or treated.
I've looked at means of quantifying back pain by measuring muscular inflammation. Interesting physics and sound physiology, but the perception of pain is enormously variable - to the extent that some people don't feel it at all and present with multiple hip fractures, complaining that they can't stand upright and asking "is there something wrong with my ears?"
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When asked to deliver an ethical judgement my response is to consider what the Man in the Street would consider reasonable if he understood the science and epidemiology behind the question.
I believe that to be inadequate because the man in the street simply cannot fathom what it's like to live with that kind of pain. People will revert to comparing that pain to pain they've experienced and think that they can extrapolate it in their mind. However that's quite wrong. Pain like this acting for a great deal of time acts to distort the brain which means it acts to twist the thoughts of the patient. Pain like that is simply incomprehensible to the man in the street and thus easily dismissed. I know because I myself was in both positions. I had a friend who had terrible non-relenting back pain. I thought he was just whining too much and that if I had it I'd act much differently. However when it actually happened to me I finally understood what he had gone through and knew what it was like to have chronic pain. It's absolutely one of the most horrible things on earth to have to deal with and incomprehensible to those who've never had it.
I've looked at means of quantifying back pain by measuring muscular inflammation.
First off, you don't appear to have understood the purpose of this thread. It wasn't created with the intention of discussing how to determine how much pain a patient is in. It's about treating the patient after that has been determined.
Besides muscular pain is not what most chronic pain patients experience. When it's a herniated disk there is no inflammation of muscle. There is only a disk that has deformed and has bulged out of its lining causing cartilage pressing and scraping against the spinal cord or the sciatic nerve. The level of pain is unbelievable. I've heard many woman who've had this who were mothers say that the pain was worse than being in labor.
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Doctors won't be able to ignore a patient's pain, once the use of fMRIs to measure it goes mainstream.
You can read more about what I'm talking about here:
http://io9.com/scientists-succeed-in-objectively-measuring-pain-472456061
For those that din't read it in it's entirety, they could tell the difference between emotional pain, and physical pain.
That's wonderful. I can't thank you enough for posting that link. It will help me a great deal. Thanks.
There's one problem with that technique. A lot of pain is intermittent. Some pain doesn't occur until you walk to much, sit up straight in a chair too much, stand in one place too long etc. I suppose the doctors will try to force pain on their patient before they test the patients pain.
Pete
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As a sufferer of back pain for the last 50 years, including from time to time all the symptoms you describe, and with a particular professional specialism in imaging of the erect and seated spine, I have a lot of sympathy - indeed it was the pain that interested me in medical physics in the first place.
Whilst weightbearing MRI http://www.uprightmri.co.uk/for-medical-professionals/papers-and-publications gives us a good image of the distortion and stenosis of spinal nerves, it is rather weakly correlated with reported pain or disability.
The penultimate sentence of Bread Girl's source is crucial
Looking ahead, it will be some time yet before physicians can quantify physical pain at the clinical setting.
fMRI does give us an insight into the primary neurological response to a stimulus but it isn't clear how that correlates with the perception of that response - i.e. the quantification of pain.
As for treatment, I've never favoured chemical suppression of symptoms in the case of any chronic problem. Where it is possible to get a definitive image of the cause, particularly of leg and spine pain, I favour a gradual approach via physiotherapy, manipulation, and surgery (beginning with minimally invasive chemical discectomy) but the outcome is very rarely complete absence of pain and restoration of full function. Fortunately life is finite and I expect the pain will die with me.
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There are people who die due to pain meds.
I have a cousin who is an example. "Good Kid". - Got into an auto accident.
- Got hooked on pain meds.
- Started self medicating.
- Died of an overdose.
I was out of state at the time and didn't learn about it until it was too late. I wish I was closer and could have talked to him, but it wouldn't have helped.
Now, perhaps if he had received better care he wouldn't have needed to self medicate.
I don't know the percentages... hopefully a very low number of the patients end in tragedy. However, such a tragedy is hard on the family and everyone involved. Probably hard on any doctors that hear the story too.
However, policy is based on that minority of patients who OD, not the majority who don't.
I agree with Alan.
Pain meds are best when used for acute break-through pain, not chronic pain. Unfortunately the pain meds can also cause rebound pain.
Anyway, try to figure out what works, and what doesn't without getting more pills. Surgery isn't always the answer either, unless there is a specific pinched nerve causing loss of function.
I've had low-level chronic back pain for years. Finally I'm getting better at preventing it. A couple things I've discovered. - I never wear a belt. They cause me pain, so I just don't wear them. (I'm not into suspenders either).
- Many beds cause pain. I can't explain why, but a Lazy-Boy chair is more comfortable than any bed I've been in
- I try to keep moving, and getting exercise. I will lift stuff as safely as possible, but haven't stopped lifting things including heavy stuff. Perhaps I should be a bit better with passive stretching.
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There are people who die due to pain meds.
I have a cousin who is an example. "Good Kid". - Got into an auto accident.
- Got hooked on pain meds.
- Started self medicating.
- Died of an overdose.
I'm so sorry to hear that. Most of the time patients who use pain meds don't become addicted. A doctor at Brigham and Women told me this. In any case, reasons like this is why I said that pain meds should be controlled by a visiting nurse. However its a bad idea to prevent patients from getting meds they need for reasons like that.
However, policy is based on that minority of patients who OD, not the majority who don't.
That's a serious problem in itself.
Pain meds are best when used for acute break-through pain, not chronic pain.
Alan is wrong. Making a wide sweeping statement like that is one of the sources of the problem. Living with chronic pain that is too high can mess with someone's mind as I said above. The result is sometimes suicide. I've been there and experience it. As I said above its a horrible nightmarish torturous experience. I'd rather be dead than have to live like that again. Now, compare it to what I'm doing now. I'm on the right level of medication and I live a normal life again and the suffering is all gone. There's no addiction to be seen and I've lived on this medication for year now. A nurse controls it and I've never abused it. This is what I'm talking about. Everyone is different so you need to treat the patient like an individual and NOT a statistic. Not doing so is a serious error in thinking.
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As a sufferer of back pain for the last 50 years, including from time to time all the symptoms you describe, and with a particular professional specialism in imaging of the erect and seated spine, I have a lot of sympathy - indeed it was the pain that interested me in medical physics in the first place.
What was the pain like though? Was is so bad that you wanted take a knife and slice your spinal cord out? Was it so bad that you couldn't fathom a pain that was worse? Was it so bad that at times you were unable to stand and walk and had to crawl around on the floor to go to the bathroom? As I indicated, there's everyday pain such as people who have back pain which lasts years and then there's chronic pain that disables and is torturous. I myself suffered from back pain for about 25 years before the spinal cord injury. When that happened it was as if I've never had back pain before because the pain levels were so radically different that the first one couldn't even compare or make it onto the chart.
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After abdominal surgery I had an epidural, which was really effective, and it did not seem to mess with my head at all. The nurse would do an ice test about twice a day to make sure the IV levels were adequate. I could feel pressure but not cold from about five inches above and below my navel. I could still walk and move. Obviously, an epidural is not an option for chronic pain, but it made me wonder why there is no way to interfere with certain nerves directly and locally for intractable pain without causing paralysis or all loss of sensation.
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After abdominal surgery I had an epidural, which was really effective, and it did not seem to mess with my head at all. The nurse would do an ice test about twice a day to make sure the IV levels were adequate. I could feel pressure but not cold from about five inches above and below my navel. I could still walk and move. Obviously, an epidural is not an option for chronic pain, but it made me wonder why there is no way to interfere with certain nerves directly and locally for intractable pain without causing paralysis or all loss of sensation.
How long did that epidural last?
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What was the pain like though? Was is so bad that you wanted take a knife and slice your spinal cord out? Was it so bad that you couldn't fathom a pain that was worse? Was it so bad that at times you were unable to stand and walk and had to crawl around on the floor to go to the bathroom?
In a word, yes. But occasionally relieved by ludicrous circumstance.
(1) getting out of the car to calibrate a chiropractor's x-ray machine: couldn't stand up. Chiropractor unable to release the spasm after an hour's treatment, so shipped off by ambulance. Wife called the breakdown service and said "the car is OK but the driver is broken" and they duly repatriated the vehicle whilst I spent 2 weeks in the State of Valium, with two hefty nurses supporting me at pee-time.
(2) After a great day's aerobatics, picked up a guitar to start the evening's concert. Again unable to stand, ambulance called, but somehow the message got scrambled and as we left the scene, police and fire engines arrived en masse because "urgent ambulance to airfield, one body" was interpreted as a major crash. I never got to play with that band again.
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After abdominal surgery I had an epidural, which was really effective, and it did not seem to mess with my head at all. The nurse would do an ice test about twice a day to make sure the IV levels were adequate. I could feel pressure but not cold from about five inches above and below my navel. I could still walk and move. Obviously, an epidural is not an option for chronic pain, but it made me wonder why there is no way to interfere with certain nerves directly and locally for intractable pain without causing paralysis or all loss of sensation.
How long did that epidural last?
Well, it lasts for as long as its in place (or several hours after they remove it.) It's a tiny catheter is inserted through the epidural space around the spine, and anesthetic flows into it from an iv. I guess there are also epidural injections. I don't know how long they last.
Anytime you introduce something foreign into that space you run the risk of infection and meningitis, so it's not without risk. But my question was, whether there was any way to intervene either surgically or with a kind of implant for intractable pain when there is pain in a specific area.
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There is something problematic about pain and how it is treated. When they took me off the epidural a few days before I was scheduled to go home, the pain hit me like a freight train. One thing I noticed was that if you can get your pain down to zero, or at least a one or two, it doesn't seem to take very much to keep it there. But if it gets away from you, it seems to take a large dose to bring it back down.
The doctors write an order for a certain amount, and some nurses would bring it regularly. Other nurses would say "How's your pain," and if you said "I'm okay," or "it's about a 2" they wouldn't bring it until you were really in a lot of pain, back up to a 7 or an 8, and then you'd be back on the pain roller coaster. I would think being a "2" should mean you are at the right dose, not that you should stop taking anything. When it was out of control they ended up giving me like a days worth of pain medication or more in 2 or 3 hours.
My surgeon and the pain team seemed to get that, but not all the nurses did for some reason.
Even though it should be academic or protocol based, I have the feeling that a health care professional's views about pain are highly influenced by either personal experience or certain non-professional beliefs. Some doctors seem much more reactive to things like lack of function or movement, or some other physically evident symptom, than pain. It's almost like they see pain as just an inconvenience, something to put up with that doesn't actually cause any harm. When actually, I found in the year leading up to my surgery, that it just shuts down everything. If your leg is in a cast, that disrupts your life, but you can still do certain things - you can still read, work at a desk, talk on the phone, etc. But pain makes every task or interaction arduous and unpleasant. I really started to feel that life was not worth living if they couldn't fix the problem.
The strange thing, though, was that in between flare ups, when I would have maybe 2 or 3 weeks without pain, I found myself forgetting what it had been like. I'd start thinking, gee, maybe I don't need this surgery, maybe this was the wrong decision. But then it would come back, and I'd think "Oh yeah, now I remember." I just found it really strange that I was unable to bring the sensation to mind and really recall it. If I had trouble imagining my own past pain, it's little wonder that other people have trouble appreciating the extent of it.
I read a study that showed that doctors tend to take pain more seriously in people who more closely resemble themselves, eg, male doctors took pain more seriously in men, ethic groups were under treated for pain, etc. There are few conditions that require subconscious empathy in order to be recognized.
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Pain is nature's way of telling you that something is wrong. Excessive suppression of pain can be counterproductive - diabetic or leprous neuropathy can lead to amputation because you don't recognise bruising, and ambulance crews are cautioned to use entonox wherever possible rather than opiods because the patient may not report serious damage if it doesn't hurt - entonox gives a quick "up" as well as a controllable "down", where morphine would just hide the symptoms.
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Pain is nature's way of telling you that something is wrong. Excessive suppression of pain can be counterproductive - diabetic or leprous neuropathy can lead to amputation because you don't recognise bruising, and ambulance crews are cautioned to use entonox wherever possible rather than opiods because the patient may not report serious damage if it doesn't hurt - entonox gives a quick "up" as well as a controllable "down", where morphine would just hide the symptoms.
That's true, and definitely a risk for patients who use pain medication chronically - would they recognize some other unrelated pain? A friend of my mother's died from acute pancreatitis, presumably because she self medicated the pain with codeine and just went to bed, and they found her dead a day later.
But when pain completely incapacitates a person, and it isn't really a progressive or life threatening condition, what's the answer? What risk is acceptable? A lot of patients were disappointed when the anti-inflammatory viox went off the market because of its link to heart disease. Some said that it was most effective medication for them and they would have been willing to take that informed risk.
Blocking pain locally and specifically would seem to have the advantage of not affecting other brain function, not causing addiction, and not interfering with pain from any other area of the body. But injury to the blocked area, bedsore like lesions, could still be a problem.
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Pain is nature's way of telling you that something is wrong.
That's its goal. Chronic pain such as that caused by spinal injury is when the body is sending the mind false signals
Excessive suppression of pain can be counterproductive - diabetic or leprous neuropathy can lead to amputation because you don't recognise bruising, and ambulance crews are cautioned to use entonox wherever possible rather than opiods because the patient may not report serious damage if it doesn't hurt - entonox gives a quick "up" as well as a controllable "down", where morphine would just hide the symptoms.
For nerve pain such as mine its optimal to use pain meds. One thing that doesn't happen with these meds is that it doesn't make me immune from all pain or new pain due to injury.
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But my question was, whether there was any way to intervene either surgically or with a kind of implant for intractable pain when there is pain in a specific area.
Someone once mentioned to me a morphine pump. I think its implanted into the body and pumped in at a regular rate. However I'm not 100% sure about this though. Have you ever heard of it?
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It's almost like they see pain as just an inconvenience, something to put up with that doesn't actually cause any harm.
That's what makes them so stupid. Chronic pain causes brain damage. See
http://www.sciencedaily.com/releases/2008/02/080205171755.htm
People with unrelenting pain are often depressed, anxious and have difficulty making simple decisions. Researchers have identified a clue that may explain how suffering long-term pain could trigger these other pain-related symptoms. Researchers found that in people with chronic pain, a front region of the cortex associated with emotion fails to deactivate when it should. It's stuck on full throttle, wearing out neurons and altering their connections.
I HATE those doctors for letting me suffer so much.
I really started to feel that life was not worth living if they couldn't fix the problem.
I've not only been there but went ahead and made several attempts.