“OK. OK. I don’t want to hear about it. You could have gone home last night, and I don’t want to hear anymore.”
I have no idea what the ortho resident or nurse told him. I thought I’d been polite.
Before entering surgery, I knew my options for postoperative pain relief. The first choice, regional anesthesia (local anesthetics injected at the base of the neck bathing the nerves to the arm) would have worked. But I had miscalculated. The pain wasn’t horrible; it just could have been treated better. The second choice, narcotics, offered immediate pain relief. The accompanying sedation, a side effect not always desired, was something I wanted to help me sleep. Shoulder injuries make it hard to be comfortable in any position. By IV, the narcotics would take effect quickly, and I could transition to meds by mouth when comfort was achieved.
THE ROLE REVERSAL I experienced with my son was worse than the one I experienced personally, because it wasn’t my body or my life. It belonged to a loved one undergoing a procedure.
It’s nerve-racking to surrender control of someone so close—worse than surrendering myself to the knife. My inability to control the situation or even assist frustrated me, and my inside knowledge only made things worse. Though I appeared outwardly calm, a fire raged inside me.
Patients choose their internist and surgeon, but rarely do they choose their anesthesiologist. Jason hadn’t selected his anesthesiologist. Neither had I. Although I made no request, I knew his anesthesiologist as a colleague, and I knew that he had been intentionally selected for his special expertise, neurosurgical anesthesia.
Being left on the outside as the OR doors closed, with Jason more than out of reach and sight, left me cold. My soul split as my father-half whispered that it was time to sit and wait and pray, while my physician-half could make no sense of leaving my son.
I routinely advise families not to stay in the waiting room during a loved one’s procedure. I’ll find them if I need them, I tell them. Let me do the worrying. I didn’t follow my own advice and was overcome with waiting-room paralysis. My body felt welded to the chair, with my feet twitching, in constant tapping motion. I didn’t heed my own philosophy and surrendered to the thought that if I moved, even to stretch, in the microsecond that I was not sitting in my chair I would miss attempts from the OR to reach me.
I rose once for coffee, but only with the assurance that my wife, his mother, remained in her place ready to receive any news. The coffee machine was in plain view. While filling my cup, I maintained visual contact with my wife and with the control desk receiving and distributing information. Still, the thought consumed me that the receptionist who had marked on a map of the waiting room the chair I occupied would look and see it empty. There was no bathroom break. There was no need for one. I think my kidneys shut down in sympathy.
I observed the other people in the waiting room. Some sat with prayer books in hand, their anxiety bared for all to see, while others sat with novels or tablets, pretending to read. Some sat in groups with food spread out in preparation for a marathon wait—a morbid picnic. I sat down in a corner chair, leaning forward, staring at my hands clasped together between my knees.
I knew the actions taking place behind the double doors. Sitting in the waiting room, I envisioned Jason’s operating room. I calculated how long he’d been gone and predicted what was taking place. I saw myself, or maybe willed myself, to be standing in my son’s anesthesiologist’s place. I wanted to be the one making the decisions. I wanted to be the one pushing drugs into Jason’s IVs. I wanted to control his vital signs. I wanted to observe the blood vessels exposed by the surgeon bouncing with each heartbeat—an indication of the vitality of my son’s heart, blood pressure, and blood flow.
I saw myself noting the color of the blood in the surgical field. Bright and red. Filled with oxygen. That’s good. I saw myself turning to look at the stacks of waveforms of the colored tracings crossing my monitor and the numbers to the side representing all that I had just assessed in the surgical field. I was watching the surgeon’s hands, predicting his next move, observing the tips of the instruments, ready to act, knowing that as the tips disappeared, unseen structures might be breached or severed and complications might occur. I was ready to counteract anything that might go awry.
A mind in the waiting room wades uncontrolled into all avenues of thought. I found myself counting backwards through my life. I reached all the way back to my dream of becoming a doctor. Raised in a blue-collar environment, I saw nothing more of medicine as a child than begging my doctor not to give me a shot. As a prospective medical student, I asked this same man to perform my pre–medical school physical exam for a discount, as I had no money. And I had no idea what lay ahead.
I have witnessed feats of prowess by all in the procedure suite, and I have experienced a miracle or two. But on this day, all of my knowledge and experience didn’t help. I yearned to sail through those doors and tend to my son. Like everybody else waiting, I wanted my son back.
AFTER SEVEN HOURS, Jason’s surgeon sauntered into the waiting room—a good sign. The surgery was a success. “We’re done,” he said, “but it’ll take another hour to close.” What he really meant was that he had completed his part, the intricate part, the resection of the vascular abnormality. Now it was left to the junior surgeon, fellow, and residents to close the hole in my son’s skull and the wound in his scalp. I breathed a huge sigh of relief and thanked the surgeon.
It was much longer before I could reunite with my son. Bureaucracy delayed Jason’s transfer from the OR; with the sun low in the sky, his room was not yet ready. To lessen my anxiety, my anesthesiologist colleague texted me a photo of Jason wide awake, giving thumbs up, in the OR.
He returned to me.
CHPATER 11
Paper Cranes
PAIN IS A MEDICAL ORPHAN. PERHAPS BECAUSE it has traditionally been considered the consequence of disease or injury, not an illness in itself, and not specific to a body organ or site, no single specialty has accepted, as a pressing goal or major responsibility, a commitment to the elimination of pain. Perhaps there’s a little too much “man up” sentiment out there, embracing the words of Nietzsche: “That which does not kill us makes us stronger.”
The roots of pain relief evolved from the search for pleasure via altered consciousness, as the Sumerians discovered from the “joy plant” over five thousand years ago. Opium from the seedpod of this poppy plant, the parent of the contemporary narcotics morphine and heroin, was first isolated and used in the Fertile Crescent between the Tigris and Euphrates Rivers, in the area known then as Sumer (present-day Iraq). Recognizing opium as more than simply a pleasurable escape, the ancient Egyptians used it for the distinct purpose of pain relief. Little attention was given to discovering new pain relievers until the late 1600s, when opium added to alcohol (laudanum) was introduced in the Western world.
The search for pain relief accelerated in the 1800s with the formulation of morphine, the name derived from “Morpheus,” the Greek god of dreams—a reference to its sleep-inducing properties. Morphine and aspirin (which came later and is derived from the bark of the willow) were used with the specific intent of reducing pain. Subsequent research has led us to understand that the opiates—opium, morphine, heroin, and the newer synthetic narcotics—act on the mu and kappa receptors in the spinal cord and brain to lessen pain. Unfortunately, they also interact with dopamine in the brain, creating pleasure, thus causing them to be dangerously addictive.
The discovery of anesthesia in the 1840s changed the landscape of medicine, allowing invasions so horrific that pain relief after emergence became a requirement. Still, it wasn’t until after World War II that anesthesiology laid claim to the responsibility of pain relief under all circumstances, and introduced the concept of pain clinics, which are still expanding in size and scope.
A LARGE PORTION OF MY anesthesia tool chest is filled with pain relief drugs derived from plants. The poppy, the coca plant, birch bark, cannabis (as an anti-inflam
matory), and coffee (for me, good effects on multiple organs and the downside not obvious). All these drugs and plants are steeped in a rich history that enlightens and invigorates me, and when used creatively, they can ease or eliminate physical pain. The pain I encounter, however, is not always limited to the body.
Freedom from pain should be an undeniable human right in all places, under all conditions, and at all times. I didn’t accept this principle in toto on entering medicine or anesthesia. I reached it in a far-too-long maturation process.
Throughout my early years of practice, I accepted the prevailing attitude of anesthesiology as a specialty: out of sight, out of mind. The philosophy in my training was that patients discharged from anesthesia care were of no further concern to the anesthesiologist. The responsibility for pain relief fell on the service and physician whose procedure had caused the discomfort.
My newfound principle grew through a series of experiences that sometimes we in medicine overlook as we become enamored with the need to use the most technical advances to treat the few, while rather simple methods are readily available and underutilized to care for the many.
After I’d been an attending anesthesiologist for several years, supposedly already knowing, mature, and experienced, I was invited to China to share my expertise about pediatric anesthesia with fellow anesthesiologists in Shanghai and Beijing. Thousands of miles from home, I walked through the halls of my host hospital in China, my head bobbing with every passing room, my eyes overcome with curiosity and irresistibly drawn into each.
It was a surprisingly modern hospital—at least, given my preconceptions of China. The hall was long, with many rooms on both sides, and the walls were painted hospital white. One room, in particular, stopped me. Dozens of paper cranes—perhaps a hundred, maybe more—hung from the ceiling and floated over the bed. Under these cranes lay a listless teen, his hair sparse, with a smattering of sores about his lips. This boy most likely suffered from leukemia. Cancer, and more specifically its treatment, has a way of stealing identity and gender. He returned my gaze, his only movement a slight tilt of his head. His mother, short and stout, stood on the far side of the bed staring at me, a foreign invader, with a look of part anguish and part suspicion.
I was to lecture on the principles and practice of Western anesthesiology. I had been under the impression that the Chinese health care system had imploded as a result of the country’s cultural revolution and had fallen decades behind current medical practices, and now it was attempting to catch up to current worldwide standards. But standing in that hallway and looking at those cranes casting shadows on a pained teen opened my mind in a different direction.
In this modern, state-of-the-art facility, the boy likely received a treatment not much different from what my hospital would have provided: a lytic cocktail of chemotherapeutic medications intended to annihilate the cancer cells. The coincidental loss of normally rapidly replenishing cells included the hair follicles, causing baldness, as well as skin cells around the mouth, resulting in painful oral ulcers. Lacking a head of hair, this teen had a barely identifiable gender. But his pain was clear. The crafted cranes represented an amalgamation of medicine and culture, and symbolized the hopes and prayers for the teen’s future. They had likely been folded with patience by a family desperately imploring the beliefs of a culture thousands of years old to intervene in a manner that medicines could not, to save the youth’s life. Each folded crane added to the chance their wish would come true.
Those cranes taught me that I was not so much a teacher, but a student learning about the power and significance of Eastern beliefs. They taught me how much I didn’t know about Chinese culture and medicine. I also learned that the origami art form that I associated with the Japanese actually began in China thousands of years before medicine stepped in to treat cancer. That paper was a sign of wealth, and the carefully folded cranes beckoned good luck or recovery from illness. The color of each crane was specific for the wish at hand.
I found expanding my cultural knowledge fulfilling, but my first truly seminal moment came on a different ward. I approached a room, outdated by my standards, with four beds. Only one was occupied. In the farthest corner from the door, the farthest possible distance from the nurses sitting at a nursing station outside the room, a young boy writhed in a bed, his arms and legs tethered to its four corners to prevent him from hurting himself. A day or maybe two earlier, he had undergone surgery to repair a chest wall deformity. Rolling in bed, he clearly wasn’t attempting to injure himself, but rather was experiencing excruciating pain. Unable to comprehend why his extremities were tied down, he struggled and pleaded for comfort and peace.
To me, the problem was perfectly clear: this boy needed more narcotic pain relief medication. However, my attempts to explain the importance of more complete and more compassionate pain relief, and to argue that healing would improve with strong analgesia, fell on deaf ears. The Chinese physicians I met accepted paper cranes and acupuncture (I attended a clinic about attempting to repair nerve injury by acupuncture), and they performed invasive surgical procedures. But they seemed impervious to my urgings on pain relief.
WHEN I RETURNED HOME, one of the sponsors of my trip hosted a dinner. Physicians from a variety of specialties attended, and after the obligatory cocktails and conversation came the announcement that the organization had raised sufficient funds to cover the surgical repair of a heart defect in one Chinese child. I asked about the heart defect and recognized it was a type associated with Down syndrome. I summoned the strength to stand up and press for the funds to be diverted from treating a single patient to relieving pain in many. I knew this was a risk. If I presented my views cogently, I would win the opportunity to provide my expertise on pain relief to the benefit of society. But if not, I would lose the chance to interact with this group again.
Mine was not an issue of ethics or of providing care to people suffering congenital abnormalities. Thousands of my patients have suffered from genetic or congenital defects. I knew from experience that a Chinese child with such a defect would, in all likelihood, do well with the surgery and correction, but would return to a culture that refuses these children societal acceptance and places them in an orphanage. During my trip I did not see one person suffering from an obvious genetic syndrome, Down syndrome included, outside of a hospital or orphanage. Not in a market, shopping mall, or restaurant, or even on the street.
The China trip forced me to reassess my efforts at alleviating pain. I wasn’t anti-child—especially not anti–Down syndrome. I was pro–pain relief. My rediscovered passion concerned the ability to provide successful care, and to allocate health care dollars and effort for the greatest benefit. With little concern regarding expense or compensation, the United States provides care to anyone and everyone. After that haunting image of the boy in Beijing, painfully writhing, it became my mission to urge these benefactors to allocate their limited resources toward the benefit of many over the care for one. The boy begging for relief from pain was emblematic of an overarching tendency in China to undertreat patients. Although caring for a single afflicted child allowed photo ops and plenty of favorable press for all involved in the funding and care, redirecting the funds to educate many Chinese physicians on the use of inexpensive pain medications could alleviate widespread suffering in the long run. (The cost of treating significant pain today averages $1.67 per dose.) I urged treating thousands over treating one.
I lost.
Still, I remained resolved to stand by my commitment to alleviate pain, or at least to attempt to relieve all pain, beyond the walls of the procedure suite, the perceived boundary for many anesthesiologists.
Relieving pain would seem to be a primary goal for the anesthesiologist. And analgesia isn’t difficult to understand—“Do you hurt?”—or to treat. But for a long time, and like many anesthesiologists, I simply put patients out of mind once they were out of sight.
Witnessing the Chinese boy’s suffering was the final solidi
fying moment in my understanding of the importance of pain relief before, during, and after medical procedures. Initially, my concept of pain relief was limited by preconceptions and prejudices that kept my mind closed. Pain itself remained an enigma to me. The thesaurus lists over sixty words interchangeable with “pain.” That doesn’t include all the qualifiers—“dull,” “lancing,” “constant,” “throbbing,” and many, many more. The challenge of defining pain compounds the challenge of eliminating it.
One tool I use in teaching—not so much for its educational or even patient care value, but to grab the attention of those I’m speaking with—is an outdated instrument for assessing pain called the dolorimeter (dolor is Latin for “pain” or “grief”). Described in an issue of Time in 1945, the dolorimeter was a goofy-looking, double-pressure, pain-inducing contraption appropriately lost in history. Unlike the MAC (minimum alveolar concentration) of the volatile anesthetics, which can be succinctly measured, pain is an elusive property. All current pain measurement instruments continue to rely on a subjective assessment by patient or health care provider—a guesstimate at best.
The current pain scales are either visual or numeric. The two scales known as VAS (Visual Analog Scale) and FACES consist of cartoon drawings representing circular faces that range from happy (a smiling face) to sad (downturned lips) that are intended to assess pain in young or nonverbal patients. The VAS dates back nearly a century, with most current research efforts claiming a 1923 paper as the origin. On a line with “No pain” at the start and “Excruciating pain” at the end, a mark is put where the pain is ranked. The numeric scales rank pain on a scale of 0 (no pain) to 10 (the most excruciating pain ever).
In contrast to these simple forms of measurement, Donna Wong, by all standards a nurse extraordinaire, and Connie Baker, a child life specialist, teamed up to produce and publish their FACES scale in 1988. Then the debate begins: Is a 6 a 6 for everybody? At which ranking and with which drug and at what dose should a patient be treated with pain relievers? My intention is for every patient to score pain a zero, but that goal is unrealistic. Without additional attempts at pain relief, nobody leaves the recovery area with a score greater than the second face on the scale or a numeric of 3/10.
Counting Backwards Page 12