To continue on the same discussion as last posting, I saw a patient who had been a "frequent flyer" to the ER for pain. Headache, back pain, arthritis pain.....here she is again and as soon I lift the chart, there's a long list of previous visits and all the narcotics that ended each visit. Taking a few clensing breaths, I entered the "cage". Me versus the evils of narcotic drugs, no holds barred, no referee (aside from the DEA) and hopefully I can stay calm and use my doctor know-how to put a finishing move on this evil and rescue my patient.
She had a headache that was 10 out of 10. Lights were off due to her sensitivity to light, neck was stiff, position was in an embryonic defense. Like one fighter approaching another, chin tucked down, shoulders forward and curled in, arms close in, eyes being hid and forehead wrinked like a chinese shar pei. Husband was sitting in the corner, patiently relaxing but there was a little look of frustration and a kinda "here we go again" face. I interviewed her and drove down all those roads that would pick up stroke, seizure, head trauma but all seemed negative. Physical exam was normal aside from the description above. The MD in me wanted to cut to the chase and see what would happen if I just gave her a shot of something and maybe she would go. The ER was backed up at that time and people were poking their head out into the hall looking for when I would come see them next. I decided to order something "different", an alternative that no one may have tried before just in case she was going to say "it's still a 10". For chronic pain caused by muscle, I have used capsaisin, a pepper derivative formulated in cream that is strong enough to distract the perception of pain and divert the patient to concentrate more on the burning of the pepper. (Science also says it depleats substance P in free nerve endings) After getting to a few other patients, one of the nurses stated she was unchanged and wanted an IV of narcotic medicine. At that point, I went in but noticed she wasn't as curled up as before. Glasses were off and she was laying down in bed. Husband also came out to tell nurses she was looking better. Physical exam revealed a softer trapezius and more supple neck. I asked her to relax her forehead, take some deep breaths and try to pull her shoulders back and unclench the neck muscles. She was able to do so and for that fleeting moment, she looked like a normal grandmother. After explaining the theory of muscle relaxation and the ways narcotic pain killers can actually cause a headache, she started to frown again but I came right back and told her to fix it. I also asked the husband to consider giving her a mirror to carry that would help her with biofeedback. She soon unleashed an emotional cry for all the things she has been through for headache help. She had been to the Diamond Headache Clinic in Chicago, University Hospital in Chicago and thento a Pain Clinic at Mercy Hospital. All the docs had done a million dollar work up and started her on a few pain medicines. While talking she had developed dry mouth and I figured it was from one of the muscle relaxers we give for chronic pain. I tried to keep her on track but she did elaborate all this in about 10-15 minutes. I looked her in the eye and said there is another way of medicine she hasn't tried yet. Two minutes into her monologue, acupuncture immediately came into my head as an alternative. I thought she would make an excellent patient for traditional chinese medicine. I repetitively mentioned an herb shop down the street and the last time I visited there, I found an acupunturist name and number. (This was 2 days ago...funny how positive things happen for a reason.) I told her it would probably take about a year to get good results but even one medicine bottle in the garbage every 2 months would be a success. I explained to her that she has to change her concept of temporary success in the ER from bringing down the level from a 10 to just having a softer muscle or a more mobile neck or being able to take off the glasses. Short term success can keep a patient going till the next goal. This versus telling them get off pain medicine by next month.
The interesting thing about last night was I remember not giving her any further medicine aside from the shot and cream 1-2 hours earlier. I also remember walking her out with her husband carrying her purse (the thing weighed 2-4 pounds). She was also smiling and joking about seeing me outside the hospital intead of inside the ER. If I played the usual treat her and street her, she wold probalby be back to another ER or pain center in a day or two. Don't know if she will follow up with what I suggested (the power that narcotics has for altering lives in a bad way is unimaginable). Put it this way, if she continues on this path, she will probably have a major complication from the list of meds, husband will leave her or she will attempt suicide. Sounds very morose but with no balance in her life and her only savior for 1-3 hours being a strong narcotic pill and the doctors that give her this saying there nothing else that will help her.......what would anyone else do?
