Pain – when it affects the person

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A young man with acute maxillofacial injuries and a tracheotomy in intense pain was denied pain relief for several days. Intermittent suctioning of the trachea was agonizing. He became psychologically affected to such an extent that he was totally focused on his pain and suffering and unable to make intelligent decisions regarding his future treatment.

He required major maxillofacial surgery but refused consent for the same. A doctor called in to counsel him found that pain was his predominant problem and treated it. The patient was magically transformed to a sensible person, now thinking straight and promptly consenting for surgery. The author, a doctor himself, learned from this experience what a devastating experience pain can have on the person, that one should look for pain to find it, that most of the time pain can be relieved by simple means, and that relief from pain changes the whole attitude of the sufferer.

Eight years have passed since the fateful day of September 29, 2003, but the memories are fresh and the wounds on the psyche still raw. R.K., my brother-in-law, was then 35 years old. A happy-go-lucky, but intensely spiritual person with a “come what may” attitude, he had a never-fading smile and a spontaneous sense of humor. He was returning to his hometown after a week-long celebration of his spiritual guru’s 50th birthday in another city when he had a road traffic accident. 

The accident knocked him unconscious. He sustained an orbitomaxillo facial injury, flail chest, and dislocation of the hip. He had cerebral edema, and an unstable airway compromised his respiration. He almost had a cardiac arrest in the first hospital that he was taken to, which was averted by timely endotracheal intubation and artificial ventilation of the lungs. On the same day, he was referred to a tertiary care hospital with the best of facilities for maxillofacial surgery.

The next day he regained consciousness. A tracheotomy was done for prolonged ventilation of the lungs. He could soon be weaned from the ventilator but the tracheotomy was retained because the airway compromise was expected to be corrected only after stabilizing his fractures by maxillofacial surgery.

This was a period of intense pain and suffering for him and for his family. With returning consciousness he experienced pain all over the body, which was worst in the head and neck. Every now and then he would have sudden stabs of intense sharp pain down his chest, and frequently a sensation of something hitting his innards that he later identified as suctioning of his trachea. T

his process went on being repeated and he got to such a state that the very sight of an approaching nurse filled him with panic. Desperately and repeatedly he asked whether there were any alternatives for suctioning. When he thought no pain could be worse, it would get even more excruciating. No position at all was comfortable for him and he twisted and turned, seeking some position that was tolerable. 

Due to his multiple injuries, there was limitation to the positions that he could assume and that made him very restless. To compound his suffering, the tracheotomy made verbal communication impossible. We provided him with a notebook and pen. Now he could communicate but the listener and he had to have tremendous patience!

There were brief partial respites, however, when a staff nurse would come along and inject some pain reliever. But this was not often and invariably happened only after repeated requests and hours of severe pain.

The pain totally demoralized him. It was hard to believe that this was the same jovial, easygoing fellow that I had known all my life, now turned into this brooding and depressed being. The inner light that he carried with him used to make others happy and stimulated. But now the brightness in those eyes was replaced by darkness. 

Neither he nor those of us around him could understand that it was the unrelieved pain that was making him depressed. He was seeing it just as a mishap that had befallen him. A lot of damage had happened to his body and it would take time to become all right. He would have to endure it till then! That was his fearsome understanding of the situation. 

But the pain was becoming worse and impossible to endure. Those around him were focusing on the surgery that would set every thing right and so none bothered enough about the pain that he was suffering. He felt isolated.

He would not give consent for the surgery. He had been told that the surgery would take anywhere from 8 to 15 hours. “I can’t even bear to think of a tooth extraction; then how am I going to get prepared for this sort of a major surgery?” he scribbled down in his notebook. The surgery could not happen without his consent, of course. The family could not persuade him. 

We sought the help of a doctor who was heading the twin departments of Anesthesiology and of Pain and Palliative Medicine. We hoped he could counsel R.K. and persuade him to give his consent for surgery. The doctor sat beside R.K., placed a hand on his hand, and asked his simple but magically effective question. “What is it that is troubling you most?” R.K. gave the obvious answer of pain. 

The doctor gave him an injection of an opioid and after ensuring that R.K. was adequately hydrated and monitored, an injection of diclofenac. Both were continued around the clock. The result was dramatic. R.K. became pain free. Later he said the pain relief enabled him to think straight. It gave him enormous confidence and made him feel naturally in command, with the strength to endure anything now. He readily gave consent for the surgery.

The next day when the pain physician visited him, R.K. was smiling and ready for surgery. But he was a little angry too. “If it was so simple to relieve that pain,” he hurriedly jotted down his question to the pain physician, why was this wonderful medicine denied to me for several days? Why was I punished with those days in Hell?” The doctor seemed familiar with this sort of “understandable anger.” He smiled ruefully and said, “I keep asking the same question!”

I am an anesthesiologist myself. This incident was an eye opener for me. I learned that:

  • unrelieved pain has a devastating effect on the sufferer.
  • one should look for pain by asking the simple, direct question.
  • most of the time, pain can be relieved by relatively simple means.
  • when pain is relieved, the whole attitude of the patient changes.

75% of the world population does not have adequate access to controlled medications for pain relief. As a result, millions of people suffer from pain which is avoidable and could be managed with proper access to the correct medications.

The theme of World Hospice and Palliative Care Day 2016 is: ‘Living and dying in pain: It doesn’t have to happen’. You can learn more about the World Hospice and Palliative Care Day campaign online, including key messages and downloadable resources. 

This article was originally published as part of the series: Narratives in Pain, Suffering and Relief in the Journal of Pain & Palliative Care Pharmacotherapy. It is republished with permission. To view the original article please visit the journal online

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