Tag Archives for Pain Management

Pain Clinic #6: Acute Pain Service

I’m steadily working my way through my pre-surgery appointments. My next appointment at the pain clinic was supposed to happen in August, but because of my upcoming surgery, they moved it up to this past Tuesday. I met with a doctor who recently started his one-year Fellowship in Anesthesiology and Pain Management at the hospital’s pain clinic – there is an annual program rotation that starts at the beginning of every July. I had to catch him up on what’s been happening since I had my nerve block.

I told him that I had dutifully kept my pain log every two hours for 48 hours after the nerve block and sent the log back to the pain clinic as instructed. I also expressed my disappointment that the nerve block didn’t last longer than two weeks, but I tempered that by letting him know that it was still nice to have had a little pain relief even if it was for such a short time. He asked if the nerve block had made it possible for me to reduce my pain medications. Unfortunately, the answer to that question is “no.” I wasn’t able to reduce my pain medications but I believe that during that short period I felt some benefit from them for the first time in a long time. They enabled me to do a bit more than just the basic daily functioning of moving around. For instance, I was able to go out with a friend to a local market where I picked out fruit, vegetables, spices, and cheeses for myself from different shops; and the relief was enough to make it possible for me to cook myself a complete Sunday dinner. It was good to get out of the house and walk through the market for the first time since becoming ill and it was even better to use produce I selected – instead of some anonymous person from my online grocer – to make myself a tasty meal.

After talking about the nerve block, we moved on to my surgical pain management plan. I will have an Anesthetic Clinic consultation during my pre-admission appointment. During that consultation, an anesthesiologist will review my current pain medications, the pain management plan designed for me a few months ago by the pain clinic, and factor in the results of my nerve block to determine the level of pain medications I will need during surgery. My pain specialist believes that the suggested epidural should remain a part of the pain management plan so that I can receive a constant flow of pain medication during surgery and for up to two days after because my surgeon is going to use a vertical abdominal incision, which is of course the more painful technique. Following surgery, I may also have a patient controlled analgesia (PCA) pump so I can control the frequency of the doses of narcotic/opioid pain medications I receive immediately after surgery.

In addition to having my body flooded with pain medications through these invasive methods, I will be closely monitored for the length of my hospitalization by the Acute Pain Service (APS). The job of the APS is to “to ensure patients with pain have individualised, safe and effective therapy” and “to provide safe and effective pain management to patients undergoing surgery…from admission to discharge”. An anesthesiologist will lead the APS team. The team will see me daily to assess my pain management needs, make adjustments as required, and measure my rate of recovery from my surgical pain and chronic pain. The team will also make recommendations about the type and amount of pain medication I’ll need when I’m recovered enough to be discharged from the hospital. Before this conversation, I had no idea that such a service existed and that I would receive this level of pain management care after surgery.

Surprisingly, I left that appointment feeling buoyed with confidence. A few days ago, I didn’t feel that. I instead felt overwhelmed by anxiety and fear. I think the anxiety is starting to shift because as I go from appointment to appointment and make phone call after phone call from the many points on my to-do-list, I’m realizing there is a supportive network of healthcare professionals around me who feel invested in getting me better. To meet that goal they are openly communicating and sharing information with each other and me so all I have to do is show up. I just have to show up and let them worry about the surgery and the post-operative care. Let them worry about the sharpness of the blades of the scalpels; the amount of pressure in surgical suction pumps; the number of stitches and staples needed to close my incision, and when they will reintroduce solids to my diet. I’ll let them worry about those things and the piles of other things rolling around in my head and in the meantime, I’ll work on trying to sleep more, laugh more, and take in the love and support of the many friends and family who want to carry the rest of my worries for me.

Now on to doing the work of making this positive perspective my reality…

 

Bob Marley – Three Little Birds

Surgery By The Numbers

Yesterday I met with my surgeon to discuss a laundry list of questions I started putting together as soon as he made the decisions that I need surgery and he would be my surgeon. My list consisted of twelve detailed questions with bullet points to cover all the possible combinations of what could happen during and after surgery; and how he might address all of those issues. He was very patient with me. With his team of two surgeons, he answered all my questions.

He gave me answers that included statistics about the probability about whether some things might or might not happen. For instance, there is a 10% chance that I might need a blood transfusion during surgery. That 10% depends on whether there are large blood vessels in or around the growth or other organs that could be injured in the process of removing the growth and cause significant bleeding. From my perspective, 10% is not a big number for probability of risk. The other statistical numbers he gave me were under 10%, and these low numbers gave me comfort.

He also talked numbers in terms of the size of organs. Did you know that your colon is about 5 feet or 60 inches long? He talked about how much of your colon and other organs you need to function normally. However, the one organ I’m most concerned about is my rectum. The rectum is about 18 centimetres or 7 inches long. According to my surgeon, you only need about half of your rectum for normal bodily functions. He does not believe that he will have to remove that much of my rectum. Therefore, I won’t need an ileostomy – temporary or permanent. Still, he did caution me again that imaging never tells the full story, so although he feels positive about what he will find we’ll have to wait and see what happens when he makes the incisions.

The last set of numbers he talked about related to my recovery. The typical recovery time required for someone who undergoes a resection – where everything goes well – is about six weeks. He will release me from the hospital after five nights if I am eating without any issues, there are no leaks in my resection, and my bowels are functioning normally. I will have my first post-surgical check-up three to four weeks after I leave the hospital. My surgeon will examine my wound to determine how well it’s healing. I will have staples in my incisions so he can remove them if I develop an infection. He will also use benchmarks like how I’m tolerating foods – solids vs. liquids – and how well my digestive system is functioning from top to bottom.

Surgery By The Numbers - My Hope

If everything goes well with the surgery, the rest will be left up to the pain specialists to manage my pain. My surgeon believes removing the growth will eliminate my pain. I hope he’s right. I know I have to be realistic based on what I’ve been living with for the past two years, but I hope his surgical skills combined with his optimism will lead to a full recovery of my health.

 

Brian McKnight – Win

The Second Opinion Surgeon Takes Center Stage

I was having a chat with one of my online blogging friends, All Things Chronic, a couple of days back and I realized I never finished writing the post I intended to about my impending surgery. A few months ago my reluctant surgeon sent me off to get a second opinion with the best colorectal surgeon in the city. After he advised her that I needed surgery to remove the mystifying growth in my pelvis to improve my quality of life, she chose to ignore that advice and wanted to send me for a third opinion with another surgeon who she called her “peer” at the hospital where my misdiagnosis nightmare started.

When I told her I wasn’t comfortable going back to that hospital for any reason – not even to have impacted earwax removed – she offered to perform a laparoscopy to further investigate the nature of the growth. I was more than a little unnerved by that proposal because she also added that if while she was poking around in my pelvis she determined that it was definitely a colorectal issue, she would then move forward with the larger surgery – a laparotomy. The laparotomy is the larger pelvic incision needed to remove the growth and do the necessary resection. The problem with this approach is what would be missing. She would not be able to follow the surgical pain management plan developed by the pain clinic to make sure I didn’t experience unnecessary pain and give the doctors a better chance to manage my post-surgical pain. She also didn’t have a surgical team identified, beyond herself and her resident, to deal with any unexpected issues that might come up during surgery. The final thing she said that really plummeted my comfort level was that if I were her sister she wouldn’t recommend that I have the surgery. Think about that for a second… The question that came to my mind was would she want her sister living with the level of pain I do on a daily basis for the rest of her life.

I left that appointment feeling the most hopeless I have felt since this whole ordeal started. As soon as I got home I called the specialist managing my referrals and got an emergency appointment to see him a few days later. I explained the situation and my fears and he expressed his own concerns about my reluctant surgeons proposed approach. The main concern being that if she only performed a laparoscopy and scheduled the resection for a later date I would have to go through two surgical recoveries, and my pain response couldn’t be predicted. He asked what I wanted to do and said he would support any decision I made. I told him that I wanted the second opinion surgeon to be my surgeon. He put things in motion and all I had to do was call the second opinion surgeon’s office to schedule a follow-up appointment.

The follow-up appointment was about a month ago. The second opinion surgeon agreed to take me on as his patient and immediately got to work on my surgical plan. While I was sitting in the consultation room, he looked at my imaging results again and determined that the mystifying growth is in a place on my rectum that should not require a resection that involves the complete removal of my rectum. He did make one caveat, that imaging doesn’t always give a full picture of what he might find during surgery, but fifty percent of the time, he does find good surprises. If he has to remove a large section of my rectum, I will have a temporary ileostomy inserted. If he must remove my entire rectum, I will have a permanent one. The decision will be made depending on how low the growth actually is to my pelvic floor. However, his optimism about what he sees in my imaging boosts my hopes that even though this surgery is complicated – no bowel surgery is sterile and I could have unexpected bleeding – I have the best surgeon doing the surgery.

The second opinion surgeon also identified the doctors that would be part of the surgical team. There will be a gynecologist – my referring specialist – in case the mystifying growth has caused damage to the right hemisphere of my reproductive organs and my right fallopian tube and ovary must be removed. There will be a urologist, who I most likely won’t meet before surgery, to deal with any damage to my bladder or ureters. If the second opinion surgeon runs into any other unexpected issues during the three hours he booked for the surgery, there will be a pool of doctors he can draw from to join the team while surgery is underway. He will also follow the pain management plan from the pain clinic.

My Hope Is Blooming

My Hope Is Blooming

I don’t have a date for surgery yet. It will most likely happen at the end of August or beginning of September. Although this will be a life altering experience, I feel hopeful. Now I feel secure that whatever the outcome, I’m in the hands of the best surgeon for the job, and he is optimistic and hopeful that I will come out of this with positive results. He was also kind enough to give me his email address in case I have any questions in the meantime. I hope that the positive results he wants for me includes the elimination of this pain I’m living with every day, but I know that realistically that might not happen.

 

Coldplay – Fix You