A Pain Filled Deposition

We were seated around the dining table in my office break room, two attorneys, a court reporter and I. A patient of mine was suing someone for injuries sustained in a car accident and that someone’s attorney had subpoenaed me regarding the case. It was a relatively straightforward disagreement. The patient said he had been injured and was experiencing ongoing pain, the defense was arguing there was no way he could have been hurt that badly in the accident.

The defense attorney showed me photos of the cars (there was almost no visible damage) and asked me about my findings and diagnoses for each patient visit after the accident. The patient had no physical findings consistent with an injury at any of the visits, did not consistently follow up with a physical therapist as requested, and had ultimately undergone an MRI of his spine that was perfectly normal. It was clear from his questions he believed this meant that there was no way the patient could be having pain. Brimming with confidence, he proceeded to ask me a stupid question.

“The normal MRI means the patient does not have a radiculopathic pain, correct?”

“No,” I replied.

“But doesn’t a radiculopathy mean that there is something compressing a nerve?”

“No, it means that the patient is experiencing pain in the area supplied by a specific branch of a spinal nerve. There are other causes of such pain.”

“What else could cause the pain?”

“I can give you an answer, but it is going to be a long one,” I replied. As i did I saw the confidence drain from his face.

I went on to give him the long answer. I explained there are many causes of pain that do not show up on an MRI or other imaging scans. I summarized the nature of pain fibers and how they could be activated without physical trauma, how once triggered even normal stimuli could lead to these nerve fibers firing and a patient experiencing severe pain.

In a resigned tone he verbalized the realization that he would have been better off not asking me that question. “I opened a can of worms,” he said.

The mistake he made is a common one. Most people do not understand pain. They understand pain after surgery, when a kidney stone gets stuck, or when a bone gets broken, but when there is no visible cause, they doubt it. If it can’t be seen it with the eyes or in a medical image it can’t be real.

This was the teaching I received when I was in medical school and residency. Patients who complained of pain in the absence of physical findings were filed into one of two categories. They were either crazy or they were “drug-seeking.” They were often treated with scorn instead of compassion.

It took years for me to understand how wrong this teaching was. My first inkling that there was more to pain than I had been told came after I had a knee operation in 1992. Several weeks after the surgery I was standing in the clinic when I had the sensation of something like a hot drop of oil running down my leg. So intense and real was the feeling that I turned and looked to see what was on my leg. The only thing touching my skin was the fabric of my pants. There was nothing there. The sensation was the result of a rogue nerve misfiring and sending inaccurate signals to my brain. There was “nothing” there, but the sensation was real.

My understanding expanded further 17 years ago when I suddenly began to have excruciating, burning pain in my right shoulder and arm. Over a period of weeks I saw 5 different doctors in search of an explanation. MRI scans and nerve tests were all normal. It was the fifth doctor who finally gave me the diagnosis of an inflamed spinal nerve, possibly from a virus. He gave me a diagnosis but could not promise a cure. The pain gradually faded to a persistent tingling but never passed. The pain returned a few years ago, this time deciding to stay, but MRI scans and nerve tests were again normal. The only evidence I can give others for the pain is a description of how it feels. It is “undetectable” but it is definitely real.

Pain of this nature is more common that many realize. Fibromyalgia, a pain condition that impacts as many as 10 million Americans, falls into this category. No visible damage can be detected and no blood tests are abnormal, but the pain can be debilitating. Many patients suffer for years while being told by doctors and others that they shouldn’t have pain. They shouldn’t, but they do.

The current theory is that these unfortunate patients have pain nerves that are overly sensitive. In the same way that some people are always cold, even on a warm day, fibromyalgia patients always hurt. Unlike those who feel cold, fibromyalgia can’t be helped by putting on a sweater. Medications can sometimes lessen the pain but there is no cure.

I cannot cure many of my pain patients, but that does not mean that I do not, or cannot care. I can listen to them and pray for them. Most importantly I have learned to avoid the mistake made by the attorney. When someone says they hurt, I believe them.

- Bart

Blessed by a Dying Man

He was a bear of a man, in two varieties. He was big, strong and burly, an imposing presence like a grizzly. He is also warm and kind, always ready with an encouraging word, like a teddy bear. He is one of those remarkable patients who always takes the time to ask me how I am doing and truly is interested in the answer. On more than one occasion he has asked me if he could pray for me before he left the office. It made me feel guilty at times. I was the one who was supposed to be making others feel better.

He is only one kind of bear now. The big bear aspect of his nature has faded. Cancer has removed almost 100 pounds from his frame and the tumor compressing the nerves to his left arm has resulted in incapacitating pain. He has been on hospice for over a year now, his disease incurable and his death imminent. It is hard for him to get out as much as he used to which makes the still present teddy bear side of his nature more difficult to share.

As encouraging others has been such a major part of who he is the isolation has been difficult for him. He has been wondering why he is still around, why God has yet to take him home, why he must live in so much pain when there is so little he can do for others.

He shared these thoughts with me when I stopped by his home on Friday for a hospice visit. There was not much for me to do from a medical perspective. For the last several months the only changes in his care have been increases in the dose of his pain medicine. He has been in agony, daily choosing to endure the pain rather than be comfortable yet sedated and less present for others. As bad as the physical pain is as we talked I could tell that the emotional pain was taking a greater toll. He felt he had little to give others and that was breaking his heart.

In almost the same breath as his sharing a sense of worthlessness he told me that I had been on his mind for the last several weeks and that he had been praying for me daily. He asked me how my family was, if everyone was okay. If there was anything or anyone who needed prayer it was clear he wanted to know. He told me that he loved me, not just as a doctor, but as his friend. We spoke for a few minutes more and I tried my best to encourage him.

As I turned to go he stopped me and told me to wait. He reached for his wallet and I could tell he wanted to give me a gift. “Please, no,” I said, “You do not need to give me anything! This is my job!” He shook his head insistently and told me that he wanted to give me something. He took money out of his wallet.

“Take the girls in your office to lunch on me,” he said. I hesitated, he would not take “no” for an answer. He wanted to do something, to make a difference in my life. I realized how important it was to him. He wanted to bless me, to bless my office, in any way he could. He needed to bless us, because that is who he is. He is a man who lives to bless others. I let him shove the money into my hand.

I left his home, once again moved at his kindness. As unsure as he is about why he is still around his purpose is clear to me. He is a testimony to others about what it means to be a Christian. He embodies Jesus’ teaching about putting others ahead of ourselves, of loving selflessly. He is a blessing to others, and a blessing to me. Like the Savior in His moment of suffering, my patient is choosing to consider the needs of others.

 Bart

Thanks for reading. Pray for my patient, Mr. R, that God will comfort him and encourage him. Consider sharing this post and asking others to pray for him as well.

A Heart Attack in the Medicine Cabinet

People don’t like pain, even in small amounts. Look in any medicine cabinet in America and you are likely to find multiple medications for pain. Among the most common and most effective are anti-inflammatory medications such as Motrin, Advil and Aleve. Millions of people take these medications on a daily basis to treat headaches, muscle pain and arthritis. New evidence now suggests this may be dangerous.

While doctors have known for a while that there was a slight increase in heart attack risk in patients taking anti-inflammatory medications the risk was considered to be negligible. We knew about it but we didn’t talk about it. We are in the business of making people feel better and when patients are in pain we want to do something about it. Non-steroidal anti-inflammatory medications (NSAIDs) make people feel better. They are inexpensive and available over-the-counter in low doses or by prescription at higher doses and the benefits of decreased pain and improved function seemed to greatly outweigh any concerns. 

It seems we were wrong.

Recent studies have demonstrated that the risk of heart attack and death was significantly increased. The strongest evidence came from an analysis of several studies totaling over 120,000 patients. The analysis revealed an average of 3 more heart attacks over 10 years for every 100 patients. As the patients in the study averaged an age of 61 and were not typically at high risk for heart disease the results are particularly concerning.

One expert, Dr. Peter Wilson of Emery University is quoted in the NY Times,-

“The over-the-counter medications, which have the lowest doses, probably increased risk by about 10 percent, he said. Low-dose prescription medications were likely to increase the risk by about 20 percent and higher-level dose prescription medications by about 50 percent”

Interpreting these numbers requires an understanding of a patient’s baseline risk. Using myself as an example, as a 54 year old man with normal blood pressure and high cholesterol treated with medication my risk of having a heart attack in the next 10 years is about 4%. If Dr. Wilson is correct, over-the-counter medications cause a net increase of 0.4%, low dose prescription medications 0.8% and higher dose NSAIDs have a risk increase of 2%.

For men like me this translates into one more heart attack for every 250 patients for OTC use, one of 125 patients for low dose prescriptions and one in 50 for high dose medications! If I had diabetes and was treated for high blood pressure those numbers would double. When I realized that the medication I was taking every day to manage my arthritis pain had a 1/50 chance of leading to a heart attack in the next 10 years I decided my pain wasn’t as bad as I thought it was! 

While younger people at very low risk for heart attack can take these medications with little concern and occasional use for headache and back strains is not likely to have much of an impact for anyone, the reality is that a large number of older patients have been taking these medications on a daily basis. This new data will require us to reevaluate our approach to arthritis pain.

Here are some of the approaches I am considering-

1-      I am having individual conversations with all of my patients who are on daily NSAID medications

2-     I am encouraging my patients to consider acetaminophen as first line treatment for pain

3-     I am revisiting the lifestyle changes that can help ease arthritis pain. Obesity is an important factor that patients typically do not want to address. It can no longer be ignored.

4-     I am becoming more willing to tolerate mild to moderate pain. I stopped my daily medications 2 weeks ago. My pain has increased significantly, but it is not unbearable.

5-     I will consider prescribing more medications that are pain modifiers and not pain relievers such as certain anti-depressants (duloxetine is a common medication for this) and seizure medications (such as gabapentin)

6-     When necessary I will be more willing to consider narcotic pain medications

Medicine is changing. Treatments we once thought to be safe weren’t. Doctors will need to individualize approaches to the management of pain and patients will need to be willing to consider new options. It is not hyperbole to say that lives are at stake.

Bart

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Sharing a Patient's Pain

At first glance there seemed to be nothing wrong with her. She appeared young, fit and attractive. The first glance was wrong. She was young and fit, but she was also in significant pain and quite afraid.

A few years ago she had meningitis. Her life was never in danger but she was incapacitated due to pain and needed to be hospitalized for several days. Her struggles didn’t end with her hospitalization as she battled severe headaches on a continuous basis for the following year. Her headaches sapped her energy and made it nearly impossible to work. After 12 long months the headaches finally remitted and she went on with her life, free from such pain. Until ten days ago. The headaches had comeback.  She was desperate when she arrived in my office.

We talked about the nature of headaches and how they could be difficult to treat, none of which was news to her. It was part of why she was afraid. She knew that treatments did not always work, she was just hoping that I could do something.

Without making any promises of cure I told I would do all her can. Then, almost in passing, I said something that I think helped a little. I said, “Your pain matters to me.” I shared my experience with severe pain years ago and the fear that came with, fear that I would not be able to live my life if it did not go away. I then told her again, “I will do everything and anything I can to help you. I will not just throw a pill at you and say, “Come back in a month.” I will work to help you through this. I gave her a few prescriptions to try and had her come back in three days.

She was back three days later with only minimal change so I adjusted the medication again. We agreed to touch base again within 4-5 days. While I was not able to give her a lot of hope, I think that knowing she had a doctor who cared meant that she was not totally hopeless.

Here is praying I stumble on a solution in the coming weeks. Her pain matters to me, and shouldn’t it? 

Her story reminds me that we all encounter hurting people and how much better it would be if other people's pain actually mattered.

- Bart

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