Odysseys of George

What is pain? This was the question directed to me by our very first and own pain management expert, Dr Mary Suma Cardosa. I enjoy talking to her. She talks about her field of interest with much passion and commitment. So, what is pain? There I stood dumbfounded, as the last time anybody ask me this was when I was a medical student.

Pain, the word “pain” comes from the Latin: poena meaning punishment, a fine, a penalty. It is a sensation, a feeling of discomfort. But what does it really mean? Actually, pain is a protective mechanism of our body when we are injured in one way or another. In other words, when one feels pain, one has sustained some form of injury. But pondering it for a moment tells us this is not necessarily true in all instance.

I once met a young girl, she had lots of deformity as a result of a genetic fault making her unable to perceive or feel pain. Therefore, she often hurts herself by accident as she feels no pain. So, to feel pain is important and possibly a good thing.

When pain occurs acutely, then most often than not it means one has sustained some form of bodily inury. This is different in those who suffer from chronic pain, where though often the injury has healed but the tissue continues to defectively trigger or fire pain impulses causing pain. Chronic pain is a whole lot of a different scenario and involves behaviour modification and gradual tolerance and counselling with minimal dependence on medication.

Acute pain for instance after a surgery or trauma is a totally different ball game. Many physicians and nurses have under-recognised its importance causing in prolonged hospital stay and increased in post-trauma or post-surgery complications.

All this while, to assess for patients health status, the nurses would record a few vital signs to enable us to intepret and assess patient improvements or deterioration. These vitals that were taken mainly by the nurses included the blood pressure, pulses, respiratory rate and the body temperature. Pain has always been the neglected sign and has caused much confusion and fear among some regarding the usage of pain-killers and disregard from health care workers.

To ensure proper management of pain and reduction of usage of unnecessary painkillers(analgesia), the Veterans Health Administration (VHA) has introduce a directive to enable pain be assessed objectively and treated promptly and thus increase patient comfort and compliance to their chest and limb physiotheraphy. In Malaysia, Selayang Hospital is pioneering this before implementing all over the country and as you have guessed, my ward and the neighbouring male surgical ward have started treating pain as the fifth vital sign.

Assessment of pain is made objectively by combining :

1. Wong-Baker Faces Pain Rating Scale

2. Numerical Pain Scale

The numerical pain scale, uses a scale from 0 to 10; where 0 represents no pain and 10 represents the worst pain imaginable.

3. functional ability

* Where is the pain?
* When did it start?
* What makes it worse?
* What helps to ease it?
* Is it sharp, dull, aching, throbbing, shooting, burning?

It is important to understand that medications will not cure your pain or eliminate it. Medications work in many ways to help ease your pain such as by changing how your brain perceives the pain, by improving your flexibility, by treating underlying factors causing your pain, or by reducing inflammation or swelling.

Hopefully, pain as the fifth vital sign would stay as an assessment tool. It would also bring physicians back closer to their patients as this assessment though mainly done by nurses would require verification by the doctors and therefore cultivate the need to talk and touch your patients which in this modern age is very much lacking. Are we then making all these assessment as a result of us health care providers both doctors and nurses are slowly losing that human touch and connection with their patients? Maybe that is for another post to blog.

International Nurses Day is celebrated around the world every May 12, the anniversary of Florence Nightingale’s birth, who is widely considered the founder of modern nursing.The theme for 2007 is: Positive practice environments: Quality workplaces = quality patient care.

So to all my nurses of today and yesteryears, Happy Nurses Day.

**Update**

The nurses in my ward had a small celebration thingy for the nurses day. Thanks to the ward sister, Sr Nariah, it was simple and sweet. It brought smiles to all the ward staff. She also got each of them a rose.

The medical blogosphere grandrounds is up at Medical Humanities Blog

Go check it out!

“Happy Mother’s Day” means more
Than have a happy day.
Within those words lie lots of things
We never get to say.

It means I love you first of all,
Then thanks for all you do.
It means you mean a lot to me,
And that I honor you.

But most of all, I guess it means
That I am thinking of
Your happiness on this, your day,
With pleasure and with love.

As I was blog-surfing I came across a blog post by WJ of an email he received from his mom. It was lovely - so much I thought I would share it with my readers of my blog.

Ooops in my busy schedule, I almost forgot about posting for Photo Hunters. This weeks theme is a little difficult especially when I am trying to keep to an underwater theme but let me see…….

Hah! After many 3’s or 4’s or 6s’, I managed to find something relevant and also very appropriate:

A STAR FISH / SEA STAR

Starfish may well be the most unusual well-known creature. They have no front or back: they can move in any direction without turning. Rather than using muscles to move their hundreds of tiny legs, starfish use a complex hydraulic system to move around or cling to rocks. The intake valve for this system is generally located on the top of the Starfish, just off center.

A good read about Starfish from Wikipaedia

and then

FIVE HINGEBEAK SHRIMPS

Hinge-beaked shrimps have bright, conspicuous colour patterns, which vary between species, and a rostrum that is capable of being moved up or down. Some species live in the protection of the long spines of sea urchins but most live independently, gathering in dark coral caves by day and becoming active at night.

Enjoy

Up to 5% of patients with recurrent gastrointestinal (GI) bleeding will remain undiagnosed by standard gastroscopy and colonoscopy. In these patients, the small intestine is often suspected as the potential site of bleeding. During the past two decades push enteroscopy has become an important investigation in the evaluation of patients with obscure GI bleeding, with diagnostic yields varying from 38% to 80%. However, studies on the impact of push enteroscopy on the clinical outcome of these patients are lacking. Two retrospective studies have suggested that push enteroscopy may influence management decisions in 40% of patients.

Well, I had such a patient. He was an elderly gentleman who presented to us with a diagnosis of Upper GI bleed. I proceeded to do an OGDS which did not reveal any source of bleeding. So, I proceeded with colonoscopy and apart from an unhealthy colonic wall, diverticuli and some angiodysplasia, there were no reall source of bleed and no evidence of any recent bleed. As I was about to withdraw the scope, my intuition attracted me to the opening into the terminal ileum (the end of the small bowel). I manouvered my scope into it and wallah — there was a rare diverticula of the terminal ileum and evidence of fresh blood within the small bowel.

I decided to proceed for a push enteroscopy.

These scopes have a working length 210-cm or more and have standard and therapeutic sized biopsy channels that will accommodate a full range of accessories. They are similar to standard upper endoscopes in that they have up/down and right/left angulation along with a field of view of 120° or greater.

To aid in achieving the greatest possible depth of advancement, an overtube is usually placed over the endoscope prior to its insertion. The overtube reduces looping of the scope within the stomach or colon. Gradual insertion and withdrawal movements of the enteroscope help to pleat as much small intestine onto the scope and improve the depth of insertion. Using these techniques it is possible to examine 100 cm of small intestine beyond the ligament of Trietz in the majority of patients. Complications from push enteroscopy appear to be more frequent than for standard upper endoscopy. Perforation, possibly related to the use of an overtube, has been reported.

Using a standard colonoscope to examine the small bowel, a diagnostic yield of 38% has been reported.5,6 Whereas the use of a small bowel enteroscope resulted in diagnostic yield rates of 52% to 80%.

Well, this is what I managed to see about 200cm proximal to the ileocaecal valve(terminal ileum) — multiple large ulcers and one of them had a visible pulsating vessel waiting to rupture.

He was started on treatment and was discharged well yesterday.