How Is Pain Measured Accurately?

Have you ever had to go for a pain evaluation? What did they do? Do you know that the experience of pain is quite personal and related to your anxiety? The pain threshold, in fact, is directly related to anxiety. The more anxious you feel, and who doesn’t feel anxious if you have a medical illness or a procedure, the less able you are to tolerate pain.
But how do they know how much pain they need to treat and how do they actually measure it? Comes right down to the fact that they don’t know at all how much pain to treat because the one pain “instrument” they have is to ask you, the pain sufferer, to evaluate your pain on a scale of 0-10. Medical staff believe that most patients either over exaggerate their pain while others understate it. Here’s what one scale looks like using numbers but without the appropriate emoticon faces.  The chart is placed in the patient’s room for all to see just how much the patient is or isn’t suffering:
Face 0 is very happy because he or she doesn’t hurt at all.
Face 1 hurts just a little bit.
Face 2 hurts a little more.
Face 3 hurts even more.
Face 4 hurts a whole lot.
Face 5 hurts as much as you can imagine, although you don’t have to be crying to feel this bad
But that’s only one problem with the scale because, remember, I said it goes from 0-10? The main problem is that you really have no idea, and neither does any medical professional, exactly how 2 is different from 4 or, on the larger scale, how 6 is less than 10 for example. It’s a dumb, meaningless scale that is much like one of my least favorite scales in clinical trials; the CGIC (Clinical Global Impression of Change) or what I’d rather call it the LMAD Scale (Let’s Make a Deal Scale).
The pain scale is left entirely up to the patient to measure and to make decisions regarding how much they can tolerate. The CGIC is left up to the memory of the clinician as to how much change you’ve exhibited in their OPINION regarding how you responded to the intervention. Both lousy measures that shouldn’t be used anywhere much less in a medical setting.
Oh, sure, you’ll find something on a Google search about a major breakthrough in pain measurement. It involves fMRI (functional magnetic resonance imaging) where they do brain scans to see how much of your brain is lighting up with pain responses. Now a simple question appears to be mandated here. Just how many hospitals and how many clinical settings utilize this fMRI-measuring device? Should I be somewhat fussy here and say I doubt more than a handful in the U.S. and probably no patient that you will ever meet will have had their pain measured in this manner? Sure, why not.
Ever hear any semi-professional or professional tell a patient that’d just have to hang in there until they are due for their next dose of pain medication? A good illustration is the scene in “Terms of Endearment” where Shirley MacLaine screams at the nurses that her daughter needs her medication NOW! Oh, such poor hospital manners!
I remember visiting a patient in a surgical ward and, in the next bed, a woman was telling her physician about the excruciating pain she was feeling. “Well,” the physician said blandly, “you’re going home today and I’ll give you some Tylenol to take with you.” Please, this lady had just two days prior had her abdomen opened, yanked wider open to reveal everything, poked, prodded and pulled and then stitched and now all she got was an OTC med from this empathic woman doc? The patient I was visiting had a morphine pump and she had the exact same surgery. Two docs, both women, two patients, same operation but not the same pain relief they both deserved.
Terminal cancer pain as well as surgical pain is something to be considered carefully, of course. But the first is one where the thought of “addiction” should be quickly tossed out the window where it belongs. When someone is dying don’t they deserve all the pain relief they can get? Would you send a terminal cancer patient to a drug rehab because of their oxy use? Don’t make me laugh. If anything is dark humor or muddled thinking this one surely is.
Pain measurement must come into the 21st century and it should happen quickly and not via sophisticated machinery that no one can afford or cares to get the personnel to use.

Hospital Communication and Medical Mistakes

The saga of the cancer diagnosis and future treatment continues with a poor start. The first hospital did an x-ray and thought they found a slight fracture, gave pain medication and said they were too full so the patient had to go home.
The next hospital, after two days of intense pain, thought it might be bone cancer, so a full body scan was scheduled for the next day. The patient, who had indicated that there seemed to be a language problem with staff having thick, difficult to understand accents, was compliant. Good patients don’t necessarily get the best treatment.
Down for the scan, which the patient had misheard as a “skin” test because of the accents. No one corrected the misunderstanding. Older patients are quickly dismissed as not totally cognizant, so laughs and nodding of heads accompanied her unanswered questions. It’s like being a stranger in a strange land this world of current medicine.
Another bump in the medical road followed. The tech delivered the wrong dye for the scan into the vein and now the patient had to wait for it to clear her blood stream before another scan was scheduled. Was this because of poor verbal communication or a lack of attention to the orders, the chart or the MD requesting the wrong dye? Or was it all of the above? I tend to think there’s a very great potential for all of the above.
Two days without food and no sleep (the patient in the other bed talked all night) later and still no results regarding a definitive diagnosis.  The calls come from loving friends and relatives, but the fear continues albeit but no one can tell from any outward appearances.  There is rigid stoicism to keep others from worrying about the patient.  Quick jokes are exchanged as substitutes for real concerns and all is dismissed with one question: “When am I going home?”
The mistake with the dye wasn’t fatal as it had been with another patient in a different hospital who had, as her family understood it, her physician’s note in her chart in his office that stated she was allergic to the dye. He wrote the script without the proviso and the woman died in the room where the diagnostic imaging was to take place.  How did this tech in this hospital use the wrong dye this time? Patients scheduled for surgery now have black marker on any limbs that are the site of surgery, arm bracelets identify the patient and any allergies and patients are also asked to identify themselves as they lie on the gurney. But still this happened. How?
The patient knew something had gone wrong when the tech came into her room with her head lowered and her eyes fixed on the floor.  The simple phrase proffered that there had been a mistake and the test would have to be done in another two days. That meant two more days in the hospital and two more days in diagnostic limbo. Thank God she wasn’t there for surgery.

A Case of Intense Cruelty for Fun and Profit

The adults quickly realized what was happening as they signaled the mothers with their young to split off and go in another direction; the adults would try to pull the pursuers away from them. All around them, bombs were going off, swift motorized vehicles with men throwing the bombs produced frightening noise and confusion. They tried to escape, but they were no match for the spotters in the plane above. The young and their mothers had been tracked and a large trap awaited them.
This was the scene of the relentless attackers who would rope and steal the young orcas from their mothers. It was a Sea World catch for new entertainers. What awaited them was a life of extreme confinement, ridiculous training for the “enjoyment” of children and the pain that separation from the group brings.
Orcas are social animals that travel in close pods and isolation is surely the closest thing to intense cruelty for them. They are not the “killers” we have been led to believe by all the promotion to get us to spend our money at these “entertainments.” Don’t call them Killer Whales. Call them orcas and begin the process of allowing these animals to be just like any other sea creature. Oh, BTW, do you think dolphins are cute? Are you aware that they hunt just like orcas? But they haven’t been called Killer Dolphins, have they?
These young orcas would be paraded out into small enclosures (nothing can match the open ocean) where trainers would ride on their backs, signal for them to jump into the air and slide up onto the concrete apron around their enclosure. It would be a life without freedom, a life of emotional pain without having done anything more than being born the wrong species.
The recent PBS special was almost too much to watch and the end result was, for me, highly disturbing. I don’t often agree with TV talk show hosts, but I have to agree with Jane Velez-Mitchell when she says that keeping an orca in a bathtub can drive them crazy. Yes, Jane, I agree with you 100% and if I were their defense attorney, I would not find them guilty of the murder of the trainers who have been killed at Sea World and other facilities. I would look, instead, at the facilities that keep these animals in these jails for profit and I would never take another child to see these shows again.
I don’t limit my concern to orcas, however, and I also think that any animal that has been born with four legs to walk on should not have to “dance” for anyone’s enjoyment. Do you know how they make these animals dance or how they train Tennessee Walking Horses to step the way they do, or rodeo animals to buck wildly? Try putting hot coals on your feet or a tight strap around your penis and let’s see how you walk.
There’s enough sadness and cruelty in the world without creating it and then making a profit from it. Next time you see something like this, think how it was brought about.  Think also about how cruelty for entertainment sake was seen with regard to people in the U.S. If you are a student of history, you will recall how people threw pennies on sidewalks to make African-Americans dance. Not to their credit, I believe The Rolling Stones used something like this in one of their videos.
Poor children used to have pennies thrown to them from passing freight trains as the engineers laughed and watched the kids try to find all of them. These kids were, after all, poor and their mothers could use every penny they found, so it sometimes resulting in yet more fun; fist fights for pennies.
I was told once about a Wall Street commodities dealer who offered $10K to his young brokers to engage in fistfights for his pleasure. No, it’s not a myth. I knew the people involved. One famous newspaper syndicate used to offer lunch hour fights for their employees at a special in-house ring they set up in one of their buildings.  Fun, right? Great fun seeing men get concussions and bashed, bloody noses.
Bread and circus didn’t go out with the decline of the Roman Empire. It’s still here in many forms.

Death Watch: When You Want the World to Stop

Two distinct paw marks are on the outside of the glass in the kitchen window. It’s a sign that we’ve had nocturnal visits, probably from the raccoons that spent part of their early days in a nest on the fire escape. The paw is a reminder that no matter what happens in our lives, life still goes on and the world doesn’t stop for anything, even when we want most surely to scream out loud that it should stop, even if just for a moment.
The politicians go on TV cloaking all their unsavory dealings with the utmost sounding sincerity while plagiarizing from totally unacceptable sources. People look at their serene countenances and believe them because they are so dandily dressed, their hair so neatly combed and their faces so unmarred by lines. The fix is in, the billionaires get more bloat and still it doesn’t stop for one moment.
A thin, elderly woman lies behind the curtain that separates her from her roommate and only briefly is she awakened. The resident has come to tell her that she will be getting hospice care when she is discharged tomorrow, but he fails to explain what that means. I wonder how a woman whose primary language is Spanish and who has spent her life in a loving, large family is seeing all of this. The drugs that keep her in almost perpetual sleep must have done their work as the medical staff had hoped. She is carefully rolled by a male nurse, cleaned and placed on a fresh bed sheet. Now she sleeps and waits to be returned to her loving family.
Conversations in these settings are startlingly similar to pinball machines; they bounce from topic to topic with only a hint of the underlying fear that is present. Perhaps if we don’t talk about it or if we don’t dwell on it, we’ll all be able to get through this without screaming our heads off for the loss that is coming. Even when the inevitable diagnosis is coming, there is a wish for some understanding how this could have happened. Why did it happen? What was done that would place this burden on someone and their family? Was some sin committed or something forgotten? Where is the reason? There is none. No sin, no injustice, no reason. There’s just the diagnosis and the medical staff know nothing more than the patient; they are just good guessers at this.
Forget about the scientist-nun who found a possible cure for cancer in raw clams or the breakthrough some researcher found in telomeres because, as they say on the evening news programs, “clinical use is still years away.” But you don’t have years and this seems like so much cruelty. It’s a birthday balloon floating on a sea where you need a life raft. No raft is coming.
The word radiation slips out from a friendly nurse’s mouth and you wonder how much the patient knows about why the use of radiation here. More than once you hear a faint utterance that if they can’t do anything, the patient wants to go home. The cats are waiting to be fed, the garden needs pruning and maybe a photo should be taken of those wonderful sunflowers in the yard. Yes, those wonderful sunflowers in the garden should be photographed. The camera’s at home, so it will be ready.
There’s a fire drill and soon the pain medication will be given again and sleep will come as welcome relief from the stress of being in this factory of medicine. The visitors will leave and find it ironic that they were permitted to park in the spaces for radiation patients who won’t be here on this day for their treatments. The garage attendant has shown special kindness to these visitors and allowed them access. The huge parking garage is filled to capacity.
The day is over, the trip home is begun and now the wait for not answers but the beginning of a new chapter in this patient’s life. How long will this last? No one knows, not even the good guessers.

The Question is Who Will Treat You

A long, long time ago in a land called the United States of America, people worked at small and large companies and corporations that did not provide health coverage. If you got sick, depending on the company, you were on your own and the ER was your only hope. Physicians made house calls, yearly exams were practically unknown and any lengthy illness could mean the end of your job. Maternity leave was non-existent as was much of the employment for women in the corporate environment, except for the secretarial pools.
But all that changed and, suddenly, workers were being encouraged to see their docs for yearly exams, mammograms and to use the corporate wellness facilities on-premises. Executives were sent for extensive, yearly work-ups at medical facilities established specifically for this activity. Everyone was seen as a valuable asset for the business. That, at this time, is also fast becoming long, long ago for much of America’s workers and retirees.
Technology has brought changes faster than at any time since the Industrial Revolution and profit, above all, has become the prime incentive.  Today, it seems we have new “Robber Barons.” The wellness of anyone is now no longer of concern as employees find themselves in the maelstrom of healthcare revisions. As it has always been, when an opening exists for profit, it will be seized immediately and that appears to be happening with health insurance coverage.
People caught in the tangle of ineptness exhibited by those responsible in the Government for laying out and setting up the technological aspects of the insurance exchanges are left worried and wondering. Insurance companies, on their part, have seen the opportunity and the letters of termination of coverage went out. Physician, too, have seen themselves removed summarily from programs for no rhyme or reason. Anyone living on Block Island, Rhode Island no longer has a physician in the plan they formerly used for their Medicare coverage; all of them were terminated. The same thing is true for a large group of physicians in the Yale Medical School practice group; all terminated without cause or reason.
Do you have to look for a physician who is still covered by your Medicare plan or do you switch plans and go with someone else? A cardiologist, writing on one of the medical blogs online, indicated that years of coordinated care and patient confidence mean nothing now as patients are forced to go elsewhere.
One woman wrote and asked me if she should look for a physician who takes Medicare so that, in the future, when she needs it, she will know she can stick with that doc. There are many answers to that question. For one thing, there is no assurance that the plan she will have in the future will include that physician as we have seen by the onslaught of sudden terminations of docs. Then, too, there are many ways that someone can remain with a doc who doesn’t participate in a specific Medicare plan, doesn’t accept assignment or will see Medicare patients and send the forms to Medicare for the patient.
Some docs won’t take on a Medicare patients and that’s their right. Others will see Medicare patients but will not accept assignment and will bill the patient, but also send a bill for services to Medicare for the patient. So, while there’s no way to guarantee you will be covered completely and that you won’t have to switch healthcare providers, you can still see your doc. Unfortunately, you may have to pay more to do so, but how much is confidence and good care worth to you? Beginning all over with someone new and who you don’t know may not be an appealing option to you.
The one thing I find most objectionable in all of this is not only the incredible terminations of physicians and groups, but also the total ineptness of Kathleen Sebelius, the Secretary of Health and Human Services. The test run and rollout of the online exchanges website is a terrible indictment of her failures in this regard and apologies are not going to wash it all away. When you test a website and it crashes after a few hundred hits in a beta test, you know you have a major problem and I’m no computer programmer but I know that.
It’s too late for apologies, Madame Secretary, what’s done may not be easily or efficiently undone and you bear the ultimate blame here.  As Harry Truman said, “The buck stops here.” If you didn’t understand the technology, you should have educated yourself or your staff should have been up to the task. It appears neither of you were.
In this the 21st Century, there is no excuse for technological ineptness in a most technological age and people should have to bear the consequences of intellectually lazy decisions.

Insanity in the Hospital Room

Many people who have had to have their elderly relatives admitted to a hospital intensive care unit have little or no knowledge of how that environment’s impact can affect the patient. Even some medical staff are poorly trained in this aspect of care and begin to exhibit their ageist bias when they talk about the “dementia” or psychosis now manifesting itself.  You see, if you’re over a certain age and your treating healthcare workers unconsciously subscribe to the notion that with age comes dementia, your goose is cooked.
Mightily trying to stave off the decline that they see, they may begin to administer drugs which are not suited to geriatric patients in the belief that it’s not dementia but a psychotic process that is only now making itself known. Time for a reality check, guys.
Are any of you familiar with the experiments that were done in the 50s where people were put into isolation water tanks with masks for breathing? The exact purpose of this work escapes me for the moment, but I do recall reading an entire book on it. Striped of their clothing, tethered to a breathing hose and mask, they floated freely in warm water in a completely black space. With time, some of the subjects began to experience incredible auditory, visual and even tactile hallucinations in the absence of all sound, vision or touch. One of them even thought someone was trying to pull at his leg to drown him.
If you’d care to see what an experiment like this might be like, get a copy of the Dirk Bogarde film “The Mind Benders” (1963) and you’ll have a pretty good idea. Interestingly enough, after these experiments in sensory deprivation were concluded, someone got the bright idea that this might be marketable. Then came the era of the water isolation tank to help you ease your stress away while floating in warm water. The thing looked like a coffin and I can’t imagine relaxing in one.
Now put yourself into a hospital environment, perhaps in an intensive care unit. What do you know about them? For one thing, the lights never go off and the sounds never stop. Hour after hour, there is clanging, talking, yelling, carts crashing around and perhaps screams of patients. Ever think what it would be like not to be able to sleep or have some rest from this massive stimulation? Well, it has earned itself a name; Intensive Care Psychosis. Want to read more about it? Here’s a link to it:
But it’s not only in the intensive care units (ICUs) that this subtle form of cognitive impairment has an opportunity to stretch its wings. Look in any hospital room and tell me what is missing. Can’t see anything? Sure, there’s a TV (or maybe not), a phone, all the tidy little bits of furniture patients need, but there’s one thing missing. How about a calendar and how about marking off the days so that the patient knows what day it actually is? No, you probably won’t find one.  The simple isolation of any hospital room can produce a disconnect with reality and, in the elderly, it’s misperceived as pathology.
The effects of this isolation, medications, anxiety and sleeplessness, too, can add up to a misperception of “the patient is in denial” when they can’t remember why they’re there or what their diagnosis is. Please, give me a break here. Take heavy-duty meds, mix carefully with the aforementioned and what do you get? Disorientation and memory impairment.
Your task now, should you choose to accept it, is to be the vigilant one who will retain this information and use it wisely in the service of those you love who are hospitalized.

The incredibly blue glaciers of Alaska calve at intervals and as they do, the birds (look carefully) fly up to avoid them.

25 posts! Well, I’m getting there. One thing to remember: No matter what happens in your life, keep going toward your goal. There is no time to be wasted in life and everything matters.

25 posts! Well, I’m getting there. One thing to remember: No matter what happens in your life, keep going toward your goal. There is no time to be wasted in life and everything matters.

An ibis walks on a Florida beach and remains oblivious to the beachgoers.

The Temple of Dendur at NYC’s Metropolitan Museum of Art is in a magnificent glass enclosure with a small pond running around it.

A phoebe built her nest in a most unusual place but guess what? A rival bird tossed her eggs out and left its eggs in her nest for her to hatch.

An endangered red-headed woodpecker at a deserted NJ water pumping station goes about the day as you get to watch.

Take a walk on the beach and listen to the music as it brings some calm into your life. It’s a few minutes that can work just as good as any pill.

Take a walk to the beach and immerse yourself in its tranquility. It’s good for any stressful day. Take a walk to the beach and immerse yourself in its tranquility. It’s good for any stressful day.

Take a walk to the beach and immerse yourself in its tranquility. It’s good for any stressful day.

Get into the mind of a shrink

Beginning Nov. 3, for one week only I have special promotional pricing on my ebook, Fired Up: A shrink’s musings for $.99: