Part III of V, Pain Management
Portrait of a Recovery Derailed – Opioids and Knee Replacement
Perhaps I need to begin this article with a reminder that this is a personal journey and I make no claim that my conclusions are based on empirical research. Pain Management is possibly the most crucial aspect of the recovery process with any surgery. Effective pain management is the first layer of building that trust relationship that allows the patient to be an active partner in their own healing from the inception. Sound feedback from a coherent patient i.e. one with minimal pain, allows ease of communication for each layer in the patient care chain to meet and ultimately anticipate patient needs. This facilitates trust not only for the initial personnel attending the patient, but also for the entire process of healing – patients are more willing to be guided and share their concerns more readily. Recovery times are thus significantly reduced and the patient emerges from the experience with a positive view of medicine and medical practitioners.
Flexibility and Open-mindedness
I have very low pain tolerance which was discussed with my doctor beforehand. By the morning after surgery when I am begging for pain meds before they are due, my doctor could very quickly adjust the pain regimen because it was something he might have anticipated. But no two patients will react the same way to pain which essentially makes it a moving target when it comes to establishing and managing benchmarks, and knee replacement is one of the most painful surgeries. This is not to scare a prospective patient but to present realistic expectations as well as a glimpse into some of the attendant issues. This article is, however, to illustrate the importance of flexibility and open-mindedness in managing pain. Moreover, the importance of the trust relationship cannot be overemphasized because openness and honesty about needs, expectations, and fears offers valuable information to provide the best care. In a patient-centered culture, care begins with the patient and all expertise and information converge to meet both medical and emotional needs as they relate to healing. This makes pain management an area that remains critical in post-surgery care.
Rehab Derailed (My Issues with Opioids and Knee Replacement)
My post-surgery care plan included a brief stay at a skilled nursing facility because I live alone and needed to be steadier on my feet before I was left to my own devices. But not all facilities embrace the patient-centered approach and I was not so wise about those differences before my surgery. I chose a rehab center based solely on its proximity to my daughter’s college campus to facilitate her visits. What I failed to do was to visit the facility beforehand to get a sense of the culture. I hope no one reading this makes such a mistake. On arrival at rehab, with the X10 machine and two recovery coaches to set things in motion, I was seen by an admitting physician who looked at my transfer notes from Meritus Hospital and immediately reduced my pain medication drastically. I experienced some trepidation because she shunted me from two pain meds – one at 12 hour intervals and the other at 3 hour intervals to only one med at a 6 hour interval.
I knew that given my history with pain, to suddenly veer away from my particular pain management regimen, which had evolved to a certain comfort level over time, was going to present a challenge. I was by no means pain-free but the pain was manageable. Even a lay person could recognize that such a drastic stepping down of the pain meds would present an exponential increase in the pain experienced. I voiced this concern to the doctor pointing out that we were doing two stepdowns – eliminating one medicine, and at the same time, widening the interval on the other. I asked whether we could not do the stepdowns one at a time and eliminate the 12 hour pill but leave the three hour interval on the other medication intact in the short run and revisit in a few days. The doctor refused to even entertain the notion. I had serious questions about whether it was ethical to make a radical shift in patient medication on the first day of entry into a new facility, or if it was legal for that matter. But I tried to steel myself to take whatever comes.
I am willing to concede that I was indeed “spoilt” by the level of caring both at Dr. Salvagno’s office and at Meritus Hospital. There was commitment to my healing, my comfort, my health and my well-being in a manner that spoke the true meaning of total patient care. Moving to this rehab center immediately felt like I had stumbled into the twilight zone. Over the next week I was to discover a culture so divergent from what I had come to expect that it was disorienting. From an environment of professionalism, empathy, and consideration I was now in an atmosphere that was essentially characterized by the “doing my job” philosophy which meant that care was a feature of “how things are done here i.e. routines designed to achieve pre-determined outcomes within specific time-frames without factoring the individual needs of the patient.
Throughout that first night (Thursday), I was in excruciating pain made more acute by the fact that even after a six hour medication interval, the medication was brought a half hour to one hour late. A really good and capable physiotherapist attended the next day to begin my rehab. I had not slept, I was in pain and tearful, my blood pressure was way above normal, and I was terrified of her touching my leg. This was the first inkling that I was now riddled with fear of anyone getting near my leg. She was creative and compassionate and spent way more than the allotted time with me trying to find some strategy that would relax me sufficiently so that we might get to work. We did manage to get some basic exercises done but I could do nothing with the knee except a brief stint on the X10 machine. When I left the hospital, I was bending my knee at a 63 degree angle. One day later, I was bending at 45 degrees and no more. I asked the physiotherapist to speak to the doctor about adjusting the meds.
A young and very knowledgeable occupational therapist visited in the afternoon. Since I was able to manage a sponge bath myself and get dressed, there was not much for her to do except try to make me comfortable and give some valuable advice on care issues. I again asked that she speak to the doctor about my level of pain in order to have the regimen revisited. By Saturday it occurred to me that the only way to have any kind of relief from the pain was to stay ahead of it. We could not allow the pain to take hold and then medicate because then the meds only took the edge off, and for at least four hours to the next dose, I was in agony. I don’t remember many details about Sunday but my X10 recovery coach who is based in New York City from where we are set up for intense telephone direction and guidance, tells me that I was on the telephone to him in tears asking him to come to Maryland and get me out of there. Needless to say I did no rehab work on Saturday and Sunday, at a most crucial period in the rehabilitation process.
In Part IV Merlin continues her gripping narrative of her fight through pain management (opioids and knee replacement) after her surgery. She will explore the trauma that resulted from poor pain management.