Thursday, May 11, 2017

You break it, you buy it

My morning chronic pain consult clinic made me think of this.

I saw 4 patients that morning.  2 of the patients were young men who were cancer survivors.  Unfortunately combinations of surgery, radiation and chemotherapy have left them with disabling neuropathic pain, which in both cases prevents them from working.

Naturally if you read the progress notes from the Cancer agency you will read glowing, back patting descriptions of the success of their cancer regimen.  Both men are going to survive.

The problem is that both of them have severe pain, and nobody really wants to address it.  Despite what you may read in the American and sometimes in the Canadian media, cancer patients actually get quite good care in Canada with a huge infrastructure of nurse practitioners, social workers, psychologists and patient navigators.  If you are dying of cancer, you will go into a similarly endowed palliative program.  This is as it should be; when my cells start acting in an antisocial fashion, I want it all there for me.

If you are "cured" of cancer however you enter the dismal world of the Canadian healthcare system with its waiting lists and silos of care.  Unfortunately if you have chronic pain nobody really wants to take ownership of you, least of all the oncologists and surgeons who caused the problem in the first place.  This usually leaves it to chronic pain "specialists" like me who are stupid enough to still want to see these patients.  We are usually not talking about narcotics here although that is what they frequently need; anticonvulsants or antidepressants are often effective but I frequently see a patient who has gone for the 18 months or so my wait list is, without trialing them at all.

When you think about it, it takes a special kind of sociopath to leave a patient in pain as a consequence of their treatment, (even if they did save the patient's life) and not feel responsible to at least do something to try and help the patient or at least direct him to someone who can.  Back surgeons are of course big offenders in this regard.

Working in my other life as an anaesthesiologist I see the other face.  As I work in a big city hospital, in what could sometimes be seen as tertiary care, a lot of the work we do in OR, is as a consequence of surgery done at other sites, usually out in the country, often by somebody who had no business doing that complexity of surgery but also alarmingly from within the city.  I often pity my general surgery colleagues who get stuck with complications of gynae or urological surgery.  Talking about podiatrists to one of our orthopods is a sure fire way to generate a long rant.

We anaesthesiologists of course get to tag along on these little misadventures because they almost always end up in the OR, usually after hours, occasionally bumping the enjoyable list you thought you had, often in ICU with 20 infusion pumps going or with MRSA, VRE, XYZ etc.  I remember early in my career noting that I had worked until 0400 all on complications of surgery done at other sites.

And we all love to hear of the patient with the post-spinal headache in the ER, who had her baby at another hospital or who had a misadventure with a lumbar puncture.

My chronic pain side is not immune.  I get to struggle with the patients put on megadoses of narcotics by other people, those on big doses of benzos and of course the sloughs from my colleagues who have exhausted their repertoire of lucrative blocks and now want me to manage their patient medically.

Complications are a consequence of medicine and modern medicine is really just a bet that the benefits of the procedure or treatment outweigh the adverse effects, transient or permanent.  This is a bet patients frequently lose.   Sometimes the adverse effects are something we can deal with ourselves, sometimes in the best interest of the patient, some else is better able to deal with it.  It would be nice if there was some mutual respect and communication.

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