Pain Management - Team Approach During And After The Hospital

Hospital Team, ReSurge International, FlickrIn The Hospital, Down In The Dumps

Whenever a serious injury occurs to someone, there is often an associated feeling of being alone - even when family and friends are close by or still in the room with you. It may be a side effect of the drugs being administered to you or something to do with the injuries. Expressing your feelings can be difficult at an early stage of treatment and recovery, but can go a long way towards helping you deal with pain levels. Try to be  more positive in outlook and not dwell  on uncertainties to help keep your brain working in ways that diffuse and reduce pain.

Try to engage the hospital staff a little when your family and friends  aren't around to keep your spirits up and to help avoid getting  depressed about your situation. Should you already have issues with  depression, let your nurses know about it if you haven't told any of the  staff about it. The trauma center will have a variety of people  available to help. You endured a physical trauma and are getting help -  some help for mental trauma isn't beyond their scope or capability.

The Hospital Pain Management Team

At Harborview, there is an actual team of three doctors - two residents and an attending, who come around before surgeries proven historically to be painful and will go over the strategies in current use to help keep you from going over the pain edge. For me, it was the use of the standard intravenous pain meds with the addition of a femoral catheter block. This was inserted into my leg up at the inner thigh and threaded down to the nerves just above my knee to help block the pain signals that come from the repair sites below. From what I have read since about tibial plateau fractures, I'm glad they did the block. It's supposed to be one of the most painful recoveries imaginable without one.

The pain medications are not without side effects. Nausea is a big one for many people, including me. It took a couple of attempts at finding the right combination of pain reliever and anti-nausea drugs to work for me. The first attempts shut off my appetite and I continued to lose twenty five pounds of weight until we hit on the right mix. There is something to the old sage advice that a little extra weight isn't such a bad thing. Had I been at what I used to consider my ideal weight, I don't know how much weaker I would have become with my body using up more muscle instead of fat. Good thing I was a bit chubby, I guess.

The i.v. drip pain meds today have a controller that is a bit like the buttons used on "Jeopardy". Using this system taught me to identify the onset of pain when the medications would begin to wear off and the need to watch the clock to see how much time I would get from the dosage controller. It was set up to allow the patient (me) a dose every 15 minutes as needed, with one push of the button.

Pushing it more often or more times within the 15 minutes didn't work. This teaches one to pay attention to one's body signals, the machine and the clock.

Thanks to that infernal machine, I can now pick up on subtle clues that tell me it's time to grab some ice and Tylenol before the pain goes nuclear.

Stay On Top Of It

You may have had someone tell you about the difference in pain control when they either skipped a dose or waited too long to take something for the pain. It's true - heading it off at the pass, cowboy-style, does help keep it down to a dull roar. Once you let the pain get beyond control, it becomes much, much more difficult to reign back under to a manageable level.

Specifically, what I'm referring to is pain that started out as a twinge, a dull ache, or even a momentary pop, that then turns into a raging pain monster refusing to let go of your leg, arm, back,or whatever is ailing you. Keeping on schedule with RICE (rest, ice, compression, elevation) and your medications , as well as learning to identify the onset of serious pain and to deal with it in a timely fashion is the way to keep on top of it.

Don't Overestimate Your Strength

Before and after surgery you will be told what to expect in the way of recovery time estimates and how your progression though the different stages of recovery might go. The best advice I can impart to you at this point is to be acutely aware of weakness in the legs and back. You culd very easily injure another part of your body just when you need it the least.To enable my bones to start healing properly, I was non-weight bearing ( no weight whatsoever) on the repaired leg for three full months. After that, I was allowed gradual 25% weekly increases, while still using crutches. So, quads? What quads? The muscles that help stabilize knee joints were basically gone. I had to be extremely careful to not twist the leg when beginning to put some weight on it, and so should you if you find yourself in a similar situation. Yeah, it is necessary to push yourself a bit to improve and build strength, but don't be stupid about it. It takes time.

Here Comes Physical Therapy

In my case, the doctors had to bolt together a good portion of my lower leg. 

Due to the high energy impact nature of the crash, the parts list of stainless steel screws, bolts and internal fixator was quite long, indeed (On more than one occasion, the x-ray techs at followup appointments missed getting a picture of the entire assembly since they rarely see one as big as the one that's a part of me now). A level VI (6) on the Schatzker scale tibial plateau fracture repair can have a high complication /failure rate, so physical therapy is no joking matter. You have to do it and do it correctly.

In order to keep your knee joint from freezing up and having significant loss of range of motion, many hospitals will start you on a CPM (continuous passive motion) machine right in the hospital bed. The idea is to get you moving the joint as soon and as much as possible before scar tissue starts to interfere with motion. The CPM machines kind of worked for me, allowing me to maintain a real range of about 48 degrees on the repaired leg. This in contrast to my other leg at 140 degrees.

When I started P.T. in earnest at the 48 degree point, every single movement was a challenge. I was still on crutches, non-weight bearing, with the hinged brace off for the sessions. Just doing simple stretches, then a few leg lifts was enough to have my leg remind me I was alive. (Yeow!) Looking back, it hurt but was absolutely necessary for me to be able to walk again without dragging my leg behind me. It took months, but I'm walking with only a small limp and can move my leg beyond 112 degrees. Not perfect, but I still have the leg.

Yay, Team !

You, your family, your doctors and nurses, and physical therapists all have to work together in order for a successful outcome after a major surgery or surgeries. Communication between everyone is a critical component to avoid relapses, re-injury or more surgeries. If you notice that something isn't working or there are differing opinions on how to proceed in your recovery, stop the show and hash it out. Get up to date information and make informed decisions. It's your body and you have the final say on what to do with it. It's your team and you are allowed to make substitutions where you deem appropriate.

No more sports analogies for now, I promise.

Dave

Shoreline,WA

Injuries from Motor Vehicle Accidents: What is a Trauma Center? Why Should I Care?

Emergency Room, Chealion, FlickrWhere should I go?

When I had my motorcycle crash and received a severely broken leg, I had no idea that the hospital I had chosen to be taken to for treatment was a level IV trauma center. Nor was I aware that Washington State uses a 5 level rating system for the various hospitals/trauma centers associated with these hospitals.  The trauma nurse and doctor at Northwest Hospital looked at my x-rays and discovered that they were going to stabilize me for transport and that would be about it. I was going to need much more surgical specialty personnel than was immediately available for them to muster. Oh, joy.  Another ambulance ride.

The pain from being moved around for a dozen x-rays was getting to the point where medications alone weren't effective and it was time again for distractions and daydreaming - taking my brain away from the pain, like with the Shoreline paramedic talking with me about my once- beautiful bike (Grrrrr!). Yup, that worked and now that I know it will only work for a couple of minutes, I started thinking about trips my wife and I have taken - standing on the observation platform atop the Eiffel Tower in Paris, gaping at the Crown Jewels in the Tower of London, watching humpbacked whales in the Strait of Juan de Fuca ; the vivid, Technicolor type memories that are forever etched in your mind. Those memories are the ones that seem to work best to push pain down and away. I still felt it, but the pain was much more tolerable and allowed the medications to work better.

Trauma Center Ratings

Level V (5) is the lowest rating for a Washington trauma center and level I (1) is the highest. If you live in Washington, Idaho, Montana or Alaska and need a level I trauma center, you will be going where I wound up - Harborview Medical Center, Seattle, The State of Oregon has two level I trauma centers in Portland to help cover that state and SW Washington.

The trauma center with a level I rating is going to have 24/7 staffing and on-call availability of every specialty doctor, nurse, anesthesiologist, and technician that severely injured people might need, including burn and plastic surgeons.There will also be on-site most diagnostic and imaging devices these specialists will need to help fix you up.  In my case, it was for the orthopedic surgeons. (Yay, HMC Green Team!) The centers with levels II, III, IV and V will triage patients, and if they can be stabilized, they will send them off to a higher level facility that will have necessary staff waiting or on the way when the transferred patient arrives by ambulance or helicopter. There are many rules of triage and transfer these trauma centers follow and these guidelines vary from state to state. Look up specifics for your state or states you're likely to travel through as part of a pre-trip planning guide. It could help steer you towards a better choice and eliminate unnecessary transferring. And unnecessary pain.

Triage at the Trauma Center - Three Days Without Food

One thing to keep in mind about trauma centers is that they are very busy places, indeed. The Friday I crashed was the day before the Seattle Seafair festivities began and man, was that hospital busy. Remember I mentioned triage?

If your condition is relatively stable or can wait for treatment, you will probably wait. Here's where the letting your mind wander technique can help, especially if you're bored with watching tv or there's no tube where you've been stashed. Once a code blue is called on your floor, you will have to wait for more pain meds until the emergency is over and your nurse is freed up. You may have to deal with the pain one on one, using the power to reduce pain your mind has built into it - you against the pain beast. Kick the beast where it hurts, but remember to stay calm, relaxed,centered, sitting on the beach or wherever it is you choose to go.

The nurses called it "getting bumped" or as I found out, no food for three days.

Each time I was scheduled for the first surgery to install an external fixator (lovely piece of equipment - Google it to see examples), someone more seriously injured would come to have their life saved. Usually. Not everyone who made in in survived. I didn't have anyone die next to me, but a temporary roomie did.

Once, I made it as far as having the surgeon initial my leg and have the sleepy-time guy go to get the good knockout drops when Nurse Killjoy came in again to bump me. No ill will towards those bumping me, but three days without food made me a little cranky. Seafair weekend in Seattle gets a lot of torn-up people into the hospital, and depending upon what is going on at the time you're ever admitted to a trauma center, be prepared to wait.

Distraction Pain Control

Practice a little distraction pain control at home before you really need it.

Practice controlling your breathing and breathe like an opera singer - slowly, from the diaphragm, up and down, not in and out. I got pretty good at it and found that I could slow my heart rate quite a bit and lower my blood pressure (being hooked up to monitors made it easy to quantify). You can learn how to do it, too, Use it to work on relaxing pain away a little at a time, one spot at a time.

Dave

Shoreline, WA

My Motorcycle Accident: August 6, 2010

Motorcycle Accident, akeg - Eric Schmuttenmaer, FlickrHello and welcome to my eventful day on August 6th, 2010.

The ferry ride back to Seattle from Bremerton, WA was relaxing. I had finished paperwork generated from a day at the Puget Sound Naval Shipyard and was enjoying the sunny weather.
The Navy has a variety of fire suppression systems that I install, maintain and repair as needed.Sorry I can't go into more detail, but then I'd have to...you know.

Once back at the shop I worked from, I hopped aboard my 2007 Yamaha VStar motorcycle - my pride and joy machine. We took trips over Chinook Pass to Yakima, rode the Cascade Loop over the North Cascades into Twisp, back around to Wenatchee, and generally all around the state of Washington.

Around 5pm, August 6th, I was nearing home, going into a banked curve when a car suddenly stopped in front on me. The bike was already into a lean to the right when I had to brake - straightening up was not an option as that meant going head on into several cars and trucks in the opposite lane.

 The bike started to slide and slow as the car in front of me started moving again. We never made contact, but the front tire of the bike did come within a foot or so of the car's rear bumper as I noticed the front fork start to bend. (This is happening in real time of two seconds, maybe three) As I am trying to control the slide and see the fork bend, something on the side of the bike catches on the pavement and snaps rolls to the right incredibly fast. This is probably where my right leg was subjected to at least 600 lb-ft if force, since it takes a minimum of that much force to break the bones I did that day.

The car takes off , never to be seen again. A small black import - Acura, Honda, something similar. I didn't get a plate number since by the time I stopped skidding, rolling and bouncing, the car was out of sight. Jerk.

Rolling out of the traffic lane, I looked up and saw a car behind the scene stopped police-style, and was blocking cars from proceeding to smack into me and what was left of the bike. I thanked him for stopping and we decided that he would watch for inattentive drivers while I called 9-1-1 to get help.(Thanks again, plumber-man!)

I looked back at my formerly beautiful bike and then stood up. Oh.  To say that was a bad move is an understatement.

Standing there, glancing down at the lower right leg below the knee bending the wrong direction, I realized that I wasn't going to be running after the little black car and sat down.

A battalion chief from the Shoreline Fire Department arrived on scene first and took control. Police cars and the paramedics arrived a minute later. Fast response times and  professional attitudes every step of the way, guys. Thanks to you, all, too.

Thanks in part to the armored suit I always wore (and a good helmet), I had no other significant injuries. There were some friction burns on my arm from heat transfer through the suit where there was not an armor plate and a cut on my pinkie where a glove ripped. Nothing too bad -  besides a tibial plateau fracture and a broken fibula. In other words, my right leg was broken in 8 places, and some of the bone was pulverized, too tiny to count.

While being loaded in to the aid car, the medics asked where I want to be taken for treatment. Had I known what I now know, my choice would have been to go to the Harborview Medical Center, which has a level I trauma unit. I didn't know at the time that my first choice of hospital could not treat my injury and  that they would only stabilize me for transport to the trauma center.

The next portion of the saga will cover what to do now that you have had a serious accident and why thinking ahead before it ever happens can help save you from experiencing more pain that you need to endure.

Dave
Shoreline, WA