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Counting ‘Dolor’ – Is There A Real Way?

It was a new consultation case from my surgical colleagues for a lady, having pain in the lower back from metastatic colon cancer. She had just celebrated her 40th birthday last week. Being considered inoperable, surgeons thought that the palliative radiation would give her some pain relief. As I entered the room, I was greeted by the patient who has been fighting bravely with her cancer since 2011. She was accompanied by her mother and later on – her boyfriend joined too. My interview with her started with some routine questions about her previous treatments, past medical history treatments – and then I geared towards the actual purpose of her visit of pain assessment.

The basic teaching of taking a pain history is the first thing which we learned in clinical medical school years and almost every medical book explains different kinds of questions about elucidating the pain history in its entirety. Yet, on occasions, I find it to be the most challenging part that is of gathering the history of the patient and taking the physical examination. I started off with the usual questions about pain, its onset, duration, character, frequency, aggravating and relieving factors, associated features, shifting or radiation, and severity (on a scale of 0-10). She was comfortable with all the previous questions, but when I asked her to quantify her pain from zero being the least and ten being the most, her eyes suddenly lost their glim and she was numb for a moment. The next thing she uttered after a pause just jolted me from inside. She inquired if any scale exists on this damn universe that can quantify her pain? What if the pain is much beyond ten? She told her pain begins where our measurements end.

The stage is all set, characters are about to begin performing, there is a knock on the door, I separate myself from my thoughts and sit in the corner of the room over the shelf that is made for retaining the medical examination equipment items, and simply observe the physician inside me, asking questions from my patient. I see my mirror image devoid of emotions, repeating and obliging the sequence taught to him, without pouring his soul and putting in a real zeal. I want to mingle, mix, absorb and extract the feelings of the patient, but I can’t do it. I want to do it, but the ethics and norms of my profession – place the computer screens in front of me and demand the exact quantification of patient’s feelings, thoughts and expectations on predetermined charts and data sheets.

I tell her in percentages the risks and benefits of having and refusing the treatment, I think about all the odd ratios, relative risks, p-values, hazard ratios, Kaplan Meier curves,  the disease specifically, and overall survivals, local relapse and distant failure figures and the facts. I try to elaborate them in simple words. In this whole process of converting ratios into words, I forget to console, mourn, sympathize, feel and express as my soul would want me to do so. The encounter continues, we both perform quite well, we shake hands in the end and depart with a clear agenda in our minds. I now will take an informed consent from her and begin palliative radiation as soon as possible.

As a radiation oncologist, about 30- 40 % of my time is spent in palliating the symptoms caused by cancer. Pain is certainly on top of the list. The emotional aspect of the pain certainly outweighs its physical character. Pain control deserves the best possible care in the world. The suffering should end, both in its physical and psychological aspects. Feeling pain is the first step towards treating it. It demands putting yourself in the shoes of the patient, thinking, analyzing, manifesting, and behaving in a proper way. If we can’t do it practically, we should practice to do it until we become the master of feeling and treating the pain.

It needs a well-coordinated atmosphere involving pain management / palliative care team, titrating the doses of intravenous, oral, subcutaneous or patches of opioids, providing psycho-social and emotional support. Usually we take pain management as an easy task, but its complexity is heightened with multiple co-existing patient factors – including the physical and psychological trauma, side effects from potent analgesics and comorbidities.

Proper referral to ancillary and other supportive services are the key factors in understanding the dynamics of pain management. No tool invented so far has the capability of measuring it, so the overall picture of obtaining history, doing physical examination, ordering minimal relevant investigations, incorporating step wise ladder pattern of analgesics and wisely calling upon invasive surgical or radiological procedures,  and getting the input from radiation oncology becomes integral and important tools in decision making. Early referrals into palliative care -physicians do make a significant difference in managing patients with advanced malignancies.

About twenty non-uniform and heterogeneous group of pain measurement scales available worldwide – currently make the task of quantifying the pain even difficult with the risk of overestimating the pain in mild pain and underestimating in severe pain. The dilemma of properly assessing the pain rather than measuring it, will remain until we stand in the shoes of the patients. Being mechanistic than humane is easier, devising a scale for measuring the pain is much easier, but understanding the true extent of pain is for someone who is going through the pain him/herself. Are healing hands  and soothing words being replaced by measuring software tools available commercially? Aren’t we spending more time on documentation of  pain rather than taking care of the patients needs in fear of law suits?

Will the suffering ever stop? Will the pain in its ultimate shape of agony and disease manifestation is going to cease or surrender?  Can this monster be killed or at least controlled? Our fight is against cancer and all its worldly shapes; most important of  is still a pain. All the tools in this battle of Goliath and David need to be used in proper proportions and albeit, radiation is one of them, the holistic picture of pain control should be drafted before attempting to alleviate it. A good carpenter knows when to strike a nail on the wood at the right time with perfection, so close to a target, yet so much away from his own thumb.




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