Adding insult to surgical injury
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MY WIFE Wendy recently underwent a routine colonoscopy at a teaching hospital in the Boston area. This effective and sometimes lifesaving procedure can locate and remove cancerous polyps in the colon (intestine). But Wendy was unlucky and experienced a medical injury that only occurs in one of 1,000 patients.
And as the hospital staff struggled to deal with the consequences of that injury, my wife and I got a first-hand look at the difficulty healthcare providers have in controlling patients' pain.
During her procedure, the colonoscope - a long, flexible, lighted tube - broke through the wall of her colon, creating a nickel-sized tear in the intestine. The injury could be seen immediately on the monitor.
That is when her problems really began. For the next 1 1/2 days she suffered from preventable, disabling pain and nausea. The epidural that earlier had numbed her pain became unplugged before the doctors started IV painkillers. We then found tangled IV lines on the bed and called for the nurse, who discovered the line for the painkiller was blocked, but couldn't tell how long the block had lasted.
Wendy's discomfort, drug-induced nausea and retching, which caused searing pain in her abdomen, made it hard for her to move or speak to visiting family members. Her suffering was palpable.
Exhausted after four days without food, she often woke after dozing for a few minutes and attempted to treat the breakthrough pain, fumbling for the button to release restricted amounts of opioids (or trying not to because the drug nauseated her). We asked for new drugs with fewer side effects, but communication between residents and the attending physicians was so slow that it took several hours before orders for new medications arrived.
Unfortunately, Wendy's experience was not unusual. Hundreds of studies throughout the world document that ordeals similar to Wendy's occur in about 50 percent of post-surgical patients.
Several problems contribute to these patients' unnecessary discomfort and poor pain management. One is that overworked doctors are rushed and often unresponsive to a patient's self-assessment of pain. Another is that care of a patient's symptoms takes a back seat to high-tech diagnostics. Interdepartmental communication of pain and drug management problems is painfully slow. In addition, cutbacks in funding and nursing shortages drive hospitals to hire part-time agency nurses. Wendy never saw the same day nurse during her four-day hospital stay.
The result? Poor continuity of care and infrequent assessment of patient comfort and pain. Even though the basic principles of pain management are well established, too often they are ignored.
How can these problems be avoided? There should be more continuous nursing care; more full-time nurses are needed who can work regular shifts. The pace of communication about clinical problems among nurses, residents, and doctors is glacial and needs to speed up. Hospitals need to keep better track of the patient's discomfort - this is so important that accreditation agencies should penalize hospitals that don't check every four hours on the severity of a patient's pain.
Doctors should choose medications carefully, based on symptoms and history, watch for important side effects, and change medications as needed. Treating side effects (such as Wendy's morphine-induced retching) with more drugs may just compound the problem when the solution really depends on a different drug.
At a broader level, doctor attitudes and incentives that favor procedures over humane care must change. Clinicians and regulators need to understand that postoperative pain medications do not lead to addiction, and that patients who experience severe pain take longer to recover and function independently, which raises medical costs. For difficult cases, doctors should consult pain control teams.
For Wendy, it was only after her niece, a surgical physician's assistant, recognized that the morphine might be causing the retching and called a doctor to suggest a different painkiller that our misery began to ebb. It did not have to take so long.
Stephen B. Soumerai is professor of ambulatory care and prevention and director of the Drug Policy Research Group at Harvard Medical School.
