How long can pain relief last after the procedure?
How long can pain relief last after the procedure? This is a very common question and I have been asked many times. Almost every patient asks me the same question. How long can the pain relief last after a procedure? It really depends on many factors, majorly three as follows:
1. What problem or disease does the patient have?
2. How severe is the problem or disease?
3. What does the patient do after the pain has been resolved or reduced?
We cannot control number 1 and number 2, because what the patient has is what the patient has. However, we can control number 3: What does the patient do after the pain relief or reduced? This factor can decide how long the pain relief can last. If patients do a lot of heavy duty work with heavy lifting and carrying after the treatment, after the pain has been resolved or reduced. The pain may come back earlier.
For example, a construction worker may constantly be bending forward, do liftings and carryings. Those people may have the pain come back earlier. For example I had a patient who had a good pain relief after three (3) lumbar epidural steroid injection. Several months later, I came across him in Home Depot. He was carrying a door and windows. I told him, “Don’t do it.”, but he said he had no choice and then I told him you’re gonna come back soon and he did come back several months later with recurrent disc herniation.
On the other hand if people do office job, most of the jobs that do not demand them to have a lifting, carryings or bending forward. They can do much better than the people who do heavy carryings and liftings.
Therefore education is very important after the treatment and during the treatment. For example, if a patient has a lower back pain due to the disc herniation, after treatment, the pain is resolved. I always have a follow up with them and do some education. I discuss with them what they can do and what they are not supposed to do. For example, I advise them to never bend forward when picking up anything on the floor. I advise them to bend their knees to pick up things on the floor. Another thing is I advise them not to do heavy lifting or carrying. If they have to do the lifting or carrying, it has to be lightweight and it has to be close to the body. In that way they can reduce the pressure on the disc.
Two Things You Have to Constantly Remind Your Physician
Two important things you should constantly remind your doctor in my opinion, your allergy and side of the problem when you have surgeries or procedures.
Allergy especially fatal allergy can be dangerous to you. Your doctor is responsible to remember that and try to avoid any thing or any medication to cause the allergy. However, your doctor may forget it. He or she orders the medication you are allergic to. It happens more frequently in the hospital setting with many doctors who don’t know you well. It also happens in your doctor’s office even though your doctor knows you well even though it does not happen less frequently. That is one of the reasons why there is a big red label in patient chart, said allergy to penicillin etc. when a doctor gets the chart, the first thing in his vision is allergy. Medical record system is evolving. We are getting rid of traditional chart system i.e. paper chart and charging to electronic charting system. There is no such big label in the chart anymore. This can be potential problem in the near future.
One day I was doing procedure for one of my patient. The patient was lying on the table and equipment was ready. I was about to put gloves on, my patient reminded me of his allergy. He said “Doc you know I’m allergic to latex”. I looked at the gloves I was about to put on. It was regular gloves my assistant prepared for me. I know he is allergic to. However, I did not remember or did not realize it at that moment. I am very glad that the patient reminded me of that. We avoided an incident. You know what I did. I throw the regular latex gloves away and changed to non-latex gloves. What if the patient did not remind me? I may realize that I put a wrong pair of gloves or may not. Then who is going to suffer, the patient! The patient has only mild allergy i.e. rashes. What if the patient has fatal allergy for example, swelling throat and stopping of breath. There are two implications. It’s good for the patient to remind doctors of their allergy. On the other hand, he did a little late. He should remind anyone he met that morning when he had the procedure. He should tell my assistant in that morning. Then he had more chance to avoid the incident.
Side of our body is also easily confused. Some people have problem to figure out which side is left and which side is right. It’s also easy to forget or confuse which side the problem the patient has.
There was a report in a newspaper several years ago. A lady has woken up after an amputation surgery. She touched her good leg. It was gone and she touched her problematic leg. It was still there.
I remember I went to an unfamiliar place with one of my friend. I was the driver and she was the navigator. That was the time we don’t have GPS. Very frequently, she said we should turn one right side, but she pointed to the left the other side. It happens in the procedure rooms too. One day I was about to do the procedure for one of my patient I asked her “which side do you have pain. She said, on my right” and she pointed on her left.
I always confirm the side with patients before I do procedures. Sometimes I ask patients several times to make sure I do the procedure in the right side. Some of the patient can be annoyed occasionally. One patient said to me “did you write down which side I have pain” my answer to him was I may put wrong side in my chart or my typist may type wrong. That was the reason I try to confirm with you again and again.
I remember my encounter with a Gastro Intestinal physician. I had had acid reflux over past several months. I took ______ It help somewhat. I ran out of it. Therefore, I went to my friend’s office to get some samples. Unfortunately, he ran out of _______. Fortunately, he had ________ control release and advised me to take it once a day. I was very healthy generally speaking. Only one problem I had was acid reflux and only one medication I was on is ______. However, I can’t remember the name of medicine I took when my Gastro Intestinal doctor asked me what medicine I was taking. I am a physician. There are thousands of medicines we are currently using and there are hundreds of new medicine coming to the market each year. I, as physician dealing those medicines day in and day out. I even can’t remember some of the names of medicine. How do you expect other people to remember the names of medicines?
Medical history is very important. Many patients in front of physician don’t know what to talk. They don’t know what to tell their doctors. They can’t remember what medical problem they had before and what medications they are taking. Actually, what doctor want is simple. We need whole history of the patient. It includes history of present illness, past medical history, past surgical history, medications, allergy, social history, family history and range of motion.
Physicians generally follow steps to get patients information: history of present illness, past medical history, past surgical history, medication, allergy, social history, family history and range of motion. Doctor is to do physical examination.
Generally speaking, there is 3 steps when a patient sees a physician: collection of information from patients, performance of physical examination and then discussing of diagnosis and treatment plan. The purpose of these 3 steps is to get entire history of the patient. It will be hard for doctors to make decision. For example, we can’t use some medication if a patient has certain condition. We can’t prescribe any NSAID if a patient has history of stomach ulcer or stomach bleeding. It can be dangerous, the patient can be dead due to bleeding due to the side effects of NSAID.
A patient saw me first time. He sat in front of me. I asked him what medical problems do you have? I don’t know he said. What medicine are you taking? “ I don’t know” he answered. Are you taking any medication for your medical condition? This is common situation. What I can do is very limited in this situation. I can’t prescribe any medication for this patient. Interaction of wrong medications can be dangerous.
Clinical Thinking From Data to Plans
Doctors have been trained to use problem-oriented record system to collect the data, process the data and make decisions. It is helpful if a pt know how the doctors think. It can make the pt-doctor encounter more efficient and more accurate. What is problem-oriented record system? You can see it from the words. It is a problem-focused way to collect the data, analyze the data and make a decision.
There are three components for problem-oriented record system:
Database- collects the data.
Assessment Process – is the thinking process. After the doctor get to the data, the doctor has to analyze the data.
Plans – what the doctor will do or perform to the patient.
There are two types of database: Subjective and Objective Data
Subjective Data – information doctor collected from patient, family members or significant others. This is what the pt tells to the doctor.
Objective Data – It is objective. It includes physical examination and laboratory reports.
This first part – physical examination- is how the doctors observe the patient. They try to do problem-oriented physical examinations.
The second is Laboratory Report – includes blood tests, urinary tests, some imaging studies, such as MRI, CT Scans and X-Rays.
After the doctor collects all those data. Doctors do analysis based on the data gathered. It is called the Assessment Process. In this process, basically, it is the analysis and the interpretation of the database. There are two things doctors have to identify the problem i.e., diagnosis. For example, if the patient has a disc herniation or a joint problem. Also, the doctor will identify the patient’s response to the problem of illness, which is the emotional part of the patient’s response. When the patient has severe pain, it can be associated with stress, nervousness, and depression if the pain becomes chronic or lasts long.
After this thinking process, the doctor will make a plan. Plans include three portions:
This planning basically is what the doctor will discuss during the last portion of the patient-doctor encounter. For example, a patient has a disc herniation, this is the diagnosis. The treatment plan could be pain medications, physical therapy, acupuncture, etc. And then the doctor can explain to the patientt what is disc herniation how to treat it and how to prevent it.
A patient has a scratching throat and stuffy nose, which is the subjective data from the patient. The doctors examine the patient and finds out that the pt has a swollen nasal mucosa and redness of the pharynx. So this is the objective data; it belongs to the physical examination. The doctor, at this point, make presumptive diagnosis. In which in this case, Paranasal laryngitis. The doctor may order lab tests, such as throat culture. That is basically the second part of the objective data, the laboratory tests. Then the doctor will form a treatment plan. The doctor may prescribe decongestant for stuffy nose. And then the doctor will educate the patient, he may briefly review what upper respiratory infection is, what are the causes and what are the modes of transmission. In that way, the patient will have a complete picture of what he or she has.
Another example, a young person having severe lower back pain radiating down to the leg- this is subjective data. The physical examination and observation of the doctor, the patient is unable to move his or her lower back. He also has severe pain with some position changes. And then in the examination, patient is unable to bend or move his back, he may also have a decrease sensation in one or both if his legs. Doctor may order MRI and it may show some disc herniation. However before the doctor order MRI, he has presumptive diagnosis or writing. This is a typical signs and symptoms of disc herniaton, so the imaging test may confirm the diagnosis of the patient. For this patient, he may have lumbar MRI and it may show disc herniation. That is basically the database collection process. Then doctors do the thinking and the make the plan, for example the diagnosis for this pt is acute disc hernaiation . The treatment plan will include pain medications, Physical Therapy, AC; sometimes, lumbar epidural steroid injection. And last is the education, the doctor will discuss what disc herniation is and how it may occur. Also, because the acute pain is often associated with stress or nervousness, the doctor will explain that the acute dicsc heriation may be resolved within two to four weeks most of the time. In this way, the doctor may reduce the patient’s nervousness.
Doctor thinking is different from patient thinking. It is analytic, and they are trying to find underlying pathological process. For example, if a patient has pain in the leg. The pt will say he has sciatica. Patient can basically jump to a conclusion; I am not trying to blame patients for that because patients do not have medical trainings. However, the doctors have medical trainings; Doctor’s Thinking is completely different. When the patient say he or she has leg pain, the doctor may think about several conditions, such as, musculo-skeletal problems, nervous system problem or peripheral vascular disease. Then the doctor will continue to differentiate one to the other according to the other information, for example, some of the physical signs from the patient like a mild, aching lower leg with a swollen ankle at the end of the day, which would suggest venous problem, meaning problem with the veins. If the problem is in the joints, it means the patient has musculo-skeletal problem. If the pain is shooting down to the back of the leg to below of the knee, that is a suggestive of a pain originating in a nerve root. If the doctor gets additional information like varicose veins of blood clot in the veins, plus aching leg with swollen ankle, that is equal to venous problem.
Features of Pain
There are several features of Pain:
Location – Where is it? Does it radiate?
Quality – What is it like?
Quantity or Severity - How bad is it?
Timing - When does it start? How long does it last? How often does it come?
Settings in which it occurs, including environmental factors, personal activities, emotional reactions or other circumstances that may have contributed it to the illness.
Factors that make it better or worse
Doctors follows those features and collect data from patients and organize the data in this order. For example, A patient with low back pain. The physician is going to get all the information above. The discription can be as follows:
The pain is located in the low back pain and it radiates down the right leg (location). The low back pain is dull aching and sharp (Quality). It is severe (severity). It is intermittent (Timing). The pain started while the patient lifts a heave object (Settings). The pain gets worse with standing walking and better with lying down and sitting (Factors that make it better or worse). It is associated with depression, stress and anxiety (associated menifestations).
There are features that are very important for doctors. Doctors depend on these features to figure out what problem the patient has. It is also important for the patient. If patient know all these features then it will be very helpful for doctors to understand his or her problem. So let us talk about these features in detail.
Location – It is a very important for the real estate. It is also very important for the doctors. Location will tell us a lot. It tells us how to locate the problem. For example, if patient has back pain and it radiates down to the leg, we know that the patient has back problem and it pinches the nerve. So the location is the number one important feature of the illness or symptom.
Quality – We should answer what is it like. For example, if the patient has pain and it is aching down. We know it is musculo-skeletal problem if it is in the leg. However if a patient tells us it is numb or it tingles or there s a burning sensation, that means the patient has a nerve problem. That means the pain comes from the nerve.
Quantity or severity – How bad is it. Is it mild, moderate or severe? Many doctors use numbers for patients to describe their pain. Zero is no pain at all, and ten is severe pain. So from zero up to ten, the pain can be classified into different categories. That can give the doctors an idea how sever the pain is.
Timing – When did it start? How long does it last? How often does it come? These are very important questions for the doctor. For example, if a patient has a heart attack, we want to know when did start. Did it start at night or in the day time? How long does it last? If it is less than five minutes, we know it is angina. It may not be as severe as for the pain lasting for half an hour. When the pain lasts for about half an hour, the patient may have heart attack, which is myocardial infarction. How often does it come? If it comes very frequently, that makes the condition very severe, but if it comes only once year that may not be a big deal. So the patient should prepare all these before they see the doctors.
Settings in which it occurs – These settings include environmental factors, personal activities, emotional reactions or other circumstances that may have contributed to the illness. If the chest pain comes from emotional stress, and most likely it is due to coronary artery disease. If the patient bent forward to pick up something on the ground and suddenly got severe pain and couldn’t move, that means the patient may have disc herniation in the lower back. Those things may give doctors a clue what is going on with the patient.
Factors that make it better or worse. This is also very important. If sitting or lying down makes it better and standing and walking makes it worse it’s more like the problem with bearing joints like, knee problems – knee osteoarthritis, knee arthritis or back arthritis, or ankle arthritis. All those can make the pain worse when the patient stand up or walk.
Associate to the manifestations – For example, the chest pain may be associated with nausea and vomiting or dying feelings, if the chest pain is associated with dying feelings the patient may most likely have heart attack. That will be a more serious problem. Doctors use all these features to classify or analyze the patient’s data and then form a plan. Doctor’s thinking is different from a patient, doctor’s thinking is analytical and they are trying to find any underlying pathological process. Doctors use all these seven features to analyze the patient’s condition, and then form a plan. For example, a patient who has back pain radiating down to the leg, it means the patient has some back problem, like spinal stenosis, arthritis, disc herniation, and those pathogens irritated the nerve and made the pain radiate down to the leg. If the quality of the pain is numb and tingling in the leg and the aching is radiating down to the back, that means joint or body tissue pain and the leg pain is caused by the nerves. It will tell a doctor what organ has the problem. Severity of the pain will tell the doctor what action he should take, should he give pain medication right away, or should he wait. What pain medication should he give, should he give strong pain medication or just some mild pain medication with some anti-inflammatory features? Timing is very important; it can tell us the severity of the problem. If the pain is radiating down to the leg, basically that means the nerve is irritated, that is a mild problem. However, if the patient has a sever leg pain and is constant, that is serious problem meaning something has been compressing the nerve constantly. That is the reason why the patient has constant pain.
The setting in which it occurs. As I have just mentioned, if this pain happened when the young person bent forward and picked up something from the ground. Most likely this patient has acute disc herniation. If this is an elderly person and that the pain happened when he walked, most likely the patient has arthritis or spinal stenosis. It also ca give us a clue what problem the patient has.
Factors that make it better or worse. – For the disc herniation, commonly, sitting makes the pain worse and standing or walking makes the patient feel better. However, if the patient has arthritis, the pain can be worse upon waking up; the pain will be better after he or she gets up, walks around or takes a hot shower. All these can give clues to the doctor.
Associate the manifestations– What the emotional response to this problem from the patient. If the patient has acute pain, the patient can be scared, nervous or stressed out. However, if the patient has chronic pain, the patient maybe depressed. The emotional responses can be different. Also, if the pain is severe enough, the patient may also have nausea and vomiting or other symptoms.
So, if a patient does his homework and prepare all the answers for these questions, the doctor will appreciate it because it can make the interview run smoothly.