Getting through it

Some of you may know that I’ve just had surgery, and I’m gently recovering from the comfort of my own home over the next few weeks.  Posts on here will be intermittent but I find myself considering aspects of pain management from a ‘patient’s’ perspective today as it’s about 5 days since surgery and my brain is starting to unfog.

I had good pre-surgical analgesia – couple of paracetamol and midazolam – and excellent post-surgical pain relief, a combination of anti-inflammatories, codiene and paracetamol.  I also had oxygen for about 24 hours, and a drip.  Yummy stuff.  I had wonderful nursing staff who checked regularly that my pain relief was adequate – and yet despite all of this, I had several hours of feeling really horrid.  And yet I coped.  I’m trying to use my self as a subject here, to work out what I did to get by – so for what it’s worth, this is what I think I did.

1. I reminded myself that this pain is probably gas not tissue pain.  As a result, although it felt awful it wasn’t like I was worried that stitches were popped or anything.
2. I breathed.  I breathed out a LOT, and relaxed each time.  And you know what? It worked!  Each time I found myself tensing up I breathed out and relaxed AGAIN.
3. I sipped water.  Not sure why, not sure how, but it helped!
4. I noticed parts of my body that weren’t hurting and tried to really FEEL them.  The pressure of the sheets on my legs, the textures under my fingertips, the difference between warmth and cool on my arms where the sheets were and weren’t.  My toes.  Letting go muscle tension where I could.  Feeling the sensation of air entering my lungs and escaping as I breathed out.
5. Strange, but I compared this pain with the pain I’d had the surgery for – and it wasn’t a patch on what I’d been coping with!  OK that pain was a day or two at a time, but it was pretty intense – this pain was not nearly as intense and I knew it was going to go, and why it was there.
6. I talked myself through each moment, rather than looking ahead or trying to predict what might be.  I tried to stay as much in the present as I could.  And just breathed.

I had read through my pre-surgery printed material.  Lots of information on altered bowel habits, on the amount of lifting I was allowed to do (nothing more than 2 kg!! and NO vacuuming or pushing grocery trolleys!), on the need to rest after surgery, and strangely, suggestions that I might feel saddened or grieve for losing that bit of me (and the potential to have babies).

Nothing at all on how to use pain relief after I was discharged from surgery.  Nothing on nonpharmacologic coping strategies – like the ones I used most often.  Nothing on anxiety, hypervigilance, breathing, positive coping statements, mindfulness, relaxation – zilch.

The things I do remember that helped (aside from the six points above).  The warmth of the surgeon’s hand on mine as I was prepped for surgery and slipped into anaesthesia-land.  The warmth of the blanket that they placed over me as I was wheeled back to my room.  That chilled water.  The nurse stopping beside me and looking in my eyes a moment before asking me how I felt, and waiting while I replied – all the time in the world just for me.   The feeling of clean smooth sheets.  A warm flannel to wash my face and hands with – bliss!  One of the nurses saying ‘you don’t have to feel pain, there is pain relief there for you’.  And another saying ‘there is plenty of time, you don’t have to rush’.

Well, you know me, I’ll find an article to ponder over if I can, so here’s one that I thought made some interesting points about post-operative pain.

This study is a qualitative study of women’s experiences after cardiac surgery – some points to note right off.  Firstly, more women than men complain of post-operative pain than men – curious but not unexpected.  More women than men complain of pain at all ages from puberty until menopause.  Secondly, pain experiences depended on what women’s expectations of pain after cardiac surgery were.   Thirdly, early discharge requires increased patient participation in pain management.  It’s that one that I think could be much more emphasised!

The findings indicated that women described four aspects of the pain experience – location, quality, consequences and cognitive aspects – the latter dealing with ‘expected pain’, ‘unexpected pain’ and ‘devaluation’.  Cognitive aspects were the women’s judgements about having the pain, and included thoughts that the wound pain was ‘expected’ or ‘something to be endured’, whereas ‘pain in the neck, shoulders and back was described as more worrying than that from the surgical wounds’.  This in part because it hadn’t been expected to be so intense.  Notably, women downplayed their pain apart from acknowledging the interruption pain had on their everyday activities.

I was curious to read that self management included receiving instruction on how to use medication – and that women wanted more individualized information on pain management, rather than just the standard prescription for paracetamol with codeine ‘as required’ and advice to use analgesics at regular times, especially about when ‘as required’ meant, and side effects of codiene.  Few women actually used pain medication in the way it was prescribed (ie time contingent paracetamol with codiene used possibly twice a day).  The views of the women about pain relief was that it was a mixed blessing – nice to know it was there, but not that happy about having to use it partly because of fear of side effects.  Instead of taking medication, women instead adjusted their level of activity – ending up by doing less rather than taking adequate pain relief.

As I reflect on my experience – this time around I had few instructions on pain relief on discharge.  I did have a list of medications and was advised to get the prescription filled, but there were few specific instructions, nothing written and nothing suggesting that time contingent analgesia was preferable to prn.  This was in contrast to when I had my tonsillectomy – then it was made very clear to have time contingent medication and I had some very clear instructions on what to expect.  I wonder if this is because it is well-known that tonsillectomy as an adult is extraordinarily painful, while abdominal surgery has less of this reputation.

Looking further into this study by Leegard, Naden and Fagermoen, these women demonstrated that far from receiving patient-centred care and involvement in developing their own self management plan for their pain on discharge, this was largely a biomedical matter and involved providing the women with generic and nonspecific information that didn’t fit with the women’s own beliefs and lifestyle. The information was ‘given to’ rather than a plan being ‘developed with’.

Women complained of increased pain in part because they started to resume household tasks, even though they had been advised not to.  I’m in a similar position: told not to ‘lift anything over 2 kg’ my wee brain is struggling to work out why that particular weight restriction, how far can I push it? What positions can I use ‘safely’?

Complex questions, and ones that I’m surprised haven’t been explored in more depth.  Maybe this represents the biomedical focus that surgery and pain relief have.  Maybe it shows the lack of noise from people being discharged – which again isn’t surprising given that most of us don’t have all that many surgical procedures, and by the time people do complain, the pain is ‘chronic’ and chronic pain is of course a different entity from acute pain – or is it?

Leegaard, M., Nåden, D., & Fagermoen, M. (2008). Postoperative pain and self-management: women’s experiences after cardiac surgery Journal of Advanced Nursing, 63 (5), 476-485 DOI: 10.1111/j.1365-2648.2008.04727.x