No Pain, No Gain?


The most amazing thing to me about the operation to remove a substantial chunk of my right lung, the upper of three lobes to be precise and, thinking about the method of entry to the chest cavity, what has to be cut through before you even get to the lung, was the relative lack of pain – from that day to this.  As I write I fear that I may live to regret so bold a statement when the nerve endings start to repair themselves but just for now it feels like an almost pain free experience.

The same cannot be said for the two chest drains that were of course an essential part of the process.  These remove both air and interstitial fluid that builds up in the thoracic cavity following an operation of this sort.  The fluid is normally carried away by the lymphatic system but given the damage done to it during the operation and the amount of fluids being produced, the lymph needs help for a few days.  Air, of course, whilst it may sound perverse at first but becomes obvious when you think about it, is not something normally found in the thoracic cavity, it’s supposed to be inside the lungs, inside said cavity.  Air inside lung – good.  Air outside lung – bad, lung collapses and you risk death from asphyxiation – something to be avoided if at all possible. It is they that; have been the source not only of the minute to minute aching (that is for the most part entirely bearable and when not is easily made so with a dash of morphine or a tramadol capsule) that; have forced me to lie flat on my back to sleep (something I’ve never mastered in my life and thus have had very little sleep until last night) and that during removal (of the first one) gave me the most excruciating pain imaginable.

I’m sure it must be possible to have worse pain, perhaps I just lack the imagination to understand how any pain could actually get any worse than that pain was, except by continuing for longer.  Is it more painful to have your leg hacked off at the knee with a machete?  How could I ever know without experiencing it and I’m pretty sure that if I were to experience it, the knowledge of what was being done to me, the nature of it as a malign attack rather than a palliative process and the understanding of how long this was going to go on for would ensure that I placed it higher in my list of lifetime’s painful experiences but, the question has to be asked, would the actual amount of pain second by second be any greater?  Would it not just be pain, pure and simple, governed in volume by the number of nerve-endings responding to the stimulus?  I don’t know the answer, maybe there’s a scientist or two who do but I’d say it’s always going to be a somewhat subjective issue.

The fact is that removal of the first chest drain, which took place in the hospital, was excruciatingly painful.  I found the reaction of several of the nursing staff, to my tale of the event, curious indeed.  I got the impression that I was being regarded as some kind of wimp, making a huge fuss over nothing.  Well, let’s be entirely fair here, suppose I was a huge wimp and was making a big fuss over something that most people find so pleasurable that it’s a toss-up between, ooh I don’t know, popping down the pub for a drink with your friends or, nipping next door to your mate, Kevin, and asking him to whip a garden hose out of your chest without anaesthetic.  Yes, let’s suppose that’s the measure of the seriousness of the procedure to the average bloke.  Well, here’s a thing now, pain, as I mentioned before and as we all know by established research, is a subjective issue.  The fact that one person can stand an amputation of a limb whilst biting on a stick of wood, as all good cowboys do, whilst another would actually suffer a heart attack as a result of the pain and die, is what makes it subjective and, being subjective, it is all about the subject, in this case the patient, and not about the practitioner, in this case the medical staff.

So the question first arising here is what should be the relationship between practitioner and subject, between medical staff and patient.  Primum non nocere is a Latin phrase that means “First, do no harm”, it is a fundamental precept of medical ethics known to every medical practitioner everywhere in the world.  That is all that needs to be established about this relationship for my purposes but let’s broaden it a little and say that, of course, one of the primary functions of “medical care” is one of “care”.

That’s a word that has many sub-definitions, meanings and connotations but I think we all understand what it means when used in everyday parlance and particularly in a medical context.  Care is diligence, doing one’s job carefully, omitting nothing, overlooking nothing, considering everything.  Care is also concern and compassion, actively wanting to “do no harm” indeed, wanting very much to take one out of harm.  In this subjective instance, to relieve pain wherever possible, not to cause any additional pain unless it is entirely unavoidable, to consider the individual patient and their perception of pain, to work to alleviate the fear of pain which is, of course, a very large part of the actual experience of pain.  That fear causes physical tension and tension exacerbates pain so if one can bring someone to a relative relaxation there will be less experience of pain, even though the pain stimulus may be exactly the same.  We all know these things, I’m not telling anyone anything they didn’t know before but that, perhaps, is one of my central concerns.

It is these things that we all know so well that often get overlooked, forgotten about, disregarded when the pressures of the day to day, the very familiarity of it, risks bringing with it an unconscious disdain.  Cultural issues also play a part as do generational, age-related ones.  Pain is regarded differently in different cultures and it’s probably true, the more westernised a country becomes the less acceptable certain levels of pain become.  In this country, of course, we also have to measure up to that level of stoicism inferred by the phrase persistently attributed to the British caricature with their “stiff upper lip”.  It’s the same stuff and nonsense that causes even modern day liberal parents to train their children in the “big boys don’t cry” theory that blights most of their lives and is considered in professional circles to be at the root of much violence and spousal abuse…but that’s another subject for another day.  For now the point is that this so called stoicism has worked well for a country that, in times of war, rationing, poverty and deprivation needed to find ways of maintaining morale.  Well, folks, those days are long since over and I hope we no longer judge people as to their “Britishness” on whether or not they can cope with apparently intolerable pain, suffering or deprivation without so much as a whimper or a sniffle and I’d like to think we were, these days, encouraging boys to shed a tear rather than bottle up their emotions like a pressure cooker until they kill someone.

So on the day that I’m told I can have one of my drains removed I am both elated and nervous.  The elation does not need to be explained to anyone who has ever had one or, in my case, two of these buddies tethered to your body.  For the rest consider the, “wherever you go, I go” principle of the attachment with all the discomfort, complication and restriction that places on every movement from planning a trip to the lavatory ten minutes ahead of time to wanting to roll over in bed without ripping a half inch hole in your chest cavity which will inevitably strangle you in the same instant as the rushing inflow of air crushes your lungs.  It’s rather unlikely that such a thing could ever happen but not in one’s imagination it’s not, there it is an ever-present threat.  The opposing nervousness comes, of course, from those self same roots, how on earth can it not be painful to remove a half inch hose from your chest wall after your body has been busily doing all it could to accept it as part of  you and welding tissue to the tube by way of reconstruction.  Thus it is indeed the case that I approached the moment with a not inconsiderable fear, about as considerable it must be said as the bronchoscopy I had endured some three weeks earlier or the subsequent CT-guided biopsy, involving a very long needle through that very same chest wall.  In the first case I was given mild sedation but had to remain awake because my cooperation was required.  In the latter, no sedation for similar reasons but as much local anaesthetic as was called for that turned the process into something that, in my mind never really happened.  A very clever surgeon assured me at each deeper penetration that all he was doing was giving me more anaesthetic and the half of my brain that was shouting “don’t listen to him, you know exactly what he’s doing, he’s assaulting you with a very large sharp steel instrument” was subdued by the other half of the brain that readily accepted the much more pleasurable and acceptable premise that all we were doing was getting ready for a procedure that was not going to happen until I was properly anaesthetised.  Now that surgeon, one Simon Padley to give him his due credit, knew exactly what games he was playing and the benefit to both of us in playing them.  Here’s the thing, he would no more have thought to stick a needle through my chest wall without a local anaesthetic than he would to remove a hose pipe from the very same place without one.

As I later described it, these two prior procedures accurately reflect the usual situation where the fear of the procedure was some ten times worse than the actuality.  In the case of this first chest drain removal the actuality was ten times worse than the previous fear of it and that is how I knew something was not right.  From my own research and deduction, I now believe I have a pretty full picture as to why this was and what caused the very real and excruciating pain that I experienced and which continues in much abated form, just by way of reminder, to this day, five days later.

I have scoured the web and read many professional documents on the subject of chest drains and, in particular, on their removal and what considerations are given to the questions of pain and appropriate anaesthesia.  I have arrived at several conclusions:

  1. There appears to be no single authoritative work on the issue to which practitioners can turn with confidence.
  2. There are conflicting opinions as to the level of potential pain and the steps to be taken to ameliorate it.
  3. There are, incredibly, medical professionals out there who do not believe that anaesthesia is required even for INSERTION of a chest drain – that should make interesting reading for the justice profession when considering what action to take against youths on sink estates shoving penknife blades into each other’s chests on a Saturday night.
  4. Rather than the “national” health service conducting research and publishing established guidelines, each individual hospital is apparently charged with investing our hard-earned taxes many thousands of times over in conducting their own research and formulating their own individual policy to apply in their very own hospital assuming of course that they think to even do so – good god almighty what lunatics are running this enormous NHS asylum?

What comes across loud and clear, as if one needed such research or evidence, is that there is a sufficient body of it out there from around the world – the English speaking westernised world so far as my research was limited – that one cannot deny that there is a very strong likelihood that the patient will experience significant pain when a chest drain is removed and therefore that local anaesthetic should always be applied in addition to intravenous or oral sedatives such as morphine.  Of course, there must be instances where no anaesthetic was used and no pain was experienced by the patient, else there would be no variance of opinion but why on earth would that lead you away from taking the precaution of administering a little lignocaine just to be sure?  Primum non nocere.

Growing up in the fifties and sixties I learned to equate the word “dentistry” with the synonym “extreme agony”.  How did I manage that?  Well I’m sure I’m not the only one but the inevitable result was that as soon as I was responsible for my own decision making, quite early on in my case, one decision was that henceforth I would be visiting dentists over my “dead body” so to speak.  Put more simply, I simply wouldn’t be visiting them ever again.  Thus it was that by my mid-twenties and a decade or more of dental neglect brought about the very pain I had been so strenuously avoiding.  Mercifully a friend recommended their “private” dentist and it was from him I learned that, his words not mine, “Robin, there is no reason for you to ever experience pain from dentistry and so long as you are my patient I give you my guarantee that will remain the case”.  Thirty odd years and two or three dentists later (don’t they retire early, these guys?) not to mention fillings, caps, bridges, root canals and nerve extractions, I have never to this day felt any pain in the dentist’s chair nor needed to take more than one dose of painkillers after the event, when the anaesthetic wore off.  So why the difference?  Simple, it’s a cultural thing but its also a capitalist thing.  These guys are in business, they “get” customer service, they want you coming back to them to help fill that pension fund that enables them to retire early and in relative luxury.  They best do that by making sure you have not the slightest fear of visiting them – and EVERY fear of visiting someone else.  Hey presto, professionally administered, pre-emptive pain relief materialises as if by magic and absolutely no procedure commences until the patient confirms that the anaesthetic has done its job.  There’s a lot to be learned here but, unfortunately, because of the irrational structure of our “beloved” NHS we have to try to achieve this in the absence of a profit motive, which, after all, is just a motivation to give excellent customer service.  If the staff are excluded from that motivation then I’m afraid we lose an essential driving component but, what we lack in the construction of the service we can at least attempt to bolster by way of policy and training.

Gloria and Glena are both very experienced and capable nurses, of that I have no doubt.  I took to Gloria immediately, I felt very safe in her care and from various things we had chatted about I felt we could relate well.  I had never seen Glena before in my life and so when she walked into my room and was briefly introduced to me, I assumed she had been brought in from a general ward somewhere because of her specialist experience in chest drain removal.  She was to officiate with Gloria assisting.  Fair enough, it seemed like a good combination but on reflection it occurs to me that there was little or no discussion over what was about to happen – apart from some guidance on breathing instructions that I would be given again at the time.  All of this conversation, such as there was, took place behind my back, quite literally.  I was laying on my left side looking at my wife whose hand I was holding.  Gloria and Glena were behind me.

Glena’s touch was very gentle, yet very sure and I was comforted immediately.  Given she was a total stranger to me (and yes I do believe that is a major issue in the way we deliver health care in this country, one that can be solved simply and inexpensively with a little thought and conversation) the touch of her hands was my only real way of assessing how safe, comfortable, assured I would feel and it helped me to relax initially.  I hadn’t read up on what was involved, who does on such a relatively minor procedure?  No-one had explained it to me but I had automatically assumed that a local anaesthetic such as lignocaine would be used, it just seemed so obvious.  I don’t recall at exactly what point I asked for this but I believe it was Gloria that advised me that “nurses aren’t allowed to administer anaesthetic”.  I have no idea how accurate a statement this is, whether its a misinterpretation or misconstruction of an actual policy ruling but the question formed instantly in my head was the one I repeated to all those involved later: “How is it possible that it can be ok to allow a nurse to remove a hose pipe from my chest cavity with all the attendant risk that such a procedure implies and yet not allow that same nurse the responsibility to administer appropriate analgesia?”  It beggared my belief then, in agony on my side, as it does now in my very comfortable and painfree home, bathed in warm spring sunshine.  It beggars that belief to the point that I don’t believe it and because I don’t believe that Gloria would lie to me then I must assume that it is some kind of misunderstanding.

I put this point to several of the nursing staff later, during a shift change ward round and I think they misunderstood what I was saying.  I was inferring that I have no problem with the nurses doing the drain removal and thus, given that level of trust, no problem allowing them to administer local anaesthetic.  It appeared that some people thought I was implying that as nurses were not allowed to administer local anaesthetic, they should not be allowed to remove chest drains.  The two interpretations could not be more starkly contrasted and, of course, such a misunderstanding would have reflected very differently on me indeed.

Something else I recall Gloria asking me, when I was trying to make it understood just how much pain and distress I was in at that time, is what gave me clues to my later findings.  She asked me whether it felt like burning.  Well that was it, precisely.  Until she verbalised it I hadn’t considered the nature of the pain, my mind was so full of the pain it left little room for other tasks unless prompted.  As I described it to her then it was like someone had taken a burning hot flat iron and held it to my side, the way one’s skin sticks to a dull black hot metal object like a surprisingly hot chimney flue.  The only thing wrong with that analogy, I clearly remember thinking at the time, is that a flat iron has a very particular shape and the shape of this pain in my mind was square.  It might seem odd but yes it really did have a ‘shape’.  A couple of days later, still trying to mentally bridge the understanding gap of those who made me feel I was making a mountain out of a molehill and my own vivid knowledge of what I experienced, it was this shape memory that prompted me to ask my wife about the substance that had been used to disinfect the surrounding area.  I recall Glena and Gloria discussing preparing a sterile area around the drain, I remember Gloria warning me this would be cold, and it was.  There was almost no interval between the application of this preparation and the beginning of the task of removing the sutures retaining the drain tube and the almost immediate pain I started to feel.  The pain grew and peaked every time Glena sought out a thread or made some other touch to my skin, it was indeed as if this square of my body was on fire and the slightest additional stimulus was a gallon of fuel poured on the flames.  “Was it that yellow stuff?”, I asked my wife, who confirmed it was exactly that, “Betadine” she advised knowledgably, that being the brand name, in the U.S. at least, for a range of povidone-iodine (PVPI) topical antiseptics.  I was already wondering about a reaction to iodine and this confirmation sent me off in that direction.

Sure enough, I discover reams of information about adverse reactions to iodine based preparations, including Betadine, everything from life-threatening allergic reactions to the much more common reaction that I experienced.  My experience was of course exacerbated because of the substantial use of morphine based sedatives since the operation, those sedatives causing an over production of histamine which, as I crudely understand it, creates a set of circumstances which combine into a severe skin reaction.  So severe, in fact, that the following day the skin around my dressing was red raw and had actually blistered.  My wife has been treating it with TCP and Savlon these last few days and it’s starting to clear up, the blistering just bled out last night.  I have no idea what the policy is for testing or checking whether a particular patient is going to react to the use of a given preparation such as Betadine.  With what I do now know I suppose I can assume that where a policy does exist it will be different in each and every hospital across the country which, as I’ve intimated before, appears lunatic to me.  What I know though is that a pause of a few minutes, literally 2-3 minutes, between application of an iodine based preparation and the subsequent procedure would have allowed time to detect the reaction and countered the effect, delaying the procedure until the situation was resolved.  Whilst being a safeguard against my situation, that of course would not protect those who have the more severe allergic reaction so I’m rather surprised that there is no scratch test or similar as a matter of course before application of such substances, given there is no emergency being addressed here.  I guess someone might conclude, perhaps rather presumptively, that if the patient had just gone through major thoracic surgery that the same substance would have been used and that no reaction was noted.  That however is hardly a sound basis from which to presume and does not take into account the other factor referred to in respect of the build up of histamines.

Forewarned is forearmed, as they say, so it will be no surprise to anyone that when it came to removal of the second drain I was fully equipped with all the information I needed by which to direct how things were going to proceed.  I had made an appointment with a thoracic surgeon at my local private hospital for 8am on the Saturday, four days after the first drain was removed.  An hour beforehand I took a 10mg dose of oral morphine as a precautionary general sedation.  I explained the background to this new surgeon and requested that he use an alternative to iodine for the disinfecting process and that he use lignocaine prior to removal.  He clearly noted the residual inflammation and blistering and so to say that he had no hesitation in agreeing my proposals is to understate it, both he and the attending nurse displayed a healthy degree of incredulity that anyone would attempt removal without a local anaesthetic.  I normally have no problem with injections and so the acute sensitivity I felt to this particular lignocaine injection confirmed to me, beyond doubt, just how sensitive this area had become.  That said, the pain was gone in a second and the rest of the procedure was entirely pain free.

I could spend the next six months researching this topic but, frankly, life is too short for me.  For the profession, I really do think this is something that should be looked into seriously and urgently.  The questions I would want to address would be:

  1. Why do we not have national policy guidelines, developed as a result of research conducted by the most eminent professionals available and imposed automatically across the entire NHS?
  2. What training do we need to deliver to medical staff on the methodology of minor surgical procedures? Preparing the patient, allaying fear, making sure where possible that there is a bond of trust before the procedure is started?
  3. How do we best redress cultural obstacles throughout the NHS to effective pain management practice?
  4. What tests or procedures should be adopted to prevent experiences such as mine, within reason and where practicable?

What I went through was hardly life-threatening and what I was being cured of most assuredly was!  It is therefore clear that a relative perspective must be maintained here but to suggest that such minor issues should be ignored given that the patient should “thank their lucky stars” that they are still alive, is not exactly the kind of professional approach I would expect from a civilised and wealthy society such as ours.  Patients heal better and faster when their pain is well managed, it’s a simple fact.  Patients that heal faster are cheaper to treat.  Patients that do not experience pain are easier to manage.  The whole topic is a no-brainer surely, instead of the moronic “no pain, no gain” maxim we need to instil “no pain, we all gain”.

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