End Fatigue

More Care, Less Pain

By TIM HYLAND Staff Writer

Peggy Hobbs' right knee, slightly bruised and wrapped in a bulky brace, rests on a pillow. Ms. Hobbs, a smile on her face, sits upright in her hospital bed. A tray of empty food containers and dirty plates on her left is proof that, just a couple days after surgery, Ms. Hobbs has a healthy appetite. Nurse Carol Ackerman, though, still has to ask: ``On a scale of 1 to 10, how would you rate your pain?'' ``Other than this brace being uncomfortable, I don't have any pain,'' says Ms. Hobbs. Ms. Ackerman is pleased but keeps asking questions: Is there pain when weight is put on the leg? Yes, Ms. Hobbs answers. Again, she's asked to rate it. She gives it a `5.' Ms. Hobbs punches her right fist into her open hand. The pain throbs, she says. ``Do you want anything for your pain?'' Ms. Hobbs says, no, her pain is under control. And she seems relieved, maybe even amazed, that the hospital staff is so insistent on making sure it stays that way.

A Glen Burnie resident, Ms. Hobbs doesn't remember pain management being quite so thorough when she underwent gall bladder and back surgery years ago. ``You got a shot every four hours,'' she said. ``If it didn't last four hours, you weren't going to get another one.'' Somewhat ignored by doctors and accepted by patients for years, pain is being treated differently, and more effectively, than ever before.

No longer seen as an inevitable consequence of illness or injury, pain is now considered the fifth vital sign - a key indicator of overall health, an impediment to recovery and, most importantly, a treatable symptom. New national standards mean hospitals are required to treat their patients' pain thoroughly. Patients, who have a greater say in how their pain is managed than ever before, are learning they need not suffer. And in a movement that has only gained momentum in the past few years, some experts say that all pain, even chronic pain, is treatable.

Already, pain management has come a long way from the days when pain and discomfort were treated by the book, even if the book was wrong. ``Most people will not remember much of their hospital stay,'' said Ms. Ackerman, a charge nurse at the hospital's Baltimore-Washington Hip & Knee Center. ``They will remember if their pain was managed or not.''

Welcome Change

Andie Melendez remembers the old school of pain management. ``It used to be, we would give pain medication to patients every four to six hours - if they asked for it,'' said Ms. Melendez, a clinical nurse specialist and pain management expert at North Arundel Hospital. Starting last year, hospitals had to change, and patients started to
benefit.

The Joint Commission on Accreditation of Healthcare Organizations, a national hospital accreditation group, began monitoring how well hospitals and other health care facilities were assessing and treating pain. Under the new guidelines, hospitals must assess a patient's pain upon arrival, treat that pain and monitor it, during and after
hospitalization.

Today, Anne Arundel Medical Center trains its doctors and nurses in pain management, and North Arundel Hospital's Pain Collaborative Care Committee - a group of doctors and nurses - works to ensure adequate treatment of pain. Both hospitals have pain specialists on staff. ``I've been doing pain management for 11 years, and I've seen a significant change, especially over the past three to five years,'' said Linda Heckber, pain management coordinator at AAMC. ``There's a specific standard that's been set that we have to meet now.''

At North Arundel, signs are posted in patient rooms, informing them they have the right to have their pain ``recognized and respected.'' Patients are shown placards which read, ``No one should have to live with pain.'' At both hospitals, pain is checked along with other indicators such as blood pressure and temperature. Patients are to be asked, repeatedly, to rate their pain on a scale of 1 to 10. If they can't read or don't speak English, they can point to a series of ``faces'' that depict a range of discomfort.

If they're in pain, that pain is treated aggressively. ``We don't guarantee them that they'll have no pain,'' Ms. Heckber said. ``What we do guarantee them is that their pain will be adequately managed. When you get that idea across... you relieve a lot of anxiety.''

Fears Overcome

The change hasn't exactly been easy for the medical establishment. Doctors, many of whom learned little about pain management in medical school, have been forced to rethink how patients are treated, and in some cases relearn pain management. Some have bristled at the widespread changes. ``You educate folks that are more willing,'' said Dr. Jamie Caldwell, an AAMC pharmacist. ``They see that the new approaches work, and pretty much... it spreads.''

Among the biggest impediments to pain treatment has been fear of addiction, so many doctors prescribed small doses to be safe. The consequence often was unnecessary pain for patients who probably needed more drugs than they were given.

Dr. Caldwell remembers a patient dying from cancer who was told by his primary-care doctor that he was taking too much pain medicine. The doctor cut back his dosage. ``Of course, he ended up in miserable pain,'' Dr. Caldwell said. ``That doesn't happen as often; that's a terrible story. There is a
reluctance based on concern of addiction, still. But it's gotten better.'' Alleviating the fear of addiction is recent research that has linked pain to a variety of physiological effects. Patients in pain, it is believed, don't recover as well as those who aren't. They also may get more easily confused or find it hard to concentrate.

Pain-free patients are also more likely to be able to participate in physical rehabilitation, and usually leave the hospital earlier.

Misunderstood Pain

It wasn't short-term pain, but chronic pain, that had devastating consequences for Antoinette Aquaro.
The Arnold woman has been trying for years to recall the exact moment when her life started to fall apart. Her best guess is an October day in 1979 in a Los Angeles courtroom, where she was a court reporter. ``I was sitting in the courtroom, and I felt a crick in my neck, like when I twisted to look at a witness,'' said Ms. Aquaro. ``From that point on, it seemed like I just kept getting all kinds of different symptoms.'' In the years that followed, pain became a daily burden for Ms. Aquaro, and doctors struggled to figure out what was wrong.

She spent time in hospitals, sometimes in traction. She tried heat and cold and took one cortizone shot after another. Yet the pain persisted - an awful, debilitating pain that she suffered through every day at
work, tears streaming down her face.

After 13 years, by age 47, she was unable to work. She couldn't do much of anything except sit on her couch. She was eventually diagnosed with fibromyalgia, a little-understood condition that wracks its victims with pain. ``It was like someone taking knives, putting the knives into your muscles and twisting the knives,'' she said. ``It is unbearable.''

Dr. Jacob Teitelbaum, a local pain expert who has treated Ms. Aquaro since 1995, said few doctors know how to treat chronic pain, despite all the recent advances. ``Mainstream medicine is awful at treating pain,'' said Dr. Teitelbaum, director of the Annapolis Research Center for Effective Fibromyalgia and CFIDS Therapies. ``There's an old saying in medicine that all pain is tolerable, as long as it's somebody else's.''

Chronic pain is not rare. A recent survey conducted by the American Pain Foundation found that one-third of all Marylanders suffer from moderate to severe pain. Nearly 60 percent said the pain bothered them several times a week.

The key to treating that pain, Dr. Teitelbaum said, is taking the time to find its root cause. Most doctors don't have the time, or training, to do so. It is a massive failure of the medical establishment, he said.
``We don't get trained (in medical school) and they send you out ... and you're supposed to know how to do it,'' he said.

Dr. Teitelbaum, himself a victim of fibromyalgia, said he sees his patients for up to six hours at a time. Instead of relying on drugs to solve every pain problem, he first makes sure patients are getting proper
>> nutrition and enough sleep and exercise. Dr. Teitelbaum helped Ms. Aquaro see dramatic improvement, just through getting more sleep, and taking nutritional supplements and Vitamin
B-12. Now, she sees him just once a year.

``My brain is working again, and my body is able to sit and work,'' she said. ``My life has changed, drastically and dramatically.''

More To Be Done

While she admits the medical establishment isn't perfect yet, the new push for improved pain treatment is a good sign, said Ms. Melendez of North Arundel Hospital. ``We've probably come about a third of the way,'' she said. ``But the journey's not over, and the journey will probably never end.''

Janice Ulmer, an outcomes manager at North Arundel who has done doctoral research on pain management and has worked extensively with burn victims, said a burn patient needing new dressings would once have been given 2 to 4 milligrams of morphine. Nothing more.

It wasn't nearly enough, Ms. Ulmer said, and patients suffered needlessly. A patient facing the same procedure now starts with 10 milligrams, and gets more - even four times more - if needed. The difference, experts say, is that patients have more of a say in how their pain is treated, and doctors and nurses are mandated to respond.