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Guest Editor
The Personal Side of Pain
Mike MacKinnon
Publish Date: March 9, 2021   |  Tags:   Opinion

Everyone believes they have a general sense of "what" pain is. We've all stubbed our toes, slipped and fell, had horrible headaches or, worse still, stepped on Legos. Of course, this type of pain is incidental, unanticipated and often fleeting. Surgical patients face an entirely different type of pain. They've been thinking about how much they'll hurt after surgery since their surgeon scheduled the procedure. They've built up the pain and worry about whether they can handle it. They're terrified they may wind up suffering forever or afraid of the post-operative opioids their surgeon orders to control it.

This is where the entire surgical team make all the difference, not just with techniques and medications, but with reassurance, understanding and realistic expectations and goals. Surgeons discuss the operative course with patients and pre-op nurses prepare them mentally and physically for surgery. Anesthesia providers create tailored plans to minimize pain and PACU nurses reassure patients that the alarming discomfort they feel is, indeed, normal. Every member of the perioperative team has a critical role to play.

I have so many stories about patients who arrived terrified about the expected pain but left with a peace of mind that only comes from personal, team-based care. The 32-year-old patient who, already in pain, arrived for a shoulder procedure. They cried while the IV was placed and only agreed to have a regional block because of the team's explanation. I held their hand and alleviated their concerns.

The 40-year-old former drug user who didn't want any opioids after their fracture repair for fear of falling back into addiction. After a discussion with anesthesia, they agreed to a block and an opioid-sparing plan including ketorolac, ketamine, magnesium and dexmedetomidine. I watched the fear drain from the patient's face when they realized the care team listened to their concerns and was able to effectively control pain without opioids.

Then there was the 58-year-old patient who needed a hernia repair, but already had significant chronic pain from a car accident that was being treated by a pain management practitioner. They battled the pain for years, trying to limit narcotics and manage discomfort without spiraling into depression. Finally, they'd found a happy medium and were terrified the surgical pain would be just enough to push them over the limits of their tolerance and back into depression. What this patient needed was someone to listen and reassure. I explained how I could place blocks to decrease pain and that their pain practitioner was well-equipped to effectively manage post-operative pain. We can't make guarantees about the pain patients will feel, but we can guarantee that we're doing our very best to tailor the pain management process to their unique situation.

Sometimes plans fail. I remember extolling the virtues of regional anesthesia for a patient's total knee replacement, only to have the spinal and one of the blocks fail, leaving the patient in significant pain post-op. I was incredibly disappointed in myself. Luckily, I had explained the risk of block failure beforehand — and that I can always "fix" ineffective blocks after surgery. Here, a phenomenal PACU nurse helped manage the patient's pain and contacted me as soon as she realized more had to be done. After a re-block, the patient's relief was evident, and I'm convinced it was the interactions and efforts of the entire team that resulted in a happy patient — not just that second block.

Surgical pain isn't just physical; it's a mental state complicated by anticipatory anxiety and fear of pain. We have cutting-edge tools and techniques to manage the physical pain — many of which are described here in this first annual Manager's Guide to Pain Management — but the anxiety and fear inherent in surgery also requires a transparent patient relationship based on realistic expectations, mutual respect and visible compassion. OSM