PAIN “is always a psychological state"(IASP)

“ Knowledge without practice makes but half an artist” - Sierra Leonean Proverb

I was recently called by a cardiologist to avail myself in the Cath Lab for a patient with an ST-segment elevation myocardial infarction (STEMI).

The patient was a middle-aged gentleman in his early fifties, a smoker with no known comorbidities. He had a two-hour history of crushing chest pain, travelling to the left arm. This was accompanied by shortness of breath, sweating, nausea, vomiting, abnormal heartbeat, anxiety, and fatigue. The blood results and the ECG confirmed that the patient had a STEMI.

The cornerstone of a STEMI treatment is rapid flow restoration with primary angioplasty and stenting. After the angiogram, the cardiologist proceeded with stenting the Left anterior descending coronary artery (LAD)

Anti-coagulants were prescribed, and preparations were made to admit the patient to the ICU for close monitoring.

After the intervention, the patient admitted to having chest pain despite the reperfusion. The cardiologist believed that the source of pain was sorted as far as she was concerned. Any other form of pain was to be addressed by simple analgesia.

The whole scenario made me reflect on everything I had learned so far in pain management.

I realized that the cardiologist was convinced that the treatment of the underlying disease was expected to bring relief of pain. Before exposure to the pain modules, my understanding of pain was not different from the cardiologist. My motto had been" take care of the disease process; the pain will vanish" How wrong have I been all the time?

The roles of personality, mental processes and environmental factors in the generation and perpetuation of the response to tissue damage were not recognized.

I recalled a paragraph in an essay I recently wrote for my acute pain module, and I quote, " There is not a single pain centre within the cortex, but rather various cortical regions that may or may not be activated during a harrowing experience. These regions make up what is commonly referred to as a 'pain matrix'. They include primary and secondary somatosensory, insular, anterior cingulate, and prefrontal cortices" In addition to transmitting pain signals up to higher centres in the brain, these cells also project into brainstem areas. One of them is the rostral ventromedial medulla (RVM), a region that has descending projections back to the dorsal horn. The Limbic areas of the brain can influence these descending pathways, incorporating the emotional, affective component of the pain experience".

Pain perception has a different meaning for me now.

This situation of medical practitioners believing that any pain intervention to address pain yields good results every time is not valid.

Take postoperative pain management for the anaesthesiologist. Vital signs (blood pressure, heart rate, and respiratory rate) are widely used by clinicians for pain assessment. I recall several times when one is called by the nurses to give analgesia to the patient because the patient is complaining of postoperative pain. My response has always been "as long as the vital signs are normal the patient does not have pain”.

How wrong have I been all this time?

Vital signs lack specificity for pain assessment since they can increase, decrease, or remain stable due to physiologic conditions unrelated to pain . Consequently, vital signs should not be used in isolation to assess pain; rather, they should be used as a cue for further investigations regarding the presence of pain.

I recently read the Oxford Handbook of Palliative Care. The one take-home message from the book that has stuck in my mind is the following quote" PAIN IS EXPERIENCED BY PEOPLE AND FAMILIES NOT BY NERVE ENDINGS."

This is so true. I feel that this statement is not far from my previous experience with pain management. I wish I could go back and be allowed to correct my inadequate pain management amongst those few that relied on me to alleviate their postoperative pain.

I am on a mission to bring my colleagues on board as far as pain management is concerned. I sometimes get upset when a surgeon insists on stopping analgesia, especially opioids, soon after open-heart surgery because they want to see their patient awake and mobilizing. I suppose the whole aim for the surgeon is to feel good about the success of the procedure. I always point out to the cardiologists and other surgeons that the importance of pain management supersedes any gratification of a successful surgical intervention. The two fields must complement each other.