It is the only thing in my life I can control.
--A 32-year-old cancer patient talking about self-administered pain medication
Following back surgery in 1977, Dorothee Triest of Menlo Park felt as though she was on a roller coaster as the pain surged and receded. She never got used to the excruciating wait--that gap between the time when she would press the nurse-call buzzer, and the moment when pain medication was injected and finally began to give relief.
The worst part, the 62-year-old retired social worker said, was that the pain management was out of her hands.
Back in Hospital
Triest was back in Stanford Hospital last week for a total hip replacement. But this time, when she felt the pain approaching an unacceptable level, she simply reached to her bedside for something that resembles a nurse-call cord. Triest would depress a button, and a buzzer would sound to tell her a dose of pain medication was being released directly into her bloodstream through an attached intravenous line.
“By doing it yourself, you feel somehow a little more in control of the pain,” Triest said in a telephone interview from her hospital bed. “It’s not something that’s being done to you.”
Leaders in anesthesiology predict that the device Triest was using, called a PCA (patient controlled analgesia) unit, will become the norm for managing pain in post-operative and cancer patients within five years.
The machine has been shown to reduce patient dependency on nurses, to decrease the amount of medication required, and to enhance post-operative pulmonary recovery. But its major benefit, according to Dr. Paul White, assistant professor of anesthesia at the Stanford University School of Medicine in Palo Alto, is that the device “reduces the anxiety surrounding pain” by putting patients in charge of their own medication.
While PCA is in use mostly at university-affiliated institutions around the nation, Dr. Ronald Katz, chairman of the Department of Anesthesiology at UCLA, argues that PCA “is not a research issue anymore. We have the technology. We should be using it in hospitals.”
Katz invited 25 leaders in anesthesiology from this and other countries to a meeting this past summer in Aspen, Colo., in order to “stir them up” about PCA.
“Everyone there had heard of PCA, they had read about it and thought it important,” Katz said in an interview at his UCLA office. “It works. Doctors like it. Patients like it. Nurses like it. But it’s a hassle (to implement).”
An impediment to use of the device is widespread physician fear that patients could become dangerously oversedated, or even addict themselves to painkillers if they were allowed to regulate their own drug intake.
“This is a myth taught in medical school,” Katz said. “You don’t make addicts of patients (by allowing them access to painkillers). I’ve been at this (pain management) for 25 years and I’ve never seen it happen.”
To ensure that a patient would not be able to medicate himself or herself to the point of unconsciousness, a timer built into the unit inactivates the device for a period ranging from five to 10 minutes following a dosage release. Theoretically, a patient could get a dose large enough to interfere with breathing if the machine wasn’t working properly. But the risk of serious injury or death to a patient using the machine is almost non-existent, Katz said, because of the built-in safety factors and the fact that nurses and doctors monitor patients who are using the device.
A cancer patient at Stanford commented that PCA allows her to stay alert enough to talk with her parents and friends, while at the same time letting her receive adequate pain relief. That is not the case with nurse-administered analgesia, which often leaves patients groggy. According to a report cited by PCA researcher Dr. Richard Bennett, 48% of those post-op patients receiving analgesia by conventional methods are “grossly sedated.”
Bennett said that studies routinely document that pain is seriously mismanaged in more than half of the patients studied who were receiving analgesia by traditional intramuscular means. Part of the problem, according to Katz, is that levels of perceived pain vary so greatly among individuals that it’s impossible to set a standard of care that works equally well with all patients.
Katz is of the opinion that doctors are undereducated when it comes to pain. He gives the example of a surgeon at UCLA who claimed he was never able to understand why some patients complained so vigorously following surgery. Then this particular surgeon was operated on himself. “Now I know what they’re talking about,” the surgeon told Katz. “It (the amount of analgesia) wasn’t enough.”
The surgeon has since directed his residents to talk to Katz about PCA and about pain management in general. UCLA will soon be getting its first PCA unit, Katz said, which it intends to begin using with cancer patients.
Bennett, who is in private practice in Lexington, Ky., became interested in the PCA device when he observed the typical manner in which pain was treated in the hospital. A patient had to communicate his or her need to a nurse, who was often busy with other demands. It might be 15 minutes or more before a nurse responded to a patient summons. Then the nurse had to get the painkiller from a locked cabinet and make a note in the patient’s chart, or perhaps consult with a physician.
After the nurse gave the injection, it could be anywhere from 16 to 90 minutes before the drug took effect. Patient Dorothee Triest said she feels some relief 20 seconds after pushing the button on her PCA unit. (It may still take five to 15 minutes for peak effect, White said.)
The first research on the device was done 15 years ago in this country. Interest flagged because the device was not commercially available, and European researchers picked up the topic.
Bennett was the one to renew interest in PCA in this country when he started doing clinical demonstrations with prototypes of the device five years ago at the University of Kentucky College of Medicine. He said he was contacted almost daily by physicians who wanted to use PCA, but there were no units commercially available until last year.
“PCA works so well that everyone who has used it on the University of Kentucky nursing and surgical staffs supports it,” Bennett said. “But I have always thought it would spread fairly slowly because there are so many tasks involved in instituting (PCA) therapy.”
Hospitals that want to offer patients the PCA option must go to the trouble of purchasing the machines (each PCA unit currently costs $2,000 to $3,000), and obtaining approval from various committees. The operation of the device--which is “the easiest thing in the world,” according to patient Triest--also must be explained to patients individually, a task that requires about 20 minutes.
With health care becoming more competitive, Bennett said PCA will become standard, despite the added work for hospital personnel, only if patients begin insisting on it. So instead of buzzing for the nurse after the pain hits, Bennett suggests patients request that a PCA unit be waiting back in their hospital room before the surgeon makes the first cut.