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Editor in Chief

“An investment in knowledge pays the best interest.” –Benjamin Franklin (1706-1790)

by Chester Buckenmaier III, MD COL (ret), MC, USA

February 6, 2019

Julius Caesar commented, “No one is so brave that he is not disturbed by something unexpected.” My wife, Pam, and I recently traveled to Florida to visit my mother and father, who are in their seventh and eighth decades of life, respectively. My parents live in a friendly golf and boating retirement community on the west coast of Florida. They have many friends, and the street they live on is well-known throughout the community for its active and full social calendar. Pam and I were looking forward to a relaxing week in the southern warmth, tagging along with my parents and enjoying the regular festivities.

Our first engagement the evening we arrived was a birthday party at the home next door. In a festive mood, the four of us set out a side entrance to cover the 20 grassy feet to the neighbor’s patio. My mother (who has given me permission to relate this story) lost her footing in the grass, stutter-stepped back down the small slope and landed with her entire body weight onto her right shoulder. Sadly, nobody was within reach to arrest her falling, but we all had a clear view of the fall, and we all knew the outcome was not going to be positive.

My mother’s pain and loss of function in her right arm were of such intensity that no great diagnostic powers were required on my part to know she had broken her arm. After sitting her up and determining there were no other injuries, I was able to fashion an arm sling from a pillowcase I ripped into a cravat (she is still upset about the pillowcase), and we set out for the local emergency room to determine the severity of the fracture. The X-ray confirmed a proximal humeral shaft fracture. The emergency room physician described the break as a “cone driven into the ice cream,” explaining how the humeral shaft had been broken and driven into the humeral head when she had fallen on her shoulder. Fortunately, the fracture was not displaced, and alignment seemed normal (this was confirmed two days later by an orthopedist). Her prognosis was full recovery without surgery, but, much to my mother’s dismay, would involve weeks of immobilization and no small amount of pain. Needless to say, this was not the expected week of relaxation that Pam and I had counted on, but we were grateful that Pam (who is an RN) and I were there when we were most needed.

My parents are blessed with excellent health insurance coverage as military retirees and Medicare beneficiaries. Once again, the importance of universal health care coverage for all Americans has been practically demonstrated to me. The care she received was excellent, and I thank all her providers for their professionalism and expertise.

At the time, I did not pay much attention to how her pain was being managed, since I am an acute pain specialist, and the ER physician knew this and agreed with my suggestions for initial pain care. Mom was discharged from the ER with a prescription for 20 Percocet (oxycodone and acetaminophen) that we would fill from a local pharmacy the next day. I noticed that my mother received very little instruction on how to manage her pain at the ER (other than the prescription), and I initially thought this was because the ER staff were aware of my profession. When we got the Percocet the following day, my father noted she could have one every six hours, and Pam and I in a chorus (and some horror) exclaimed, “No!” This confused both my parents, because the Percocet was very effective at relieving the pain almost to zero intensity at the expense of significant nausea and constipation.

I was now in the position of educating my parents on the practical aspects of multimodal analgesia as I broke all her Percocet tablets in half. I explained how striving for zero pain was not in my mother’s self-interest, since some level of discomfort should be expected with a broken bone of this type, and some pain sensation was the body’s way of reminding her to keep the arm immobile and not re-injure the extremity. We could use less of the Percocet, reserve it for severe episodes of pain and substitute plain acetaminophen (and some NSAID initially) during the day. We took extra time adjusting the arm sling for comfort, worked on adjustments to daily living tasks to minimize pain in her arm, and Pam even provided massage to ease tension in local muscles. A simple heating pad provided great relief for muscle spasms. The pain was the primary focus concerning the fracture for my mother. Pam and I pulled out all the stops to help her manage it without falling into the Percocet every six hours trap.

This experience has been very unsettling for me, both personally and professionally. Obviously, I am very concerned about my mother and have been kicking myself for not helping her across the grass (stupid, stupid, stupid). Professionally, I am humbled by the fact that Pam and I work in the pain field and were able to manage her pain adequately while minimizing possibly dangerous side-effects. We were there to educate her on how best to manage the pain and explain why zero pain is not a reasonable goal.

The system did not provide this education. The only instructions given were on the Percocet bottle, suggesting a pill every six hours as needed for pain. Had we not been there, she likely would have used all the tablets and been on to another prescription. How severe would nausea and constipation have been? Would she have fallen again with so much Percocet in her system? Fortunately, we were there, so we do not have to deal with the answers to these questions. What concerns me is that the health system, while efficient and effective in dealing with the fracture and its treatment, provided little to no information on pain management beyond the pill bottle label. So many Americans today who injure themselves similarly will not be given the education they need to manage their pain effectively and safely. Is this not how we got into the opioid crisis in the first place?

Modern medicine has achieved incredible success in the management of disease and trauma, but along the way we have forgotten that one of our primary responsibilities as healthcare providers is patient education. As we have learned through the deaths of countless thousands of people with prescription opioids, we cannot prescribe the issue of pain away, and we must do better at talking with and educating our patients on how to handle this problem that is at the forefront of their minds. The investment Pam and I made in teaching my mother about her pain management has paid real dividends in the quality of her recovery. Every American should be able to count on this dividend from their provider.



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