Now, we're going to go through 3 very quick case reports,
hopefully just to give you an idea of when you should
use one modality and when you should use another.
So, first situation is a 27 year old man.
He's been in a fight and appears in the emergency room
with severe abdominal pain and evidence of internal
damage. He asks for pain relief.
What would you do to relieve his pain?
So, one thing you might consider doing is putting him on patient
controlled analgesia. And we've already discussed that in another
lecture. This man needs, probably
needs opioids. He's got acute pain,
he's got obvious internal damage, he needs
strong pain medication and there's no point
at this level to start fiddling around with minor
treatments and hoping that maybe they'll work.
So, patient controlled analgesia allows him to have some
control over his pain management and we always advise
patients to "push the button" whenever
pain starts to build. And there's, as
I mentioned earlier, there's a lock-out
period built in, which we program in,
and so we can avoid serious side-effects from the drugs,
such as respiratory depression. And it works
very well. So this is a 60 year old woman who
was admitted to hospital with cancer of the lung.
She requires a lobectomy, she requires a portion
of her lung to be removed. This is associated
with very severe post-operative pain. So what
can we do to help? So, in an earlier slide we
talked a little bit about this. And the ideal treatment
for this woman is to put a thoracic epidural in,
which will cover the area of her incision and allow
her to deep breathe, allow her to cough,
and allow her to get up and move around.
So, the major concern after thoracic
surgery is not breathing properly, not clearing
secretions, and developing pneumonia
or other infections in the lungs that can
lead to requirement for ICU care.
But with this treatment, she'll be able to do all those
things and she'll be able to cough really
well and keep her lungs clear. And the neat
thing about this, the thing that makes it most
valuable is that, unlike obstetric analgesia
which we'll get into in a moment, the epidural
is placed high in the thorax rather than in
the lumbar space and it doesn't interfere
with muscle activity in the legs. So the patient
can get up and walk around usually quite
comfortably. And usually there is almost
no pain or absolutely no pain associated
with this incredibly painful incision. So here's
our third case. This is a 60 year old, a 62
year old woman who complains of continuous
nagging, aching pain over her back and legs.
She's had complete neurologic and musculoskeletal
exams and they're normal. Except that she doesn't move
very much. She tends to, you know,
refrain from moving a full range
of motion. So, how should her
pain be treated? So, this woman
sounds to me like she has chronic pain
and she will benefit best from interaction
with a multidisciplinary pain team.
She may benefit from group therapy
with other patients with similar complaints.
She should not be treated with opioids, because
she's very likely to become dependent upon them.
And she has to be taught how to live with her pain,
which is not an easy thing for people
to accept, understandably, but it's really
the gold standard in the treatment of chronic