A 'NORMAL' PAIN RESPONSE: PAIN AFTER SURGERY
I place this in a chapter on normal pain in normal people because it is so common when we observe in ourselves, and in patients and friends that the reactions change from one person to another, even after apparently identical operations. Preparation for an operation inevitably involves rising tension and anxiety. Entry into hospital involves a rite of passage to translate the person from free citizen to dependent patient. Forms are filled in with an implicit threat. Next of kin and religion are requested. A permission form is signed that transfers responsibility to others. The patient is stripped of familiar clothes and dressed in a silly gown in a strange room with strange people. Even the life-giving, familiar morning coffee is forbidden. In 'good' hospitals, an attempt is made to ease the patient's growing puzzlement by explaining step-by-step what will happen. This rarely lasts for more than a few minutes and contrasts with the long course of easy familiarization which I described in Chinese hospitals, where the patients are recruited to be members of their own treatment team. The onset of general anaesthesia is a blessed relief, not only from the pain during the operation but from the hurly-burly of the preparation, with its fatigue, fear, anxiety, depression and loss of sleep, all of which carry over into the postoperative period and influence pain.
After the operation, most patients are in pain but there is a huge variation. There is no such creature as a standard patient, even after identical operations by the same surgical teams. Fortunately, there have been great advances in recent years such that patients can expect and even demand comfort. The former inadequacies of postoperative treatment came from two sources. One was the failure to treat the patient as an individual but to give medication in predetermined doses at set intervals. The other was to give medicine in minimal doses at the longest intervals because doctors and nurses misunderstood the dangers of overdosage and were afraid of creating addiction. A more realistic acceptance of the variability in people has led to more honest monitoring and more open belief in what the patient says. In search of safety, patients in the past were given short-acting drugs, and, after a fixed interval, they were permitted a second dose when the first was no longer acting. This produced particular misery as the patient cycled between comfort and pain with no helpful response by the staff to their painful phases until time came for the next dose. Now the ideal is achievable by prolonged or continuous analgesia and by steady monitoring of the patient.
One of the particular miseries of postoperative patients is their helplessness, a condition rare in normal life. Infancy reappears and adds shame. If the recurrence of pain means that the patient must attract the attention of a nurse, who has to ask a doctor for permission to give analgesia, there is an all-round increase of tension and irritation. For exactly that reason, patient-controlled analgesia was invented in which the patient can administer their own additional doses through a machine with built-in safety controls. The effect is to restore control to the formerly helpless patient and, unsurprisingly, the total amount of analgesic medicine that brings pain relief to the patient is usually less than the amount that would have been given by the staff.
There is no time in a hurried hospital routine to diagnose why some patients are in more pain than others. It is true that some operations, opening the chest for example, tend to be more painful than others, such as opening the abdomen. However, the causes of the variations in pain go far beyond these simple mechanical reasons. Every sensible surgical patient has good reason to be fearful, anxious and depressed. The intensity of these will affect the intensity of the pain. No amount of psychotherapy or drug therapy will abolish these entirely reasonable emotions, but they help. A particularly difficult feature to measure is the patient's personal assessment of the meaning of the operation in terms of what the future will bring. A patient may not believe the euphoric assurances of the most charismatic surgeon who declares that everything is in order.
Beyond the period of pain, there are often surprisingly long periods of fatigue, depression and malaise. Some of these are detectable before the operation. They too do not have simple explanations attributable to the disease, the anaesthetic or the surgery. In a recent study, it was shown that recovery from hip replacement is particularly brisk despite the fact that this is a very major operation involving considerable tissue damage. It is suspected that patients have an extremely optimistic attitude to the outcome of this operation with a good chance of pain relief for their arthritis and for greatly improved walking. In other types of operation, the patient may have a more pessimistic view of the future, which they express in prolonged depression and malaise.
This chapter has been about the variability of people. It is deep in human nature that we respond individually to any threat, including pain. Our internal variation is compounded by the attitude of others who impose their stereotypical cultural expectations. There are external sources that influence the amount of pain. These include authority and the cultural stereotypes of the hero, ethnic groups and gender. In addition, the amount of pain is influenced by internal states that are themselves often affected by external events. These include fear, familiarity, expectation, depression and anxiety. Behind the personal variable reaction lies the origin of the pain itself, to which the next two chapters are devoted.
*34\219\2*
Pain Relief