Palace of Care – COVID Symptom Trading Cards

Photo by pisauikan on Unsplash

New day, new symptoms. The whole body aches and pains subsided today which was a relief. Just as I was lulled into a sense of lessening unwellness, something else arrived to knock that idea out. A sore throat the likes of which I had not experienced since I had my tonsils taken out as an adult came to say hello. I would describe it as swallowing rusty liquid razor wire. It was such a lovely greeting that with each swallow I was overwhelmed with emotions and tears came to my eyes. I threw all the medications I had at it, and then some, but nothing worked apart from lying down in the foetal position, but that didn’t bring any relief. Or was I lying down in the recovery position? Probably not as I do not feel recovered as of yet.

I was hungry and had to eat through each painful mouthful. The dry crusty parts of the bread were like sandpaper on my disease-ravaged throat. I winced and grimaced through each gulp of food. My appetite had returned but had to contend with the pain barrier. I persisted and after a few minutes, the pain started to abate. If the drugs don’t work make your own. As a response to the pain, my body produced endogenous opioids, bringing relief to my agonised throat. The second half of the meal was swallowed with relative ease.

Both of my Latissimus dorsi, those big wing-like muscles on the sides of our backs, were aching today as if I’d had a huge workout yesterday, which I hadn’t. My pectorals on the opposite side of the lats also felt similar. I had not done any heavy lifting at all but had done some coughing yesterday. Curious symptoms continue to be collected. What will happen tomorrow?

Palace of Care – Omicron BA.5 variant Top 10 lessons

Photo by Rodrigo Curi on Unsplash
  1. Writing is difficult when you have brain fog.
  2. Pain does override everything else going on.
  3. End-of-dose pain return is a thing.
  4. Oral medications take a while to kick in.
  5. Nerve-related pain sucks.
  6. I am not alone, many others are going through the same symptoms as me.
  7. Friends have been kind and have offered to drop stuff off.
  8. Being sick for even two days feels awful, I can’t imagine what it feels like for my patients.
  9. It is demoralising when you’ve taken all your medications and you are still in bad pain.
  10. Writing is difficult when you have brain fog.

Palace of Care – A Reluctant Patient

Photo by DDP on Unsplash

I first met our reluctant patient in the outpatient clinic with his girlfriend. It had taken a number of phone calls before he would come in for assessment. He was scared of hospice and had resisted his Oncologist referring him to us. He didn’t know what we were about and what he didn’t know frightened him.

He had been unwell with cancer for over a year with severe pain making him unable to sit or lie down for more than an hour at a time. Sleep was difficult for him and he was woken up several times a night by burning pain that spread down his right leg. He wasn’t keen on any changes in medication, and it took much negotiation for him to allow us to increase the doses of the pain relief agents he was already taking. He didn’t want to consider anything new, just yet. As his pain was so severe I offered to admit him into the inpatient unit but he wanted to stay at home.

Over the next month, his pain did improve but any relief would only last for a few days at best. We again offered to admit him for pain control but he still wasn’t ready. Some weeks later the pain had worsened bringing tears to his eyes. His mother and girlfriend were exhausted and felt helpless as they couldn’t help reduce hisWith encouragement from his mother and girlfriend he agreed to be admitted.

We started him on a different opioid that afternoon. The next morning he was full of smiles. He told us he was pain-free for the first time in two years. He stayed a few more days as we helped him with other issues, and then he went home. As well as good pain control we had built a trusting relationship that would help during his next admissions.

THE 5TH VITAL SIGN: PREVENTION AND MANAGEMENT OF ACUTE AND CHRONIC PAIN WORKSHOP

Palliative doctors and trainees and those interested in pain management might want to check out the upcoming pain management workshop at the shiny new Victorian Comprehensive Cancer Centre.

“This workshop is ideally suited to general practitioners, perioperative physicians, anaesthetists and pain specialists who seek an update on evidence-based management of acute pain in the perioperative setting. We will also highlight the latest research aimed at reducing the transition of acute pain to subacute and chronic pain and its associated morbidity.”

For more information see here 

Saturday, November 12th 2016

Peter MacCallum Cancer Centre,
Victorian Comprehensive Cancer Centre,
Melbourne

The right words matter when talking about pain

Michael Vagg, Barwon Health

It is no coincidence that we describe the “pain” of loneliness or the “agony” of rejected romantic feelings. Paper cuts can be “excruciatingly painful”, but so can watching the social mishaps of Basil Fawlty or David Brent. Personal criticism can be “stinging”.

The book The Patient’s Brain outlines the evidence that later evolutionary traits such as social cognition and language appear to have grafted themselves onto the ancient brain functions that alerted us to external threats or bodily damage.

Words are neurological events. They are meaning-laden puffs of air that our brain transforms into knowledge, opinions, emotions or danger signals.

Shakespeare, perhaps the greatest wordsmith of all time, frequently used bodily sensations including sensitivity to pain as metaphors. If you’ve ever complained about the “bitter cold”, called an ugly sight an “eyesore” or felt it “sharper than a serpent’s tooth … to have a thankless child” you might know what I mean.

Words affect pain

Continue reading

Elsewhere in the Palliverse – Weekend Reads

photo by David Mao itsdavo

I hope you enjoy this week’s reads, which include topics like wills, funerals, dementia, research ethics and the experience of a hospice nurse who becomes carer for her mother. I hope there’s no typos – I’m rushing off to a communication skills workshop but wanted to post this before I leave.

As always, please leave your thoughts in the comments box below.

Continue reading

Malignant Psoas Syndrome

Malignant psoas syndrome is said to be extremely rare, but I keep seeing it. Admittedly, working in the pain and palliative care service in a specialist cancer centre, if anyone was going to see it, you would think it would be my team.

I have had three patients with MPS this year and because each time it’s something that the clinical staff are not familiar with, I thought I would share a  short summary with the Palliverse.

The original description of MPS in 1990 (1) described patients with:

  1. Metastatic cancer involving the psoas major muscle either intrinsically (direct intramuscular metastasis), or extrinsically from metastatic retroperitoneal lymph- adenopathy infiltrating into the muscle.
  2. Painful flexion of the ipsilateral hip with positive psoas stretch test (‘‘reverse’’ straight leg raise) related to psoas muscle spasm or irritation.
  3. Clinical evidence of proximal (L1–L4) lumbar plexopathy with spontaneous, burning and lancinating pain associated with hyperalgesia (allodynia and hyperesthesia).
  4. Absence of osseous lumbar vertebral metastases and/or concomitant lumbar polyradiculopathy due to other causes (e.g., malignant neuraxial dissemination, chemotherapy-associated or radiation-induced neurotoxicity).

In 2010, Stevens et al wrote a helpful review (2) of MPS with a case review, mechanisms and theories. Five years ago, according to the paper, there had only been 28 cases reported in the English speaking literature.

I will leave interested readers to explore the papers themselves, but it describes polymodal pharmacotherapy (aka throw everything at it), plus some novel strategies like local anaesthetic block of psoas sheath.

What has encouraged me to put fingers to keyboards tonight though is the referral of yet another patient with psoas syndrome, plus this Japanese case series by Takase et al (3). It describes three patients with MPS who had excellent results with methadone (15-30 mg/day). Their average pain scores were reduced by an astounding 7 points with greatly improved function.

I am pretty keen to try adjuvant methadone for my new referral.

Have you seen any malignant psoas syndrome cases before?Were they recognised and treated as such? How did it go? Particularly keen to hear whether anyone has tried methadone. 

Sonia

References:

1. Stevens MJ, Gonet YM: Malignant psoas syndrome: Recognition of an oncologic entity. Australas Radiol 1990; 34:150–154.

2. Mark John Stevens, Charlotte Atkinson, and Andrew M. Broadbent. Journal of Palliative Medicine. February 2010, 13(2): 211-216. doi:10.1089/jpm.2009.0193.

3. Takase Naoto, Ikegaki Junichi, Nishimura Harumi, Yuasa Sayoko, Ito Yumiko, and Kizawa Yoshiyuki. Journal of Palliative Medicine. July 2015, 18(7): 645-652. doi:10.1089/jpm.2014.0387.