What Is Pain Management Anyway?

Unless you are, or someone you know well is, burdened with the misfortune of needing a pain management doctor, you probably don’t know what this kind of doctor does. It’s OK. I didn’t know either.

At first, I resisted the idea of pain management because, like, it just means a prescription for opioids, right? Wrong.

First of all, we should differentiate between the pain clinics one hears about in the news and the true profession of pain management. I don’t know anything about the clinics, referred to as “pill mills,” beyond the fact they exist and have given the real field of pain medicine a very bad name.

Pain management is a specialty within anesthesiology. That’s right: anesthesiology. So, pain management doctors are MDs, they completed residency, they specialized in anesthesiology, and then they further specialized in pain medicine. They are highly trained in various intricate and delicate procedures, and concurrently have the best bedside manner of any doctor, nurse, or physician’s assistant that I have ever encountered. It’s a lot of work and effort, and not a profession that one chooses if he or she simply wants to make money writing prescriptions for hard core drugs.

My pain doctor always wants to take the least invasive measures to achieve marked improvements. In addition to the needles through my spine, she makes me work on the psychological aspects of CRPS. She makes me touch my leg with different objects to try to convince my brain that it doesn’t feel like I’m getting a tattoo on top of a road burn on top of a blistering sunburn. I am supposed to play soothing music and turn on an aromatherapy mist while I rub things like a scarf, rubber ball, and a metal ruler on my ankle (I haven’t been able to tolerate the ruler yet). It’s woo-woo; it’s pretty fluffy; it makes me feel like all of this is in my imagination. But it’s not. This fluff stuff is supposed to work in conjunction with the giant needles and the medication. I do the fluff so that one day, I can hopefully wear pants, and so that I won’t collapse in pain if my cat rubs against my right foot/leg.

And then there are the procedures. I only know what has been recommended specifically for me for my condition.  I don’t know if I have told you this already or not, but my all of doctors are the best. My pain management doctor is Dr. Leena Mathew of Columbia Pain Medicine. Columbia Presbyterian is a teaching hospital, so Dr. Mathew leads a team of doctors who are completing their pain medicine fellowship.

An IV was started for each procedure I’ve had done. A doctor starts the IV, and every time it has been fast, flawless, and painless.

They instinctively like to go for that one vein in my hand. It’s so tempting. It stands up at attention without a tourniquet. It’s a lovely and welcoming shade of blue. It is even shaped like a little smile, coyly beckoning the needle. However, having the IV in my hand really hurts. I have to hold my hand in a certain way so that it doesn’t poke up and put pressure on the side of the vein, and that causes it to rub against the tendons and bones in my hand. It’s tricky to concentrate on finagling a less painful position of an IV in your hand while an 8 inch needle is being meticulously threaded through your spine. If you haven’t experienced it, you can just take my word for it. So, the last two times, I’ve asked to have it put into my elbow vein. This vein is much more unassuming and takes it like a champ, never rolling or collapsing. The only caveat is that I can’t bend my elbow because that would put a kink in the IV line. The doctor who inserted the line said to me, “we will put the IV wherever you are most comfortable. We are pain doctors. The last thing we want to do is cause you any additional pain.”

Before my last procedure, I commented to the doctor how easily he started the IV. He smiled, and chuckled a nervous little giggle, and shyly said something like, “yeah, anesthesiologists tend to be pretty good at starting IV’s.” Oh yeah, duh. Good point.

Once my IV is dripping smoothly, two doctors usually walk me into the procedure room and patiently help me maneuver onto the table. It’s a complicated set up. The procedure is done under a live x-ray. The machine is C shaped and can move around my body to take images from different angles. It’s pretty incredible, but tricky to get in there with my boot and IV. Once on my belly with my IV bag out of the way, I am then further encumbered by a blood pressure cuff and a pulse oximeter. It sounds pretty horrible, as I’m sitting here typing it out. The experience is definitely not a party, but my doctors are so kind and attentive and really try to make me feel as comfortable as possible.

And then the needles. I get several shots of lidocaine, increasing in depth, attempting to numb the general area that will accept the big needle. The first time I had it done, they opted for some kind of regular old standard big needle. I felt like an alligator was chewing me in half. The second time, they used a much thinner needle. The thinner needle was easier for me to tolerate, but apparently it is a little more wily than the standard. The doctor had to go more slowly and delicately back it out slightly a couple of times before inserting into the ganglion. The third time, the thin needle was used again, but the doctor remembered exactly how to insert it into my body. The fourth time, most recently, while setting up the x-ray, the doctor placed markers on my back and, off the top of his head, remembered the angle he used for the previous injection. During the procedure, I thought I was still getting lidocaine injections, but the doctor was already in the ganglion. I felt the pressure on my thigh and my leg felt warm and I knew the medicine was going in. I mentioned how quickly they inserted the needle, and Dr. Mathew said that they now know my anatomy and they know how my body reacts and they have tailored the procedure accordingly.

My pain management doctors have learned about me. They know more about me than just my CRPS. They are interested in me as a person, not just a patient. They know how severely this ordeal has affected my “quality of life.” They are all rooting for me and want me to live an active life again. And throughout these nerve block procedures, Dr. Mathew speaks calmly and gently to me. She rubs my non-CRPS leg kindly while asking how I am doing. In the same soft tone, she coaches the doctor who does the injections and explains the procedure to the other doctors in the room. I’ve had the same doctor perform the past three of four nerve blocks. Before and after the injection, we have normal every day conversations: jobs, weather, places we’ve traveled. It’s a tactic to make me feel comfortable and relaxed. It’s nice. I wish every doctor could learn from pain doctors.

The only medication prescribed to me (so far) by my pain management doctor is baclofen to better control the spasms in my leg. (My neurologist prescribes the medications to try to control my misfiring nerves as well as some of the physical symptoms of CRPS.) Opioids have not yet been part of any conversation. My next steps probably include radiofrequency ablasion, with a possibility of a spinal cord stimulator. Everyone (my pain doctor, my neurologist, me) wants me to get out of this without the stimulator. The opioids would come only after all other options (including a remote controlled electric shock machine inserted into my spine) have been tried and after they have not provided long term relief.

I’m in this for the long haul, and my treatment probably won’t stop with the nerve block injections. Remission is the ultimate goal, but in the meantime, I feel confident in my doctors’ dedicated efforts to manage my pain.

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