Attention patients: don't let them hurt you. In the twenty-first century, no medical procedure should be accompanied by pain. Pain is no longer considered a side effect of a disease, but rather a disease that is treated on its own. Innovations in the study of pain that have not yet reached the public's knowledge
Rose Levy Barzilai
Photo: Gary Schneider, "New York Times"
ENT clinic in a green neighborhood and based in Gush Dan. The doctor has an excellent reputation. There is a long queue in the waiting room. He is not just an otolaryngologist, he is also a surgeon in a hospital. And he has a lot of experience with children. Some of the patients, who are not members of the health fund with which he works, come to him privately.
The doctor has a beautiful villa. Adjacent to it is a well-kept and welcoming clinic. Now it is winter, and many small children suffering from bronchitis or ear infections, come with their parents for examination. The doctor is aware of the needs of his patients. In the waiting room there is a basket full of bears and toys. Warm and cozy here. A couple of young parents, with a two-year-old toddler, are waiting for their turn. The child has a cold and an ear infection. But, thank God, nothing hurts him. His mood is excellent. He plays in the toy basket and giggles with his parents. Even when he has a fever of 39 degrees, his mother says, he continues to smile. They are lucky, he was just born with a good temper.
Their turn is coming. They go to the doctor. The boy came running in, with a teddy bear in his hand. Two or three minutes pass. Then a faint protest was heard from beyond the door. Do not want. Do not want. mother. mother. No. Then a short silence, and immediately after it a baby's cry erupts which turns into a sequence of screams and cries. All clinic residents are trained. Other small children, who until then were waiting their turn and playing with toys, are frightened. Asking to go home. Two of them burst into tears. Meanwhile the toddler's cries from inside the room continue. The child screams for almost 12 minutes. It's hard to hear it.
Fifteen minutes later, they leave. The baby is laid in his father's arms, a small stain of blood on the collar of his shirt. He struggles to breathe, little sobs shake his chest. The parents actually seem satisfied. The mother says to the child in a sweet voice, "Let's buy you a popsicle." Want a popsicle, honey?”
My turn. I enter with weak legs. The doctor asks what the problem is. I want to say that I have a pain in my left ear, but then I hear myself asking, say, what happened here with the little boy who was in front of me? The doctor smiles kindly. "Nothing special", he says. "Picuring the eardrum. He had an infection with fluids trapped inside."
What, without local anesthesia? I have another question.
"What are you talking about", he says. "During the winter, I do six or seven of these a day. It takes a second. Such a short pain saves treatment with antibiotics, and sleepless nights for the parents."
But doctor, excuse me, I'm lashing out. I was sitting here across the door. This baby cried and screamed for at least ten minutes.
He is beginning to dislike the conversation. "Children cry first of all from fear. Even before I touched his ear he was already screaming. What did you want, for me to give him an anesthetic shot in the ear? It hurt him more than any treatment."
And there is nothing else? I insist. You want to tell me that small children today have to go through such pain because of an ear problem?
This. His patience ran out. He signals that the matter is over and asks to hear what I came for. My stomach is tight. I report with concern the pain in my left ear. He inserts an ice-cold metal probe into the ear and peers with a flashlight. My diagnosis is quite similar to the diagnosis the baby received. Fluid trapped with inflammation. The doctor prescribes antibiotics plus draining pills and ear drops.
This? I'm asking.
"Yes", he says. "You won't agree that I will pry open your eardrum and be done with it chick-cheek. Right?" A sarcastic smile hangs on his mouth.
He walks me to the door. "Don't take it personally", he patted my shoulder. "Come for an inspection in a week."
A week has passed. I didn't come. I've already decided to ask this doctor, I'm never coming back.
Enough of the pain
If this had happened to an American child, the doctor would have risked losing his job. The American Association of Pediatricians has anchored in its bylaws clauses that protect babies and children from doctors who do not like pain relievers and anesthetics. In the United States, it is forbidden to perform an incision or puncture the eardrum to drain fluids without local anesthesia, and the prohibition applies to any major surgical operation, such as a toddler, that has the potential to cause pain. A doctor who does not use anesthesia, and hurts the child, is breaking the law.
Of course, not all doctors in Israel act like the same otolaryngologist. Prof. Michael Tal, for example, is shocked when he hears the description. "It's unbearable," he says. "Doctors ignore information that exists, and simple and available means that exist in the market, and patients suffer unnecessary suffering. The parents, in case you told me, don't know. do not understand. They don't have the tools to deal with a specialist doctor who tells them in an authoritative tone 'this is how we do it'. The doctor had to know that this was a surgical procedure and that he had to anesthetize the area."
What could and should he have done?
"Simply, inject a few drops of a local anesthetic liquid, such as otidine or lidocaine, and the baby would not feel anything. Regarding experiments on animals, the law requires that there be no sensation in any painful operation. So children and people these days will suffer such pain for nothing?"
So what, I just ran into a sadistic doctor?
"No. I don't think he's a sadist and I'm afraid there are a lot of doctors like him. It does not come from malice, but from bad habits. from poor professional education. It starts in the medical schools. In Israel there are no established habits of appropriate treatment of the problem of pain. Doctors want to solve the problem, cure the disease. The pain - whether it is chronic or localized - is something that concerns them less. In the twenty-first century, no medical operation should be accompanied by pain."
Unlike the pecking doctor, Prof. Tal actually took it personally. As a dentist by training, dealing with patients' pain on a daily basis bothered him. The challenge of finding more effective solutions led him to investigate the mechanisms responsible for pain. Today he serves as the president of the Israeli Pain Association.
This is an association of doctors that engraved the slogan "no more pain" on its flag. The goal of the Israeli association is the same as the goal of its European colleagues - to put pain on the medical map. The upgrade in the status of human pain is reflected in the entire world. Every reformed country has a Pain Society today. At a conference held a few weeks ago, the Federation of European Pain Associations (EFIC) issued a precedent statement according to which "pain is no longer a side effect of a disease, but a disease in itself."
The doctors, members of the associations, conduct research and develop innovative treatment methods for pain problems. They hold conferences and lectures in front of doctors and nurses. They distribute up-to-date material and try to increase doctors' and patients' awareness of the problem, with the aim of creating a turning point in reference to the phenomenon of chronic pain; To root out doctors' answers like "learn to live with it".
When discussing their colleagues - family doctors, orthopedists or internists - the pain specialists choose their words carefully. No names are mentioned, but the problem is put on the table. It begins in cases of lack of awareness: the doctor simply does not know that there is a pain clinic; Or of opacity: the doctor is worn out from years of work and indifference has taken over him in the face of the patient's pain. Sometimes these are prejudices, "it's all pagan medicine like all these alternatives"; And there are no shortage of ego problems - "I know best and no one will teach me what medicine to give to my patient".
And the patients? Sometimes they are healthy people who suddenly suffer from unexplained pain; Sometimes, people who were healthy until recently, but suffer from chronic pain that makes their lives miserable; or patients whose illness was treated, but the pain did not leave them; People who have had surgery and are left with chronic pain as a result. And very sick people, in a terminal condition, who are hospitalized in "hospices" of sorts. The pain specialists allow them to end their lives as painlessly as possible.
Good pain and bad pain
This week a pain conference with many participants was opened in London, the aim of which is to formulate a curriculum for specialization in pain medicine. There they are also now formulating, for the first time, procedures for introducing pain studies to medical schools all over the world. In the meantime, one can count on one hand the countries where specialization in pain has already been recognized (in Turkey, for example, there are studies, "algologia" from the Latin root, algos which means pain). Israel is represented at this conference by Prof. David Niv, a pain specialist from the Ichilov Hospital in Tel Aviv and the president of the European Pain Federation.
The Israeli Pain Association has existed for nearly ten years. It was founded by Prof. Mordechai Chen of Ichilov and Prof. Jesmond Birkan from Rambam in Haifa, each of them a "Mr. Kaab" in his own right, who is credited with pioneering breakthroughs in the field. Members of the association are 270 doctors, most of them anesthesiologists, neurologists, psychiatrists and dentists, but there are also internists, orthopedists, gynecologists and others.
In Israel, even though the business is not yet academically institutionalized, every HMO and every self-respecting hospital has a pain clinic today. Why do most of the country's citizens have no idea of the existence of these clinics? Probably because the pain specialists are good at threading an electrode into the spinal cord fluid and paralyzing the second nerve on the left by vertebra number nine, but are less good at advocacy and public relations.
What should one do who suffers from persistent pain for several months, was treated in all kinds of ways without the problem being resolved, and whose family doctor told him "learn to live with it"? The pain association's answer: don't give up. Ask the doctor for a referral to a pain clinic. And if he refuses, don't hesitate to contact his superior.
The members of the association are careful to respect other doctors, but a patient who needs this treatment is better off coming to a pain clinic in a hospital. The HMOs do indeed operate pain clinics, many of which are integrated into the older complementary medicine clinics. An absurd situation has arisen: those who receive a referral to a pain clinic at the HMO will not necessarily receive the best treatment available today and will also pay out of pocket for alternative treatments that will likely be offered to them there. On the other hand, those who request and receive form 17 for a pain clinic in a hospital, will be treated by the most experienced, including complementary treatments of all kinds, and without any payment.
Last Tuesday, Pain Clinic, Rehabilitation Department, Ichilov Hospital. Prof. David Niv, director of the clinic, specialist in intensive care and anesthesia, wearing a green gown and a surgeon's cap. Various surgical procedures are performed in the operating room adjacent to the clinic. Today, for example, Niv will treat a man with pancreatic cancer. He won't cure him of the cancer, but he plans to put him out of his misery.
The man has been suffering from severe stomach pain that has been keeping him out of action for several weeks. He describes the suffering as a kind of pain belt that wraps around his waist and completely paralyzes him. At the same time as the oncology treatments he is undergoing, and an upcoming operation, he was referred to the pain clinic. Here Niv performs in his body "the destruction of a section of the sensory nervous system, the one that conducts the pain from the infected pancreas area towards the spinal cord and from there to the brain".
If everything goes as expected, the intensity of the pain will decrease significantly and in the best case the pain will disappear completely. Beyond the feeling of immediate relief, medical studies show that the chances of recovery increase accordingly. When a person experiences persistent chronic pain and does not receive proper treatment, their immune system is compromised. In many cases he enters a state of stress. He may experience symptoms of sleep disturbance, anxiety and fear, lack of concentration, problems with daily functioning, sexual function, appetite disorders, bitterness, frustration and depression to the point of suicidal thoughts; All of these intensify the severity of the disease and the severity of the pain disease, and God forbid. Disappearance or significant weakening of the pain is, at this stage, a ray of light in the darkness. Something to hold on to. And often, the beginning of recovery.
The pain experts distinguish between the "good pain", the normal pain, which is acute physiological pain, and the "bad pain", which is the chronic pain. The good appears in every person's life and has an important warning role. Prof. Niv compares it to a stop sign: it is the one that signals to us that there is a problem with the functioning of a certain system in the body. He is the one who warns that continued stimulation may cause us harm. It is perceived as a symptom, literally as nausea, burning or itching. And they treat him, and the problem he warned about, with the knowledge, or at least the assumption, that the pain will diminish in the near future.
In contrast, chronic pain is, according to an idiom, "pain that lasts beyond the symptomatic stimulus, and lasts far beyond what medicine defines as a 'reasonable time for healing'". According to the view of Western medicine, such pain has no role in human life. Except to make life miserable for him, sometimes to the point of suicidal thoughts.
Therapists with holistic therapeutic approaches as well as therapists from the fields of the psyche will of course disagree with this basic determination of Prof. Niv and his friends. They will argue that there is no such thing as pain without a function; If it lasts for months or years, the patient must do a more thorough investigation, connect to the deep mental roots of his pain, check what he is not ready to give up and what he refuses to let go of.
Prof. Niv does not underestimate such approaches. His clinic also has psychologists and acupuncturists, and even guided imagery therapy. But he entrusts the holistic part to them. He is personally busy with only one thing: locating the nerve that is "guilty" of the pain, and its targeted disruption.
Spiritual or not, it is safe to bet that thousands of men and women walk around Israel today with the image of Buddha engraved in their hearts, not of Prof. Niv, or of his teacher and master, Prof. Chen; of Prof. Birkan and Dr. Ilon Eisenberg (Rambam); of Prof. Rafi Karso (Hillel Yaffe) and of Prof. Michael Tal of Jerusalem; of Dr. Ben Zion Sheklar McFlan; of Dr. Yoram Shir of Hadassah Jerusalem. of Dr. Orit Dolberg of Tel Hashomer, or of Dr. Aryeh Koritzky of Blinson. Or of any of the other pain specialists who rescued them from chronic pain, which made their lives hell on earth.
were born again
David Bernstein, a 76-year-old Tel Aviv pensioner, suffered for eight months from severe pain in his left foot. The X-ray and CT tests did not diagnose anything. He reached a state of complete dysfunction. He and his wife began to consider moving to a nursing care facility. Specialist orthopedists that he went to, both as part of the health fund where he is insured and also privately at a high financial expense, immediately wanted to operate. But Bernstein, whose pain did not affect his clarity, told them, "You don't have a diagnosis, what exactly are you going to analyze?" and flatly refused.
He received painkillers, physical therapy treatments, orthopedic injections, nothing helped. He just felt even worse. Then he was referred to Prof. Niv, who began a series of morphine injections into the spinal cord, into the responsible nerve. Bernstein: "Today I am sitting, talking to my wife. I was born a new person. And that's without surgery. Everyone jumped on me - surgery, surgery. Dr. Niv tells me, surgery is the last thing. the last one. There is a lot to do before then. After a period of great suffering, there is finally a benefit. I would like to say in the newspaper, I only suffered for a few months. I have friends who have suffered for years. Why aren't they referred to a pain clinic?"
Adv. Hagit Talmazio, 37 years old, married and mother of a seven-year-old child. During the birth there was some complication and she was diagnosed with a gynecological disease: endometriosis (proliferation of the uterine lining). In Israel there is not much awareness of this disease and the ways of treating it. She underwent a cystectomy, which caused her nerve damage. The pain hasn't left her since. Following treatments, more and more gynecological problems, inflammations and infections in the pelvis arose. She experienced excruciating pain. She underwent four surgeries, two in Israel, two abroad. Her condition did not improve.
The pain accompanied her non-stop. She stopped working. She reached the point where every movement caused her pain. In the last three years she could barely sit. When she arrived at the pain clinic in Ichilov, an epidural catheter was implanted in her body; Through it, twice a day, morphine was injected into the pelvic area. For the first time in years she experienced respite of hours and days in pain. After a trial period that was crowned with success, Prof. Niv implanted her with a permanent pump that delivers the morphine to the focus of the pain. Once every six weeks, the pump is filled in a relatively simple procedure. The pump is electronic, the patient can control the dose of morphine injected using an external remote control.
Telemazio: "My health insurance fund caused me huge problems in everything related to pain. They did not agree to finance this pump for me, because it is 'not in the health basket'. I paid 50 thousand shekels for her. And for the surgeries I underwent in the United States - hundreds of thousands of shekels. We recently sold our apartment because of this, and rented an apartment.
"I had no life. I have been with Niv's pump for two and a half years. I returned to function. I regained control over my pain and my life. I started to recover. Only those who have been through something similar know what a nightmare it is. There must be a revolution in the attitude of doctors and health insurance funds to the whole problem of pain in Israel."
These are two random examples. People with problems from various fields flock to the pain clinics. The Israeli Pain Association, for some reason, does not have exact numbers. It is estimated that they treat several thousand a year. The spectrum of human suffering presents new challenges to the experts. Sometimes it's someone whose "whole body hurts" and they don't know the reason, and sometimes it's someone whose movement of a millimeter in a certain joint causes him unbearable pain. Sometimes it's someone whose period pains cause her to pass out and not function for two weeks a month, and sometimes it's someone whose foot hurts when he sits down, and they didn't find anything for him in the photos. And this time it's even someone who suffers from constant and unbearable pain in the clitoris.
The most common complaints are headaches, including migraines; back pain of all kinds and in all stages; pains caused by nerve damage (after surgeries, as a result of injury, or limb amputations, including phantom pains in the amputated limb, "phantom"); and pain associated with cancer about its issue and stages.
Painful arrows to the brain
"An oncologist treats cancer", Prof. Niv demonstrates a common problem he encounters. "Sometimes the surgery is successful, the accompanying treatment is successful. The cancer is cured. The pain continues. The doctor tells the man, go home, you are healthy. he is going home But his life is not alive. The pain did not leave him. For him, the cancer exists and how else."
The operation was successful, the patient died?
"We say, the operation was successful, the patient died, from pain."
What's the explanation for that?
"The nerve damage. The cancer is eradicated, the chronic pain disease remains. The cancer damaged tissues and nerves. In mastectomy surgeries, for example, there is nerve damage. The nerves that have been cut over time produce a kind of small sprouts. Each such fiber sends arrows of pain to the brain. People used to be told, it's psychosomatic. The women were told, it's a psychological phenomenon, you miss the demon you lost. Today we know that this is also a physiological phenomenon, and that the pain can be eliminated with the help of drugs that suppress the activity of these sprouting nerves. There are also invasive methods to paralyze the nerve."
Because of these sprouts, even those who amputated their leg, continue to feel the pain in it years later?
"Yes. Here too there were many theories in the past. Today we know that in amputating the arm or leg, the nerves in the brain that were connected to that limb are not cut, and we understand the implications of this on the onset of pain. In some cases the pain comes from the brain. In another part, in the excision area, those sprouts appear that are very sensitive to touch. The surgeon, or orthopedist, in rehabilitation, examines the stump and tells the man, 'The stump looks great. The place has completely recovered. Go home. Start a new life'. But man suffers. Every moment, pulses of pain are sent to his brain. How can he start a new life?"
What do you do in this case?
"Going from the light to the heavy. They start by giving painkillers, and not here
It is actually Paracetamol or Optalgin. The clinic is multidisciplinary: nine doctors work together, some of them anesthetists, there is a rehabilitation doctor, a chiropractor, a clinical psychologist. Adjacent to us is a psychiatric ward that we sometimes use as well. Together they form a proposal for treatment. We use the experience and knowledge acquired and combine, for example, anti-inflammatory drugs with regular drugs, and sometimes with drugs that treat serotonin levels, which are better known as anti-anxiety and depression drugs. We produce a unique personal mix for the type of pain that needs to be dealt with."
When do you move to phase B?
"If that didn't work, there are gentle invasive procedures. Acupuncture of needles; A device that inserts an electrode into the source of the painful nerve and transmits stimulation, creating a kind of pleasant massage, like a jacuzzi for the nerve; Destruction of nerves or nerve channels that lead the pain to the brain; injection of alcohol to paralyze the nerve that causes pain; Injection of morphine (morphine) into the spinal cord fluid, towards the problem area. And if this temporarily solves the problem, sometimes we move to a permanent solution - implanting a pump, like implanting a pacemaker, which constantly flows morphine to the painful nerve center."
What about migraines?
"This is a very common problem, especially in women. There are different types and different strengths, and different types of treatments. Just for the sake of an example, a woman who regularly suffers from migraines and needs strong painkillers that numb her, here she will receive the medicine into the spinal fluid, and then she gets rid of the pain, without the medicine having any effect on the brain."
Prof. Niv, what is pain actually?
"An unpleasant experiential feeling, which originates from damage to the tissues, or which is mentally simulated as if there was damage to the tissues".
It hurt?
"Yes. I know, it sounds strange."
It mostly sounds very narrow. What, no pain without real or simulated tissue damage?
"Pain is very difficult to define. It is almost as difficult as defining love. And the difference between 'real' and 'fake' is like a thread. We have no way of measuring the intensity of pain that a person experiences. Take two women in labor: the same opening, the same intensity of contractions, the same fetal size. One smiles and gives birth as if nothing happened. The other screams in pain. Take a football player who takes a terrible kick in the leg in the middle of a game. He falls for a moment, gets up and continues playing. Put the same player in line for a pizza, and he will then catch the exact same kick. He will collapse, and will need treatment. The pain he will experience will be a hundred times stronger."
Who hurts more?
In the pamphlet "Pain Treatment" edited by Niv, a photograph taken from an American pain magazine was printed. This is a photograph of a small boy who is present when his puppy is given an injection. The puppy looked a little upset, nothing more. The boy, hugging him in his arms, as if trying to protect him, his mouth open in a cry of pain and crying. The caption under the picture is "Who hurts more?"
Prof. Niv says, what determines the intensity of the pain is often the interpretation we give to the event. But not only. "There are clear differences between the experience of pain and its intensity in different people. There are people who hardly feel pain. And there are those who are diagnosed as hypersensitive, every touch makes them jump to the ceiling. The pain threshold, in itself, is affected by countless things. If our player missed the kick in line for pizza after his car wouldn't start in the morning and his son got a negative score on the test and the bank informed him that his account was being confiscated - it would hurt him much more than if fifteen minutes before kick off he was informed that he had won a million shekels in the lottery. And the best example of the relativity of pain is perhaps in sado-masochistic sex. What is perceived by most people as painful, unbearable violence, is perceived by those involved in it as a delightful, extremely enjoyable experience."
Can you die from pain?
"Probably so. But we at the pain association prefer to mention that even if there are some who died from pain, many more people die from pain and many more people live from pain."
But there is such a thing, heartbreak, that you die from. No? Mental pain, of bereavement, or a great loss, which is so strong that the heart stops beating.
"Yes. There is such a thing."
For the information of those in pain
* An epidemiological study of chronic pain, in Sweden, showed that 45% of the adult population suffered from constant or recurring pain.
* The popular estimate today among pain experts in Israel and abroad is that every second adult - about 50% of the population of the Western world - suffers from chronic pain.
* A survey conducted at the Ichilov Hospital two years ago and involving 1,000 patients in the emergency room showed that 71% of the patients received painkillers that did not suit their condition.
* From a study conducted in England, it becomes clear that 50% of cancer patients (at all stages) and 75% of those with an advanced tumor, suffer from pain. In England alone, more than 100 thousand cancer patients suffer pain in their death.
* A Danish study shows that 66% of the respondents reported a current pain in their lives. 40% reported a certain pain that lasted more than six months.
* Studies from different countries show that about 75% of the patients who underwent surgery suffered from pain, which, according to the patients, was not treated optimally.
* The percentage of people who will experience back pain at least once in their life ranges from 60% to 85% on any given day, about 17% of the adult population complains of back pain. And in Israeli terms: about half a million Israelis now suffer from back pain.
* Half of those who turn to alternative medicine treatments suffer from chronic pain.
* About 20-15% of the world's women suffer from migraine. Men, only 10-5%
