August 11, 2010

Continuing the posts previously published in “Playing Doctor.”

I saw part of an episode of the TV series “House” the other day.  In it, a young man required frequent lumbar puncture for daily injection of an anti-infective agent.  I don’t remember the story line, but I remember that the spinal tap was presented as an agonizing event during which the young man sweated, gritted his teeth, and bravely pulled through with the sympathetic help of the medical staff.

Here’s news, America!!  A spinal tap should not hurt.  A spinal anesthetic should not hurt.  An epidural should not hurt.  If it hurts, somebody is doing it wrong.

Under most circumstances, once skin is anesthesized (one big pinch or sting), there’s nothing else in the midline that hurts as a needle traverses bone-free space on its way to the epidural or intrathecal space.  I tell patients that I want to be in the midline where it doesn’t hurt.  If something bothers them, it means I’m not where I want to be.  Tell me it bothers you, and tell me which side, and I can easily correct to the midline. It did take me a while to learn that if I listen to my patients, they’ll tell me exactly where I am and guide me to a successful midline puncture.

Patients who have to endure great pain during a spinal procedure are, I believe, receiving incompetent medical care.  There’s no reason for it be painful, except operator carelessness and indifference.

Even a paramedian technique should not be painful, once the needle track is anesthetized (a little more painful than midline).

So why do patients so frequently think a spinal procedure will be miserable?  I suppose in part it’s the idea, but it’s also based on real experience.

I had a patient recently who was to have a total knee replacement, for which we usually do a spinal anesthetic with enough added sedation (propofol infusion) that patients sleep painlessly through the procedure.  He’d had a terrible experience with a myelogram 40 years ago, with painful repeated punctures, and for 40 years he’d refused to let anyone touch his back.

I told him why I’d prefer a spinal myself if I were having the procedure, and told him that I didn’t expect a spinal to be a painful ordeal.  He decided to go ahead with a spinal, which proved easy and uneventful.  I just received an e-mail detailing his parking-lot encounter with a hospital administrator in which he talked about what a good job I’d done with his spinal.

And that’s the sad part.  I did a very ordinary job, the sort of job every person having an anesthetic or a spinal tap has a right to expect every day.  That we continue to send the message that spinal procedures are by nature painful is a continued failing, I think.

And while I’m at it, I think starting an IV without local anesthesia is another unnecessarily barbaric procedure.  Digging around to find a vein without local is thoughtless and insensitive.  Tell ‘em I said so.