EMS World

SEP 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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50 SEPTEMBER 2018 | EMSWORLD.com PROFILES IN EMS Continued from page 33. "Unit 1, respond, abdominal pain." D o c to r s in crea s e d h er ox yco d o n e, added Celebrex to decrease inflamma- tion. This balancing act is exhausting to the system. Her depression increased. They added amitript yline for the sero- tonin, but it lef t her completely non- functional. They added Lyrica in hopes of deadening some of the ner ve endings, but that became the most difficult to bal- ance. It took large doses to get her to a therapeutic level, and if she did not take it religiously at the same time ever y day, she would experience wicked headaches and negative ef fects. Quadrupling her ox ycodone made her pain manageable some of the time. Ovariectomy Doctors finally decided to revisit Anne's ovaries, the lone survivors of her hysterec- tomy. They were loaded with cysts—one ruptured during the exam. The team in Vail waved the white flag and sent her back to Denver. It took her another four months just to get an appointment, followed by three more until surgery. Once she was up to 100 mg of ox y- codone per day, they added fentanyl patches, allowing her to switch between the medications. She compiled a pain log, meticulously tracking doses and ef fect ranges . She turned to her alternative therapies between doses. She was heav- ily monitored, 100% compliant, and never felt she was abusing any aspect of her medication regimen. Understandably, her pain tolerance had become ver y high. A 7 for her on a standard pain scale represented a physi- cal danger zone and would likely be inca- pacitating to the average person. Stud- ies show that in general, women have higher pain tolerances than men, but not because they are stronger or tougher. By and large women have a broader array of coping skills and are more likely to seek medical help and palliative care. There is also a cultural a ssumption that they are capable of enduring it due to their reproductive biology, with child- bir th being the obvious example. "The perceived superiorit y of capacities of endurance is double-edged for women," wrote Diane Hoffmann and Anita Tarzian in their article "The Girl Who Cried Pain." "The assumption that they may be able to 'cope' better may lead to the expecta- tion that they can put up with more pain, that their pain does not need to be taken so seriously." 3 In December 2016 Anne went under the surgeon's knife yet again. This time they removed the crippled ovaries, removed old staples, and cleaned up all the scar tissue they could find. No tumors were found. Along with her ovaries, however, went the la st of Anne's estrogen pro- duction. She went through a medically induced menopause, and something that normally takes 10 years happened over 10 days. Hot flashes, weight gain, and hor- rific mood swings strained her relation- ships. She was put on Paxil in addition to her pain-control regimens. Something Off Just one week after Anne's surgery and right before Christmas, the Monteras moved into a new home. It was an incredibly active and stressful time. Throughout this period she struggled with the Lyrica. She would experience relief from the pain and bursts of energy, but with them came gaps in her memory. She would clean or bake until late into the night, then fall into a deep sleep. Chris would find her asleep on the floor with no memory of how she got there. The new goal was to get off the Lyrica. With the success of the surger y and gradual decrease in symptoms, Anne was also actively tapering off both the ox y- codone and fentanyl. A body of literature suggests that opiate receptors could be desensitized by reproductive hormones. 1 By taking her ovaries they had changed her chemistr y. Shortly before New Year's she went to refill her fentanyl patch, only to find out her pharmacy was out. She had to go to a new pharmacy, who gave her a differ- ent brand of patch. Patients should not be changed from one brand of fentanyl patch to another. If for any reason the brand needs to be changed, the dose should be retitrated, and the patient's re sp ons e clinically a s s e s s ed—Anne's wasn't. Her body reacted dif ferently to the patches—she did not feel well, some- thing was off. Januar y 3, 2017 was another busy day for Anne. She ran errands, attended a baby shower, and…well, she can't remem- ber what else. Her ears were ringing, she had hot flashes, she was anxious. She can't recall what she did that evening, but Chris can. He awoke around 11 p.m. to find Anne missing from bed. He found her in the kitchen, baking. She commented that she was in "so much pain." She ripped the patch of f, throwing it out. Applying some lavender and a heating pad, she returned to bed. Ten minutes later, she died. Anne's journey does not end here. The next chapter of Anne's story illustrates the after- math that we rarely get to see as EMS provid- ers, from the perspective of one of our own. REFERENCES 1. Jansson LM, Choo R, Velez ML, et al. Methadone maintenance and breastfeeding in the neonatal period. Pediatrics, 2008 Jan; 121(1): 106–14. 2. Harris RA. Chronic pain, social withdrawal, and depression. J Pain Res, 2014 Sep 15; 7: 555–6. 3. Hof fmann DE, Tarzian A J. The girl who cried pain: A bias against women in the treatment of pain. J Law Med Ethics, 2001 Spring; 29(1): 13–27. ABOUT THE AUTHOR Tracey Loscar, NRP, FP-C, is chief of operations for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, Alaska. She is a member of the EMS World editorial advisor y board. Contac t her at taloscar@gmail.com By and large women have a broader array of coping skills when it comes to pain and are more likely to seek care.

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