Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
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And again I'm gonna go later a bit more in what we do in interventional radiology where we do use some script reading but sometimes it's just very important what you say or that there is something you don't say.

So let's look at a situation, at a video that you kind of all know, like you have to put this IV in. And that's no uncommon and she's actually a very, very compassionate nurse but I mean this is replayed.

So you know the big question is, what do you actually believe happens when you say oh it's not going to hurt that much? What the patient hears is hurt, they don't hear that much, or it's just a little pinch and we had, when we did our breast biopsy study,

a very hard time because the team really believe that you have to use all these negative statements so we said okay, you know what, let's just get the data. So we listened to about 160 tapes in IR, what were people saying?

Just naturally what were they saying? And we listened for their statements that included pain or heat or bad or any other undesirable sensations and we were taking pain measurements every 10, 15 minutes and anxiety measurements and what we found

that if you warn for a stimulus with these kind of words they actually are gonna experience more pain than if you didn't say it and the same with the anxiety. If afterwards you sympathize and say oh that wasn't all that bad,

or how bad was that, it doesn't affect subsequent pain experiences but it will get the anxiety up. So what can you then actually say? I'm gonna show you another little video. Oops perhaps not, one moment we'll go back here

and yeah we can show the video now. Again Comfort Talk doesn't make things longer. You noticed what she did the second time? Right, okay she didn't say anything negative. She actually got the needles out of sight a little bit from the sight

and then she used something very tricky. She said well you might, because I always say give the patient the right to their own experience. You actually don't know what they're gonna feel. I never say this is not going to hurt, I mean what do I know, I don't.

So we call this a very permissive approach, we give some options. You might feel a sensation of cool or warmth or a delicious sense of tingling which we call a confusional type of induction because nobody really knows what that is

but now the brain is suddenly thinking, is it gonna be cool is it gonna be warm or is it delicious sense of tingling? (audience laughs) And that is the really very powerful phrase you can use in two settings.

One of the technologists at Boston Medical Center we trained said she had this patient come in with a real attitude, kinda under the whole idea. Oh you're putting that IV in, since how long are you in the business, do you know how to do this, yeah I'm a really hard stick, nobody does that

I don't see how you can do it, well she just put what we always say, put the confidence on and said, oh yeah and she put it in and when she said her thing, you might feel some cool or warmth or delicious tingling she said that patient suddenly went quiet

and was extremely cooperative till everything was completed. The other time this statement is extremely helpful when you are having a procedure. Somebody told me she had a vein stripping done, I mean not stripping but vein ablation,

you know you give a lot of local along the vein all the way up and down and she actually brought one of her colleagues with her because she wanted her colleague to do some Comfort Talk for her. But just in the preparation the doc was telling her the whole time, oh it's gonna hurt

and she said don't say that to me because I'm gonna be just fine. Said no, no, no but it's gonna hurt and she said, no you got this all wrong I will have a delicious sense of tingling. (audience laughs)

And I use that with my dentist too. I kind of just makes it quiet and you can have your own experience and cruise along. When we train the teams, now it's about the book, the key thing is this instant rapport and a lot of it is the matching

and leading to a more relaxed state. You shape the experience by the kind of wording you give but again the whole idea is to help these patients help themselves, to get them on autopilot because that's when they walk out the door, that's how they'll feel

the proudest of themselves. You're not doing it for them and I think sometimes it may interfere with your image as the giving healthcare provider. This is not about you, this is helping them to do their own stuff and what it does

in a very miraculous way that it actually cuts your stress level way down. And again with the self-hypnotic experience, I'm gonna show you in a little moment what it is because I'm gonna walk you through a little script we do. You can even, once you know how to do that,

support a stable physiology, get blood pressure a bit up and down although I always say this should not be your only way of keeping your patient stable.

These have been looked at and there's meta analysis of over a thousand patients that shows that this is a highly effective way to control pain if offered early. The later you offer this, these blocks,

the less effective they are. But 70 to 90% of patients experienced either partial or complete pain relief at some time prior to their death.

This is basically kind of your anatomy in hemodynamics.

Celiac axis gives supply to the spleen, gives supply to the hepatic artery, and there's increased flow to the spleen for some reason. Then flow goes back from the gut and spleen back to the hepatic graft by the portal vein. This is kind of your general circulatory

kind of hemodynamics. What the Japanese for years have been talking about was a small for size graft, a completely different syndrome, called small for size graft. In other words the liver is actually too small

for the amount of portal flow that's coming to it. It's an undersized graft. So for example, a transplant in a kid put in an adult. The liver is too small for the amount of portal flow that's actually coming at it.

And what they found out was that there was slow flow in the hepatic artery as well, and they didn't know how that went about. So for years, the Germans were talking about splenic steal, and the spleen is stealing blood flow, the Japanese were talking about

there's a small size graft and there's increased portal flow, but as a coincidence we're looking at hepatic or slow arterial flow. Then, kind of the Americans came along and actually put it all together for them. This is probably a constellation of syndromes and problems

that are occurring at the same time. One can predominate, one can be the only sole problem, or it could be a group of problems. What happens when you increase flow to the liver by the portal vein, there is actually something

called the HABR, the hepatic artery buffer response. This is a partly-reciprocal, poorly understood relationship between the portal vein and the hepatic artery. If you increase portal flow to your liver right now when you eat, if you take a big meal,

portal flow will increase to your liver and your hepatic artery's gonna slow down, because 20% of flow to the liver is from the artery, and 80% goes from the portal vein. If you eat a lot, your portal vein flow increases, your hepatic artery compensates by dropping down to

maintain that flow to the liver. That's kind of a partly-reciprocal relationship. So when you put a small graft in a patient, with relatively high flow, too much flow for the portal vein, the hepatic artery slows down. Okay?

So this is not just a steal phenomenon, this may also be a response or a reflex response to a high flow situation. The graft- and just to add a little bit more detail to this- the graft could be small, or the graft could be non-compliant and poor.

A poor graft, as well, can do the same thing. So it could be a big graft that's not functioning that well, and/or stiff, that would do the same thing as well. Okay? So increased portal flow, decreased hepatic arterial flow.

I mean I just thought I'll show you that second clip, how natural it can actually look to cross one's arms but then she opened it up and it's very hard to then not follow along, so that's how you sometimes can save the day

in a fast way. Now dealing with pain and that's something I think that gets to all of us emotionally, I mean we are gonna be poking people and there's certain things of how we feel about

what the patient should be experiencing. We've done several large clinical trials so we had the opportunity to look at the standard of care groups of those where patients could get as many drugs as they wanted and if I were to ask you, just by show of hands,

what do you think hurts the most? Okay angiography? Large core breast biopsy? Tumor embos? Okay well it's kind of like, what I thought too. However if you plot onto this graph

on the X axis is the time zero you wheel a patient into the room and on the Y axis is their self reported pain. We ask them like every end of 15 minutes, by the way we don't say how bad is your pain, we say what is your comfort level on a scale

of zero to 10, no pain at all and worst possible, and zero no anxiety at all, 10 worst possible. And what you find out is, I mean there are these three curves going up over time and the blue line is the tumor embos, the red one is the angio renal and the yellow

is the breast biopsies, there's really no difference. And furthermore when we dug deeper into this data not only is this increase in pain over time, this trend relatively independent of how hard you poke somebody, but also independent of how many drugs they get.

Actually there's a somewhat inverse relationship between the amount of drugs people get and how much pain they experience over time that is sent. And the question is why is that the case? So from nature we are used to always assume the worst

and similar curve applies, although with some differences for anxiety but there's an increase in anxiety over time in the case under standard of care and I think it goes all down, that's one explanation (mumbles), he's a surgeon in (mumbles) uses,

he says, you know, hundreds and thousands of years our ancestors, let's say who walks through the Savannah and one behind hears a little noise and says, oh this could be a tiger, perhaps I should look around and do something about it and the other one says it's just the wind it's not a big deal.

You can see that being a little paranoid over time still probably translates into higher longevity and the ability to create offspring so we are all deriving from the somewhat more paranoid people that particularly, in a setting of ambiguity, we assume it's hurting

or it's bad or it's dangerous to us and it's a protective mechanism of the subconscious. That is going to happen. Furthermore, once there had been one painful stimulus then all subsequent stimuli are going to be interpreted as being painful or even more painful

and there have been studies done where they hook people up to a machine with little flashing lights and the first time they got a little shock and the next time just the little lights were flashing and they experiencing more and more pain with the little lights flashing even though

there weren't any more shocks. So that's what you have to deal with and this is what we all know. If you do a case that's over in 15 minutes it's not that big a deal. It's like you're in hour number one,

where you now are number two or in hour number three. That's when certainly everybody can get really, really stressed out. However, the good news is if right at the beginning you do something, you say to the patient something in words but also in your behavior

that reframes this experience this doesn't happen. And this is kind of the secret sauce, all you need to do is do something at the beginning, at time zero, and then you don't get this blue line on the standard of care where the pain keeps going up

over time, time, time, time. If you do some empathic attention the increase is not as steep but if you do some comforting words at the beginning, these are IR data in interventional radiology, you can go on for ever.

I mean it's just like a very different atmosphere in the room and very similar for anxiety. We've found similar responses in a trial we did with breast biopsies and tumor embolizations under standard of care pain to go up,

getting better if you give some empathic attention but anxiety dropping down very quickly while this patient is still on your table and actually even though the whole thing is called Comfort Talk you're gonna end up to talk much less

because the idea is to get that patient on autopilot as fast as you can, particularly in MRI. You wanna have them in there doing their own thing, having, as we shall say, their own experience while you can start to do all your paperwork

and your reconstructions and whatever you need to do.

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