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Knee pain relief

June 28, 2006

Now there’s an artificial knee being made, just for women. Six years ago, Helen, a knee replacement patient, received a conventional implant to replace her left knee. Now her right knee is acting up.

“It aches. I sleep with a pillow under my knee. I sometimes use ice,” Helen said.

So she came back to Rush University Medical Center in Chicago to get a new right knee.

This time, orthopedic surgeon Aaron Rosenberg is putting in an artificial knee that’s made especially for women. It’s from an Indiana company called Zimmer.

“In general, looking at a large database of female bones, 80-percent of females would be better suited to this than the standard shape that we’ve previously used,” Dr. Rosenberg said.

The operation takes about an hour. Helen’s old knee joint is removed and the new knee is put in.

Dr. Rosenberg says the new implant is designed specifically to fit a woman. It takes into account a woman’s femur which is shaped differently and the larger space under the kneecap. Dr. Rosenberg says it also fits the inward angle of a woman’s legs.

But not everyone agrees.

“It’s marketing and I think its very clever marketing,” Orthopedic surgeon, Dr. Wayne Goldstein said.

Dr. Goldstein says the so-called female knee isn’t any different than other artificial knees. He also says there’s no research proving that the new female knee implant is any better.

“When we look at our database we have not found any reason that women do any differently than men as far as outcome and results,” Dr. Goldstein said.

Dr. Rosenberg admits there’s no clinical research yet on the female knee. He says because it’s so new.

In the U.S., more than 250,000 women get their knees replaced each year.

Posted by toshko under Pain Relief News | Comments (0)

Lost along the way

June 26, 2006

Heroin is like a parasite that seeps into your body and devours your spark for life.

When you’re addicted to the drug, it consumes your every thought. Controls your every move. Tells your brain you want more, and your body you need it.

Even when the stakes are high, when you know just one potent dose of heroin could end your life, you will stop at nothing to get the drug and end the withdrawals, the pain from a past injury, bad memories, or just plain boredom.

Locals who have fought heroin and defeated it, and those who are consumed by addiction, share one reality — they face a lifelong battle to stay clean.

Some succeed. Most don’t.

The addict

Danny Donnelly pulled his car away from the curb in a rough Holyoke neighborhood and aimed it for the first do-it-yourself car wash he could find.

In the passenger seat sat his cousin. In back, a friend.

They traveled from Pittsfield to Holyoke, “dope sick the whole way,” to buy cheap bags of heroin.

Within three minutes of leaving a drug den, Danny spotted a car wash and pulled into an open bay.

He was the first to shoot up. The warm rush hit the core of his body and slowly spread to his extremities.

“This is some potent stuff,” he said to his buddies. “Stronger than usual.”

Danny warned them to do just one bag. He exited the vehicle and slid quarters into a slot on the wall, washing the car as a cover, just in case any cops drove by.

Halfway through the soap cycle, his cousin opened the passenger door, took one step, and crumbled to the concrete. His face turned blue.

Danny dropped the hose and ran to his cousin’s side. He yelled to his friend, “Gimme a hand!”

The friend jumped out from the back seat, took a step and passed out beside the cousin.

Danny freaked out. He was high, but a sober clarity slapped him in the face — his buddies were dying; the heroin had stopped their breathing. Their hearts were next.

He slapped their faces. No response. The hose writhed and soaked the scene in suds as Danny heaved the men’s limp bodies into the front seat, arms and legs everywhere. He tore out of the car wash. There was a hospital about a mile away. He pulled up to the emergency room door, threw the car into park, and ran in screaming for help.

He grabbed the first wheelchair he saw. A nurse was right behind him with a second. Danny wheeled his cousin in and left. On probation and certain of police arrival, he headed home to Pittsfield.

His phone rang the next morning. It was his cousin. “Come get us,” he said. “They’re letting us out.”

Danny drove back to Holyoke and picked up the men. From the hospital, they headed for the same drug house, the same heroin, the same high that nearly claimed two lives just hours before.

“It was as comical as it was frightening,” Danny said as he sat inside the Berkshire County Jail and House of Correction in Pittsfield on a recent afternoon.

He’s back in jail for breaking the probation agreement stipulating that he would stay away from heroin.

It keeps pulling him back. It has for more than half his life.

“I fell in love with the drug when I was 12,” said Danny, now 46.

He was working on a Mr. Softee ice cream truck in New York City in 1972 when an older co-worker offered him heroin.

Curious, Danny stuck out his arm and tried a drug that would rule his life from then on. He had grown up in a rough-and-tumble Bronx neighborhood and was indoctrinated into the gang scene at an early age. The prerequisites for membership were centered on drugs and alcohol.

He moved to Pittsfield with most of his extended family in 1989 and seemingly was in and out of jail every other year. He’d stay clean for a few months and then fall back into the trap. About three years ago, something clicked. Danny started hearing what the counselors at the jail had been telling him for years, that the drug eventually would end his life.

He was released from jail, went to Narcotics Anonymous meetings, and found a painting job. He was clean for three months, the longest of any stay on the streets since his days on the ice cream truck.

And then fate kicked him in the gut.

“I had just gotten done with a job, and I was going to the store on break. As I’m walking on the sidewalk, I spot a bag of heroin on the ground. I’m like, ‘You gotta be kidding me.’ It just took me right back to the height of my using.”

Today, Danny says he wants to kick the habit, if not for himself, for his two young children and his wife. His brother-in-law, Eric Wickenheisser, died in the men’s bathroom of the Dunkin’ Donuts on First Street in Pittsfield last July after injecting a potent dose of heroin.

Danny partially blames himself.

“I was the first one who stuck him,” said Danny, referring to giving Eric his first hit of heroin.

Danny can reel off two dozen names of Berkshire County residents who have died of heroin or opioid overdoses. The names all match death certificates in City Hall.

Pam, his wife of 18 years, said she always believed she could change his behavior.

“I guess I’m a sucker for love, because I thought I could fix him,” she said. “I can’t. He has to help himself. I don’t know if he can. In jail, he’s a model citizen. When he gets out, he can’t cope. He goes right back to the drugs.

“Every important event in an addict’s life is centered around the drug, and when their next hit will come. Their memories just disappear. It takes a toll on everybody in the family, from the youngest to the oldest.”

Danny is scheduled to get out of jail in July. He knows what he has to do to break the cycle.

“I have to go to NA meetings, just like I went to Holyoke (to buy drugs). This place helps me. But then we’re let out and go right back to the same thing. We need more places to go after jail. We need more beds. Take those dilapidated buildings downtown and build us a place for transitioning.”

The teenager

Nick has seen “The Beast,” and he knows it’s real.

That’s what he calls an addiction to heroin. He’s a 27-year-old handyman from Adams who has been clean for nearly five years. He asked that his real name not be used.

To this day, he’s amazed that something as insignificant as a powder 0.025 grams in weight — a pinch of salt — could push him around for four years.

At Hoosac Valley High School, he started drinking alcohol and smoking pot as a freshman.

“We used the excuse that there was nothing else to do,” he said.

He used LSD and mushrooms, and then occasional hits of cocaine. In 10th grade, friends started passing around pain relief pills, opioids such as Percocet, OxyContin and Vicodin.

“We’d steal them from our friends’ parents,” Nick said.

The more they popped, the more they needed, as their bodies became tolerant of the drug. So he and his friends started crushing and snorting them to speed up the effects.

Nick said he went through the DARE (Drug Abuse Resistance Education) program in school, but was never scared enough to stay away from the chemicals. He was part of a four-boy pack that liked to experiment. Wherever the party was, there they were, boozing and doing drugs.

At one point, popping eight high-strength opioid pills was the norm for a Friday night. But their link to stashes of opioids started to run out. Purchasing them on the black market was expensive, as much as $80 a pill, and they began dropping large sums of cash on the opioids.

At a New Year’s Eve party in North Adams during their junior year of high school, the teenagers met a 22-year-old college student from the Albany, N.Y., area. They talked about opioids.

“He told us for a lot less money, we could get something that produced the same kind of high but only better,” Nick said.

It was heroin. Two days later, the four 17-year-old boys from Adams drove to an affluent neighborhood north of Albany, walked up a flight of carpet-covered stairs to the student’s bedroom, handed over $15 each, and snorted heroin for the first time.

“I puked within minutes. We all did. But then it was great. The feeling … it’s a warm, euphoric feeling. Nothing matters. You could be sleeping in the pouring rain and not feel a thing.”

Within a month, they were “booting” it with needles. They’d make trips to Albany three or four times a week to pay $60 for a bundle — 10 bags. They did this for four months until they learned about Holyoke and Springfield, where the drug was cheaper and easy to find.

“We figured we’d cut out the middle man,” Nick said.

More friends started experimenting. The four would drive to Holyoke with large sums of money collected from their friends, charging them more to make their habit less costly.

Nick estimates that within a four-year period, he and his friends drove the 54 miles to Holyoke between 800 and 1,000 times, sometimes twice a day.

In all those trips, they had only one bad incident with dealers. One of Nick’s friends was set up and mugged in an abandoned apartment. Nick said a lot of their dealers were nice people. The boys even befriended a group of middle-aged Latino women who would sell heroin out of their home.

The drug quickly took over their lives. Nick couldn’t hold a job. He kept calling in sick to work. He dropped out of high school because his grades suffered.

Eventually, his parents gave him two options: Get clean or get out of the house.

He chose the latter.

He lived with friends. Slept on couches. Scrounged for money for heroin. Tired of it all, he checked into the McGee Unit, a detox clinic at Berkshire Medical Center, on Oct. 15, 2000.

“I was there for 15 days,” Nick said. “It was hell. The withdrawals were so painful. It took me five days just to come out of my room. But I got clean. I started going to group therapy and got back with my parents.”

But within a few months, he was back at it and got kicked out again.

“I remember sitting on my friend’s couch on Sept. 11, 2001, watching the whole thing unfold. We had taken some methadone pills and then went golfing. The whole day was surreal. I remember around that time, thinking clearly that if I didn’t stop, I was going to kill myself.”

On Oct. 2, his friend said he was checking himself into McGee.

“I said, ‘So am I.’ He went in in the morning. I went in the afternoon.”

Both have stayed clean since. Of the four friends, three are clean; they’ve lost touch with the fourth, who moved out West.

“I wasn’t ready to get clean before,” Nick acknowledges. “There comes a point when it’s clear to you. No matter how many people tell you you have to quit, it takes yourself wanting it.”

Nick, who kicked his heroin habit cold turkey, credits attending Narcotics Anonymous meetings for his success. In his first year, he went to more than 500 meetings. He still goes twice a week. He has his own apartment now, and works full time with a local contractor. He’s able to enjoy the little things, the natural highs in life, like baby-sitting his siblings on a Friday night, and wrestling and eating pizza with them.

“One of the things we talk about at the NA meetings is coming to grips with reality and surrendering to the truth,” Nick said. “I’m an addict, and I realize that. That’s the first step.”

The dealer

Stacey loves getting high. She says she can’t help herself.

“I have an addictive personality.”

She’s a 41-year-old recovering heroin addict from Pittsfield who asked that her real name not be used. She wants people to know that heroin is the deadliest forbidden fruit in the jungle, and she warns the curious to stay clear of the stuff.

She started drinking at an early age and progressed to marijuana and cocaine. Fourteen years ago, she fractured a disc in her back, and the injury forced her to suffer through long days of constant pain.

She went in for surgery and was put on opioid pain medication.

“I was an alcoholic before, so when I got a taste of the 300 milligrams of Fentanyl, I was hooked. I loved it.”

When she got out of the hospital, doctors placed her on 20 milligrams of OxyContin. The dosage later was increased to 40, then 80.

“If I had known OxyContin would’ve led to heroin, I would’ve been scared enough to refuse it,” she said.

After surgery, she started eating all of her pills at once, sometimes 10 at a time. She burned through her prescription in days and was forced to pay big bucks on the black market for high-strength opioids.

“I was so dope sick at the time,” she said. “I was fiending for pills and fed up with the expense. A good friend of mine said, ‘Try a little of this,’ and one sniff of heroin and I was better within 10 minutes. No pain.

“A couple of hours later, I called him up and said I wanted to buy two bags.”

Within a month, Stacey was doing six bags a day. A few months later, 20 bags a day. She always snorted it. The thought of injecting it was too extreme.

“I tried it once and I got sick, so I stuck to snorting it,” she said.

She’d drive with her boyfriend to New York City, where they had a good connection for dope. But that got risky. She knew people who were stopped by New York state troopers and arrested. So she started making the shorter trip to Holyoke and Springfield.

Within a short time, she started selling the drug to friends to finance her out-of-control habit, pushing about 50 bags a day out of her apartment. She made a little extra money, but the important part was that she didn’t have to pay for her heroin.

Then, on Oct. 19, 2002, the cops came knocking.

“At that point, I wanted to get away from the stuff. I just wanted to get rid of the people. I was happy the cops came,” she said. “If I hadn’t been arrested, I probably wouldn’t be alive right now.”

With her arrest, she was forced to quit cold turkey.

“I was dope sick for two weeks,” she said.

She served a year in prison, and in the 31/2 years she’s been out, she’s slipped once. She’s on the methadone treatment program and receives daily doses of the drug. She says it allows her to enjoy a normal life and helps her fight the urges to fall back in with heroin and its crowd.

“I guess this is my routine for the rest of my life,” she says.

And if you placed a bag of heroin in front of her today?

“I don’t know if …” Then she paused. “No. I can’t be around it. I don’t want to be. I have to remove myself from all of those people. I just can’t be around the scene.”

The worker

Harry realizes what it takes to get clean, “the first step” — acknowledging that you have a problem. It’s the second step he’s not sure of.

Harry, 48, who asked that his real name not be used, is originally from Framingham. He was married, worked as an auto mechanic, and dabbled in alcohol, marijuana and cocaine.

In 1997, he got an offer to become the service manager at a large auto dealership in the state of Florida. The job paid $80,000 a year. He moved to Florida by himself to start work and find a place for him and his wife to live.

On a spring night in Framingham, his wife was staying at a friend’s apartment, and there was a carbon monoxide leak. She died in her sleep.

“I was mad at the world,” he said. “Home wasn’t home anymore. For a long time, I wanted to die. She was my best friend, and I didn’t really know how to function without her.”

Harry, living in a new place by himself and dealing with the gut-wrenching blow of his wife’s death, felt lost.

He started having unpredictable mood swings, snapping at co-workers over the smallest dispute. His boss noticed and threatened to fire him.

“Men aren’t supposed to cry. We don’t like whiners in our society. But still, months after she died, I was feeling like (expletive).”

One of his co-workers, a man he had become somewhat friendly with, suggested he take some pills while they were out drinking one night.

It was OxyContin, and Harry said the high helped him “squash his feelings.”

“I loved it,” he said. “It made me a better mechanic. I was more focused on my work. My boss actually made a comment that he was impressed with my turnaround.”

But the pills were expensive. He learned that heroin produced the same kind of high. He went out driving one night to find a prostitute, employing the thinking that “prostitutes can get you anything you want.”

For a fee, she put him in touch with a dealer who sold $10 bags.

He’d snort one before work and one when he got home. For five years, this was his routine. He was the typical functioning addict.

He moved to the Berkshires to help his sister — who was going through a divorce — fix up her old house in Sheffield.

“I was clean for a while because I was away from it, away from the scene and the people,” he said.

He was working in a local body shop. But loneliness and boredom set in, so he started making the drive to Pittsfield to sample the bar scene.

He met a woman, and the two started dating. The only problem was that she had a steady supply of morphine on hand.

“I found Pittsfield and I thought, ‘Man, these people up here are pharmacists,’ ” he said.

He started using again. Then an old injury, a double hernia, resurfaced and the problem snowballed. Now he was doing a half-dozen bags of heroin a day, partly to numb the pain, partly because of a physical dependency.

He and his girl split up, but he found another one. She, too, was an addict, a smart one, and she introduced Harry to Holyoke and Springfield.

They’d hit places like Saratoga and Oswego streets in Springfield and “The Flats” in Holyoke, a project area where drugs are in homes like candy in a corner shop. They’d buy bundles for $50.

To this point, Harry had never injected heroin. But as his injury grew worse, the prospects of quick pain relief broke down the barrier of shooting the drug into his veins.

“You shoot it and ‘Boom,’ you’re not in pain anymore,” he said. “It’s a warm feeling, very relaxing. It eases your mind. I’ve done every drug known to man and I’ve been able to kick ‘em all. Not this one. It’s a physical addiction as well as a mental one. You gotta have it.”

But after years of drug use, six bags became eight, then 10 and 12. Then came the pain of withdrawals the next morning — stomach cramps, sweats, shakes, diarrhea. The only cure: another fix of heroin.

“Your first bag in the morning doesn’t get you high — it gets you normal. You need the drug just to be you.”

On his way back to Sheffield last year from Holyoke, Harry was stopped in Great Barrington for not having an inspection sticker. Police found two bundles of heroin in his car, and he was sent to jail.

Today, he sits there, clean for nine months — he quit cold turkey, just as everyone in prison is forced to do. He’s due to get out shortly. When he talks about the drug and his addiction, he speaks in a tone of guilt, like he let himself down. He knows it’s not going to be easy to stay clean. There will be traps in the outside world.

“If you put 1,000 people in a room, the two junkies will always find each other,” he said. “I’m going to try like hell to quit (for good) when I get out.

“I’m tired of it, tired of the circle. I’ve lost too much in my life to keep adding to it. But I’d be lying if I said I think it’s going to be simple. I’ve got to fix my own lifestyles, stop the stupidity

Posted by toshko under Pain Relief News | Comments (0)

Total replacement

June 20, 2006

Lillian Fondren describes herself as a poster child for joint surgery. She’s had not one, but two operations; both of them at St Francis Hospital in Columbus and both of them by doctors named McCluskey.

For the Dothan, Ala., woman, it began on a rainy day in 2001. Her car hydroplaned and crashed, leaving her unconscious and en route to an emergency room with two broken feet. One foot was so badly mangled, doctors considered amputation. The only reason they didn’t, she says, was because her daughter wasn’t there to sign the release.

Her damaged foot was initially repaired using “fusion.” That’s a procedure in which two bones are locked together with screws and possible bone grafting. The goal is pain relief, stability and strength; not mobility.

Fondren, formerly an active woman, wasn’t happy with the result, and started looking for alternatives. Other doctors, she says, turned down her request for an ankle replacement, so in May 2003 she came to Columbus to see Orthopedic Surgeon Dr. Leland McCluskey . On July 3 of that year, McCluskey gave her a brand new, artificial ankle.

When it comes to joint replacement, “ankle orthoplasty” is the new kid on the block. The procedure was first attempted in the 1960s, but didn’t work well, so doctors stopped performing the operation. Since then, the prosthetic has been greatly improved. “With all the new technology and new designs,” Dr. McCluskey says, “the results are now more equivalent with other replacement surgeries.”

McCluskey is one of only three surgeons performing ankle replacement operations in Georgia. He has successfully performed more than 30 of them over the past three years and is now teaching other surgeons.

Fondren went home two days after her surgery and performed her own rehabilitation exercises. She says she has never needed any pain medication, and the ankle has never given her any problems.

To say she is pleased would be an understatement. “I can’t run,” she says, “but that’s not because of the ankle. It’s because of the fusion. Other than that, I can do anything I want to do.”

Everyone is not so lucky. Most joint replacements require weeks of painful physical therapy. McCluskey will be the first to tell you joint replacement is not for everyone — he calls it a last resort.

“None of the things we create,” he says, “are as great as what God created.”

Orthopedic surgeon Dr. George W. Zimmerman agrees. “I tell my patients, I’m not going to tell you when you need it. You’re going to come back to me and say I’m ready.”

xnot without riskx

Replacement surgery is mainly for patients with joints that have been severely damaged by injury or arthritis, and only when other, more conservative treatments have failed. In many cases, Zimmerman says, “You take somebody who is disabled, sitting in a wheelchair, and you can make them get up and walk. You’re returning them to a functional lifestyle and giving them a quality of life.”

But no surgery is without risk. Zimmerman says there is about a 1 percent chance of infection, blood clots or dislocation, but most people do very well and are very happy with the results.

How long the joints last depends on your lifestyle. “If you drive your car only to church on Sundays,” Zimmerman says, “it’s going to last longer than if you drive it every day.” Ninety-two percent of all artificial joints, he says, are still in place and working 10 years later. That’s better than most household appliances you buy.

Posted by toshko under Pain Relief News | Comments (0)

Tramautic Amputations

June 14, 2006

An amputation is the surgical or traumatic separation of a body part from the body.1 It is estimated that one out of every 200 individuals in the United States has had an amputation.2 Medical conditions like peripheral vascular disease (PVD) account for most surgical amputations, which are most often planned procedures that occur within operative suites in healthcare facilities. In contrast, traumatic amputations are not planned and usually occur outside of the hospital setting. More than 30,000 traumatic amputations occur every year.3,4 This article focuses on traumatic amputations involving adult patients in the prehospital environment. EMS providers who are knowledgeable and well trained in the management of traumatic amputations may contribute significantly to the successful reattachment of amputated body parts and reducing patient morbidity and mortality.5

Basic Anatomy
A traumatic amputation can involve any body part, including the arms, hands, fingers, legs, feet, toes, ears, nose, eyelids and genitalia. Upper limb amputations account for more than 65% of traumatic amputations.2 While anyone can be involved in an amputation, most victims are between ages 15 and 40. 2,3,6,7 A majority of the victims (80%) are male.3,7

The upper limbs include the fingers (phalanges), hand (metacarpals), wrist (carpals), forearm (radius/ulna), upper arm (humerus), shoulder blade (scapula) and collar bone (clavicle) (see Figures 1 and 2). Neurovascular structures include subclavian, axillary, brachial, radial, median and ulnar arteries. Axillary, radial, median and ulnar nerves are also present.8

Lower extremities include the pelvis (ilium, ischium, pubis), upper leg (femur, patella), lower leg (tibia/fibia) and foot (tarsals, metatarsals, phalanges) (see Figures 3 and 4). Neurovascular structures include the abdominal aorta, femoral, popliteal and anterior/posterior tibial arteries. Lower extremity nerves include sciatic, tibial and perineal.8

Amputation Terminology
Amputations are either complete or incomplete (partial).5,6 In a complete amputation, there are no tissues, ligaments, muscles or other anatomical structures connecting the amputated part to the body. A partial amputation is one in which an anatomical structure, such as a ligament, tendon or muscle, is still intact between the body and the amputated anatomy. Although the body part may not be functional at the time and complete amputation may appear to be imminent, the body part is still connected to the body. In a partial amputation, every effort should be made to preserve this connection.

Amputations can involve proximal or distal anatomy. Proximal amputations involve anatomy that is attached closely to the body’s core, such as an entire arm at the shoulder joint or a leg at the hip joint. Distal amputations involve anatomy that is distant from the core of the body, such as fingers or toes. Distal amputations are more common than proximal amputations.9,10

Specific phrases may be used when describing the anatomy involved in the amputation. For example, if the patient’s leg is amputated below the knee, it may be referred to as a below-the-knee amputation, or “BKA.” An amputation occurring above the knee may be referred to as above-the-knee amputation, or AKA.

Amputations can also be described according to their association with other injuries and the patient’s condition. Simple amputations are those that do not involve extrication, shock is not present and additional injuries, such as multisystem trauma, are absent. Complex amputations are associated with complicated extrication, the presence of shock or the presence of additional injuries.

Mechanisms Of Amputation
There are numerous scenarios that can involve a traumatic amputation. Common examples include industrial, farming and motor vehicle accidents. The use of power equipment, including electric saws, lawn mowers and snow-blowers, also puts people at risk2,6,7,9,11 (see Tables I and II).

In a traumatic amputation, specific mechanisms of injury (MOI) tend to be involved. Crush, guillotine and avulsion mechanisms are three of the most common forms of traumatic amputation.6,12 Other possible mechanisms are listed in Table III. Crush injuries tend to be the most common and can result in significant tissue damage and injury. Because of the injury associated with crush mechanisms, amputations resulting from these forces are less likely to be successfully reattached. In contrast, guillotine injuries involve sharp edges, resulting in less tissue disruption. As a result, body parts that are amputated by guillotine forces are likely to have better reattachment and recovery outcomes.6,12

Avulsion injuries tend to have the poorest outcomes with regard to reattachment. A classic example involves a ring avulsion, where a finger with a ring on it becomes caught on an object as the individual is falling. The injury that results from this “catching” can range from partial degloving of the skin to complete loss of the finger. Structures proximal to the point of amputation, such as tendons within the forearm, may be involved when a finger or hand is subject to an avulsion injury. Neurologic, arterial and venous vessel interruption can occur, and soft tissue damage or destruction is also likely. These factors result in a lower likelihood that a successful reattachment will occur.6,12,13

Prehospital Assessment
Begin the assessment with an overview of the scene.8,14,15 During this time, the MOI involved in the amputation may be identified. This time can also be used to determine the type of BSI that will be most appropriate.

Once the patient is reached, priorities include assessing the patient’s airway, breathing, circulation and neurologic status. Complete a mini-neurologic exam as soon as possible. This can be performed using tools like the Glasgow Coma Scale (GCS) and the AVPU system, where the patient is noted to be alert, responsive to verbal stimuli, responsive to painful stimuli or unresponsive.

Obtain an initial or baseline set of vitals when feasible. Vital signs should include condition of the patient’s skin (e.g., cool, moist, pale), heart rate, blood pressure and respirations. Capillary refill time and distal neurologic assessments should be included for any affected extremity.8,14,15

After conducting an initial assessment, it should be possible to determine the next plan of action. If, for example, the patient is in shock (e.g., tachycardia, pale/cool skin, hypotension), or has additional injuries (e.g., multi-trauma), the patient should be managed accordingly. This may include supporting the patient’s airway, breathing and circulation. It may also require immediate management of life-threatening injuries and deferring salvage of the amputated anatomy until additional resources are available. In an amputation, the specific steps taken will be guided by the patient’s overall condition, the severity of the amputation and the amount of elapsed time.8,14,15

Providers should also conduct a patient and bystander interview. If possible, determine the patient’s past medical history, allergies, prescribed medications and overall state of health. Also attempt to determine how much time has passed since the incident occurred. The reason for this is that time is tissue. The chance for successful reattachment decreases the longer the amputated part is not perfused. The patient’s medical history and timeline of the event can also be used by the hospital to assist in determining the appropriate treatment to pursue. If at all possible, try to determine the patient’s dominant side and provide this information to the hospital.5,8,12,14,15

Prehospital Treatment Of Amputation
Treatment provided for the patient who has suffered an amputation is influenced by numerous factors. Management of potentially life-threatening conditions is the first priority. Management of victims of amputations from blunt trauma is complicated by the concern for additional injuries. Blunt trauma amputations are often caused by mechanisms of high-energy transfer, such as motorcycle accidents, auto-pedestrian accidents, significant crush injuries and work-related accidents involving large machinery. These accidents often involve the potential for multi-system trauma, and the provider must stay alert to the possibility of other injuries. It is critical to remember that the most obvious injury is not always the most significant.

Your next steps will be influenced by many factors, including the mechanism of injury, body part involved in the amputation, presence of additional injuries, estimated fluid loss and proximity to a hospital.

Incomplete (partial) Amputation
Partial amputations should be assessed and treated as if they are fully intact. Regardless of the amount of injury, in the prehospital setting, partial amputations should be considered eligible for reattachment. If an extremity is involved, it should be splinted. Dressings, such as a saline-moistened sterile dressing, placed over exposed tissue will help to reduce additional contamination or injury. Initial efforts to control bleeding should include direct pressure and use of pressure points. Elevation may be considered.3,5,8,12,14-18 Similar to splinting an extremity, assess distal neurologic function and circulation prior to and following any manipulation. If available, pulse oximetry may be used as the patient is assessed and treated.19

Complete Amputation
If there is complete amputation and the anatomy is retrieved, it should be handled with the goals of preservation and reattachment in mind. Cover the amputated anatomy with a saline-moistened gauze, tightly seal it in a clean or sterile plastic bag and place the bag over ice. Providers should make every effort to avoid direct contact of amputated tissue with ice, as this can result in tissue damage.5,6,8,12,14,20

Anatomy that has been located
It is important to avoid delays in the treatment or transport of the patient and/or the amputated body part(s) that have been located. One reason is that the exact amount of time that an amputated part can survive before reattachment occurs has not been completely agreed upon in the medical community. Traumatic amputation tissue survival time continues to be researched. In the prehospital setting, timely delivery of the patient and any amputated parts to the emergency department should be a priority (see Table IV).17,18

Anatomy that has not been located
In cases where the amputated part has not yet been found, a comprehensive search may be initiated. The amount of time and resources used when searching for amputated anatomy varies with each scenario. Factors such as the involved amputated anatomy, scene dynamics, mechanism of injury, number of patients and availability of resources will influence this decision. Whenever possible, efforts should be made to locate and salvage amputated anatomy, as successful reattachment may significantly enhance the patient’s outcome and post-incident level of function.19,21

Entrapment & extrication
Extrication from entrapment should be accomplished with preservation of the limb in mind. Unless it is absolutely necessary to get the patient to a safer environment (e.g., out of a burning vehicle), the entrapped anatomy should not be pulled with force, as this may cause more injury. Dismantling the machinery may be the best option for extrication, and this may take hours to accomplish.

If dismantling the machinery is not possible, or for other reasons a “field” amputation is anticipated, providers are encouraged to consult with medical control. It may be possible for the prehospital crew to request that a physician (e.g., surgical team, “go team” or similar) be dispatched to the scene to assist with the amputation and additional treatments, such as local anesthesia. Providers should consider this option, as there are documented cases involving successful field amputations.19,22-24

Remaining & intact anatomy
If the amputation involves an extremity and there is a stump remaining, the stump should be immobilized whenever possible. Control external bleeding using direct pressure and elevation. In complete amputations, there may be minimal bleeding from the stump, as the vessels may spasm and retract. Partial amputations may involve more hemorrhage. Tourniquets are rarely necessary for control of hemorrhage from a wound. In most cases, appropriately applied direct pressure will be all that is necessary.

In the rare event that an exsanguinating hemorrhage cannot be controlled with direct pressure, a tourniquet may be effective. A single-cuff tourniquet (sphygmomanometer or blood pressure cuff) placed around the arm or leg proximal to the amputation site can be effective at stopping both venous and arterial bleeding without damaging or crushing underlying structures. Before application, elevate and manually exsanguinate the involved extremity, if possible. Then, inflate the cuff to 250-300 mmHg (or at least 70 mmHg above the systolic blood pressure), clamp the tubing, remove the bandage and lower the extremity. The maximum time a tourniquet can be left in place is generally 30 to 45 minutes, and is often limited by pain in conscious patients. A tourniquet can cause injury by producing ischemia, compressing and damaging underlying tissues, and can jeopardize the survival of marginally viable tissue, so it will need to be monitored closely. Remove all tourniquets before releasing the patient to another care provider. When tourniquets placed prior to EMS’s arrival need to be removed, consider having a cuff in place and ready to inflate for the rare case when direct pressure will not adequately control hemorrhage.25

Placing a saline-moistened sterile dressing over the stump will help to reduce additional contamination or injury. After bandaging the stump, it should be elevated to minimize swelling and control bleeding.3,5,12,14-18

Stump wounds should not be clamped or excessively manipulated. If the stump is dirty or has debris in it, use normal saline for irrigation. Do not use alcohol, hydrogen peroxide, iodine or other antiseptics for irrigation, as they can cause additional tissue damage.3,5,8,12,14-18

In the prehospital setting, it is not necessary to manipulate or otherwise examine the remaining stump or tissue. This can aggravate the tissue and may cause additional trauma. When treating a remaining stump or amputated anatomy, it should be handled with caution and managed appropriately.3,5,8,12,14-18

Intravenous access should be obtained, and volume replacement or administration of medications (e.g., analgesia) initiated as appropriate. Fluid selection will most often be either normal saline or lactated Ringer’s. The amount of fluid administered will be influenced by the patient’s overall condition and local protocols. If aggressive volume replacement is not indicated, intravenous access can be used as a “keep-vein-open” and medication route.8,14,15

Pain relief is often indicated and can play a significant role in the prehospital management of victims of amputations. The use of analgesia will be influenced by a variety of factors, including the patient’s overall condition, allergies, provider judgment, local protocols, available medications and presence of alcohol or drugs. An adult dose of 2-5 mg morphine sulfate, delivered IV, repeated every 3-5 minutes as needed, is commonly used for pain relief. Fentanyl can also be used for analgesia and sedation. An adult dose, in the range of 1-2 mcg/kg, slow IV, may be used. The combination of these two drugs can be very effective: Fentanyl has a rapid onset, but diminished effect after 20 minutes, while morphine has a peak effect about 20 minutes after administration. Local anesthetics, such as Xylocaine or bupivacaine, can provide more targeted pain control in certain cases. Although these are often not immediately available in the prehospital setting, they are available in most emergency departments. This may be an indication for having a physician respond to the scene when extrication issues prevent timely transport. The actual medicine and dosage may vary, depending on medical control or local protocols.5,6,8,14-20

In amputations, it can be critically important to document the times when events occurred. If possible, determine when the initial incident occurred. In a complete amputation, if the body part was located prior to your arrival, try to determine when and where the part was located. If the body part was located while EMS was on scene, note the time of discovery. Other times to consider recording include the time that the body part was wrapped and when icing began. Having this type of detailed information may help to determine if reattachment of the amputated part is possible.5,6,20

Communications
When communicating with a hospital, communications/dispatch center or other facility (e.g., transplant center) regarding the patient’s condition, provide basic information (e.g., medical history, allergies, vitals), as well as amputation-specific details. This may include the exact location of the amputation, the mechanism of injury, when the initial injury occurred, treatment provided and the patient’s overall condition. Early notification can play a role in the patient’s outcome. In some cases, it can take significant time for a hospital to mobilize all necessary resources to care for some types of amputations (such as fingers), and early notification with key information can maximize patient care by providing more timely access to those resources.19

Destination
In situations where there is only one hospital or a single trauma center, the destination choice is easy. In situations where there are more options, it should be clear which hospital, if any, is capable of performing reattachment and revascularization procedures. At the time of this writing, many areas of the country do not have personnel to perform these procedures. Local protocols should clearly direct prehospital caregivers how to choose a destination when caring for a patient with a traumatic amputation. In general, amputations proximal to the wrist or ankle should be directed to a high-level trauma center. Resuscitation and evaluation of the amputated part can be continued while speciality reattachment centers are consulted as needed.

Conclusion
The ability to effectively manage an incomplete or complete traumatic amputation can influence the long-term outcome of the patient’s extremity, his mental health and his ability to regain near-normal levels of functioning. Prehospital providers are encouraged to remain abreast of contemporary treatment and management options. By taking a positive approach, you can render optimal patient care while contributing to a reduction in patient morbidity and mortality.

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New Survey Reveals Worrying Between Attacks Can Extend Suffering For Migraine Sufferers

June 11, 2006

Main Category: Headache / Migraine News
Article Date: 09 Jun 2006 - 0:00am (PDT)
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New Survey Reveals Worrying Between Attacks Can Extend Suffering for Migraineurs
A new nationwide survey of migraine sufferers found that nearly half (45 percent) of respondents say migraine is worse than having a root canal and more than two-thirds (68 percent) say they are concerned about their next attack even when not actively experiencing one. Migraines are a painful reality for nearly 30 million Americans, many of whom are dissatisfied with their current treatments.

The survey was conducted on behalf of Ortho-McNeil Neurologics, Inc. by Harris Interactive. Among the survey’s findings were:

– More than three-quarters (76 percent) worry that they will have to suffer with migraines for the rest of their lives.

– Nearly half (45 percent) feel that concern about another migraine attack is always at the back of their mind.

– More than one-third of survey participants say they always feel anxious about migraines, never knowing when or if another attack will strike.

– On average, respondents reported suffering from migraine more than four days in the last month.

“Not only do migraineurs deal with the intense pain and physical symptoms that accompany a migraine attack, some often spend even more days between migraines worrying about when their next headache will occur,” said Elizabeth Loder, MD, assistant professor of medicine at the Harvard Medical School and director of the Pain and Headache Management Program at the Spaulding Rehabilitation Hospital in Boston, Massachusetts.
For some of these people, there are treatment options that could be right for them.

“Helping to effectively change this cycle of migraine may require taking a new approach to managing the condition for some patients,” Dr. Loder said. “Although prescription and over-the-counter medications are commonly used to treat migraine pain when it occurs, migraineurs with frequent, disruptive attacks may benefit from medications that can actually help prevent migraine attacks from happening in the first place so patients can get fewer of them to worry about.”

There are as many as 14 million American adults suffering from frequent and severe migraines who may benefit from preventive medications; however, according to the American Migraine Prevalence and Prevention study, only one in five sufferers currently uses preventive therapy. The preventive medication most recently approved by the U.S. Food and Drug Administration is TOPAMAX(R) (topiramate) Tablets, which has been shown in clinical studies to significantly reduce the number of migraine attacks. TOPAMAX is believed to help “calm” over excitable nerve cells in the brain, so they don’t send out signals that can cause migraine pain.

“I suffered for nearly 11 years before I found an effective treatment,” said Barbara DiGiovanni, 51. “I sometimes felt like the pain during an attack would keep me from fully participating in my home, work and social life, but even when I wasn’t having an attack, the anticipation of the next one distracted me from other events.”

The goals of preventive medications are to: reduce the frequency and duration of attacks; improve responsiveness to pain-relief medications; and improve function and reduce disability. Combined with lifestyle changes, preventive therapy can help migraine patients effectively manage their condition.

TOPAMAX is not right for everyone. Migraine sufferers should talk to their healthcare professional to see if they might be an appropriate candidate for prevention medication. Individuals taking TOPAMAX should also talk with their healthcare professional to set appropriate expectations about migraine reduction and potential side effects.

About Migraine

Migraine is characterized by a variety of symptoms, including sharp throbbing pain on one side of the head, nausea or vomiting, visual disturbances and sensitivity to noise and light. It is a chronic and greatly misunderstood condition, resulting in temporary incapacitation, lost productivity and significant disruptions to work and personal life. Migraine generally affects women three times more than men, particularly women between the ages of 25 and 55.

About TOPAMAX

TOPAMAX is approved for migraine prevention in adults only.
TOPAMAX is not for the acute treatment of migraines.

IMPORTANT SAFETY INFORMATION

Serious risks associated with TOPAMAX include lowered bicarbonate levels in the blood resulting in an increase in the acidity of the blood (metabolic acidosis), and hyperventilation (rapid, deep breathing) or fatigue. More severe symptoms of metabolic acidosis could include irregular heartbeat or changes in the level of alertness. Chronic, untreated metabolic acidosis may increase the risk for kidney stones or bone disease. Your doctor may want to do simple blood tests to measure bicarbonate levels.

Other serious risks include increased eye pressure (glaucoma), decreased sweating, increased body temperature, kidney stones, sleepiness, dizziness, confusion, and difficulty concentrating. Tell your doctor immediately if you have blurred vision or eye pain.

More common side effects are tingling in arms and legs, loss of appetite, nausea, diarrhea, taste change and weight loss.

Tell your doctor about other medications you take.
Please see full U.S. Prescribing Information at http://www.topamax.com

. TOPAMAX is approved as adjunctive therapy for patients 2 years of age or older with primary generalized tonic-clonic seizures, partial-onset seizures, or seizures associated with Lennox-Gastaut syndrome.

TOPAMAX is approved as initial monotherapy in patients 10 years of age and older with partial-onset or primary generalized tonic-clonic seizures. Effectiveness was demonstrated in a controlled trial in patients with epilepsy who had no more than two seizures in the three months prior to enrollment. Safety and effectiveness in patients who were converted to monotherapy from a previous regimen of other anticonvulsant drugs have not been established in controlled trials.

IMPORTANT SAFETY INFORMATION

Serious risks associated with TOPAMAX include lowered bicarbonate levels in the blood resulting in an increase in the acidity of the blood (metabolic acidosis), and hyperventilation (rapid, deep breathing) or fatigue. More severe symptoms of metabolic acidosis could include irregular heartbeat or changes in the level of alertness. Chronic, untreated metabolic acidosis may increase the risk for kidney stones or bone disease. Your doctor may want to do simple blood tests to measure bicarbonate levels.

Other serious risks include increased eye pressure (glaucoma), decreased sweating, increased body temperature, kidney stones, sleepiness, dizziness, confusion, and difficulty concentrating. Tell your doctor immediately if you have blurred vision or eye pain.

More common side effects in adults are nervousness, coordination problems, fatigue, speech problems, slowed thinking, memory difficulty, tingling in arms and legs, and double vision; and in children, fatigue, loss of appetite, nervousness, memory difficulty, aggressive behavior, and weight loss.

As monotherapy, the most common side effects of TOPAMAX (in the 400 mg/day group and at a rate higher than the 50 mg/day group) in adults were tingling in arms and legs, weight decrease, sleepiness, loss of appetite, dizziness, and difficulty with memory; and in children, weight decrease, upper respiratory tract infection, tingling in arms and legs, loss of appetite, diarrhea, and mood problems.

In combination with other antiepileptic drugs (AEDs), the most common side effects of TOPAMAX in adults (200 to 400 mg/day) were sleepiness, dizziness, nervousness, loss of muscle coordination, fatigue, speech disorders and related problems, psychomotor slowing, abnormal vision, difficulty with memory, tingling in arms and legs, and double vision; and in children (5 to 9 mg/kg/day), fatigue, sleepiness, loss of appetite, nervousness, difficulty with concentration/attention, difficulty with memory, aggressive reaction, and weight decrease.

Tell your doctor about other medications you take.
Please see full U.S. Prescribing Information at http://www.topamax-epilepsy.com .

Survey Methodology

Harris Interactive(R) fielded an online survey on behalf of Ortho-McNeil Neurologics, Inc., between May 17 and 23, 2006. The survey included a cross- section of 505 adult men and women who reported suffering an average of 2.9 migraine attacks per month.

About Ortho-McNeil Neurologics, Inc.

Headquartered in Titusville, N.J., Ortho-McNeil Neurologics, Inc., focuses exclusively on providing solutions that improve neurological health. The company currently markets products for Alzheimer’s disease, epilepsy, and acute and preventive migraine treatment. Ortho-McNeil Neurologics, Inc., in conjunction with internal and external research partners, continues to explore new opportunities to develop solutions for unmet healthcare needs in neurology.

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Arthritis Sufferers Find Relief In Needle

June 8, 2006

BOSTON — Arthritis can slow down the most active people, and it can lead to surgery. But a growing number of arthritis sufferers, including professional athletes, are finding relief in a needle that delivers cushion to their aching joints.

“The knees just feel so much better and my mobility is great,” Kevin Hickey said.

NewsCenter 5’s Heather Unruh reported that Hickey’s knees didn’t always feel so great. The 58-year-old schoolteacher and golf lover suffers from arthritis, and he said the pain was putting his life on hold.

“I had trouble walking up and down stairs,” Hickey said.

So Hickey walked into his orthopedist’s office for a round of Synvisc injections. The artificial lubricant is injected directly into the knee to provide cushioning for the arthritic joint.

“Hopefully, it acts just like the joint fluid in there,” said physician’s aid Lampros Minos. “Certainly, it decreases their amount of stiffness that most people with arthritis will get in the knee.”

Dr. Arnold Scheller has used Synvisc to deal with his own arthritis. He said the shots allowed him to continue his military career.

The injections are most beneficial for patients in the early stages of the disease, and won’t eliminate the need for anti-inflammatory medications and eventual surgery, Scheller said.

“It’s not a replacement for the total knee. If you have arthritis, eventually you’re looking at the total knee replacement. This is a big Band-Aid and it’s pushing back the inevitable surgery,” Minos said.

But it’s a Band-Aid many athletes are using. Red Sox players David Wells and Keith Faulk are reportedly among those who receive the injections. And they’re not alone.

“I’ve spent 20 years as team physician to the Celtics, and we used it on a regular basis with them. You know to make their joints more comfortable with the rigors of professional sports,” Scheller said.

And while Hickey isn’t a professional athlete, he said he is thrilled that Synvisc has put him back on the golf course.

“It hasn’t helped my golf game too much, but at least I can get around the course now,” he said.

The recommended usage for Synvisc is one injection every week for three weeks. The results will typically last from six to nine months. But comfort does come at a cost — you’ll need to pay about $600 for the three shots.

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Many approaches taken to childbirth

June 5, 2006

Joy Martin of Youngstown delivered her third son in January, and she knew she wanted to give birth naturally, with no pain medication.

‘‘I was watching ‘A Baby Story’ on The Learning Channel, and I knew I’d wanted to do it naturally. My mother had done it that way, and I wanted to at least see if I could do it too. I wanted to experience the birth,’’ she said.

She didn’t make the decision quickly, however; she discussed her options with her doctor, and switched to a certified nurse-midwife after deciding she wanted to attempt labor with no pain medications.

‘‘I learned about epidurals. I talked with my doctor about the potential risks to the baby, and decided not to go with the anesthesia.’’

Women are being encouraged to take an active part in making decisions about their medical care during labor and the birth of their children.

Birth plans, created by the mother and ideally, discussed with her physician, are one way many women try to take control of their birth experience.

Still the patient’s decisions aren’t always welcomed with open arms by practitioners.

‘‘It’s not to be etched in stone. You have to be flexible,’’ said Kim Tranter, a board-certified nurse-midwife in Warren.

It’s a dance, she said, to make the hospital guidelines meet with the desires of the mother. For example, many women don’t want IV needles, she said, while many hospitals insist upon them with safety in mind.

‘‘A compromise is to have the IV in place, but it can be capped off, and not in use, just there if necessary, allowing the woman to take fluids normally and still move around. Fetal monitoring, also. As long as the baby is doing well, fetal monitoring can be intermittent, instead of constant.’’

Rigidity has no place in the plan, Tranter said.

‘‘Some women insist on no medical interventions at all, no matter how small. That’s an example of rigidity. … Women who are inflexible are setting themselves up for failure instead of setting themselves up for success,’’ she said.

Tammy M. Pangilinan, a board-certified nurse-midwife based in Boardman, was a labor and delivery nurse at a local hospital for 22 years before becoming a nurse-midwife.

‘‘It seemed like we were manufacturing babies,’’ she said. ‘‘It’s a baby — it shouldn’t seem like we’re working at GM. It doesn’t have to be that way.’’

Pangilinan talks to her patients about what hospitals require and what rules may be bent a little. For example, she’s asked for moms in labor to be brought food — not just gelatin or ice chips.

‘‘A hospital should cater to their client’s needs,’’ she said. ‘‘Sometimes, it’s more like ‘you listen to what we tell you.’’’

‘‘We are getting used to new ideas in labor and delivery,’’ said Patty Fusselman, nurse-manager of labor and delivery at the mother-baby unit at St. Elizabeth. ‘‘Before, women were permitted only ice chips; now, they can have water. We almost fainted when one of the midwives asked us to feed her patient — it’s just something that was never done.’’

Still, what hospitals want to do and what mothers want for themselves and their babies sometimes seem to be at odds.

‘‘I did have to tell the nurses once that they weren’t going to bathe my baby just then,’’ said Martin. ‘‘It was 2 a.m. He’d just gotten to sleep.’’

Martin suggested the bath might be more appropriate in a few hours, she said, and the nurses were willing to return once her son awoke.

Kristen Borsic of Warren delivered her first child, Jacob Donald, at Forum Health Trumbull Memorial last month. Her husband, Donald Borsic, and her parents kept her company in the post-partum room after a nine-hour labor.

She didn’t have a birth plan. As her son was sleeping in his bassinet in her hospital room, she said she’d recommend women seriously consider crafting a birth plan with their doctor before delivery.

‘‘When you have a baby, all sorts of people want to visit,’’ she said. ‘‘Friends, family. Finally, we put our foot down and said, no more.’’

Visitors are just one thing women can limit on their birth plans. There are many other aspects of the birth women should consider, said Cassandra Campion, doula and head start worker at MYCAP.

‘‘Be flexible, and discuss it with your doctor ahead of time. And you can’t have outrageous demands. For example, the hospital isn’t going to let you bring in a swimming pool if you want a water birth, and they don’t have the facilities.’’

Other things to discuss, she said, are ‘‘Do I want drugs or no drugs? Sometimes, women have put a note on the door saying: Please don’t offer me pain medication unless I ask for it. Would I like to drink and eat freely? What if I need a C-section? How long will I stay? Would I like the baby to room in? What about breast feeding?’’

Many times, Campion said, women don’t think past the actual birth in their planning.

Martin, who chose to deliver without pain medication, is in the minority. Local hospitals all estimate about 60 percent of women choose epidurals during labor. Some doctors’ estimates are much higher.

An epidural is an anesthetic administered through the spine.

‘‘In this area, the rate is in the 50 to 60 percent range,’’ said Dr. Anthony DeSalvo, Warren obstetrician/gynecologist and president of the Trumbull County Medical Association. The rate differs from region to region, he said. When at a private hospital in New York, Dr. DeSalvo said epidurals there were administered in 90 percent of all births.

The way practitioners feel about epidurals and other pain relief varies.

Many labor and delivery nurses have their own opinions, too.

Diane Simcox, a long-time labor and delivery nurse at St. Elizabeth and a self-described advocate of epidurals, said pain management options have improved over the years.

‘‘You don’t get a gold star for going through the pain,’’ Simcox said.

Martin, whose three children were born with the help of a midwife, and all without pain medication, disagrees.

‘‘I have my own gold star,’’ she said. ‘‘I am so proud of myself.’’

Her husband, Tim Martin, is proud, too.

‘‘I’m a sissy — if I were a woman, I’d probably never have kids,’’ he said. ‘‘But whenever you tell someone you just had a baby, one of the first questions they ask is, did she get the epidural? If you say no, the next question is, didn’t that hurt? And when I say no, there’s a look of respect.

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Pain Relief To Go

June 3, 2006

BACKGROUND: According to the National Center for Health Statistics, when it comes to our body, we know when it hurts:

» About 31 million visits were made to physicians’ offices due to back problems in 2003.

» About 19 million visits were made due to knee problems in 2003.

» Nearly 14 million visits were made due to shoulder problems in 2003.

» About 11 million visits were made to due to foot, toe, and ankle problems in 2003.

Broken legs, shoulder tears, torn knee cartilage, fractures¡Kthe list goes on. As bad as all those injuries are, getting them fixed can be just as painful — sometimes more painful. Narcotics are often used to control that pain, but they can have a lot of unwanted side effects like nausea, vomiting, itching, sedation and constipation.

PUTTING AN END TO THE PAIN: Catheters and nerve blocks have been used to control pain following orthopedic surgery like knee replacement and ACL repair. However, to get the catheter in the right spot, anesthesiologists have had to either illicit an electrical response from the nerve with a nerve stimulator, which is uncomfortable for the patient or actually touch the nerve, which is painful and can cause nerve damage. Now, doctors are using ultrasound guidance to deliver easier and more accurate pain relief before the patient undergoes surgery. Jeff Swenson, M.D., from the University of Utah, says: ¡§With ultrasound guidance, now we can look on the screen, place the needle close to, but not touching, the nerve and watch the local anesthetic surround the nerve without ever causing any pain. That¡¦s going to revolutionize safety and speed of placement for these nerve blocks.¡¨

HOW IT WORKS: Before the scheduled surgery, doctors locate the nerve with ultrasound, thread a needle and catheter to the spot, and deliver the anesthetic. They use a low-dose and a low volume of a local anesthetic called bupivacaine. Then, they attach the catheter to a bottle that contains a balloon filled with bupivacaine. The bottle is wrapped in an elastic bandage around the leg. The patient has this attached before the surgery and the balloon continuously delivers the anesthetic to the targeted nerve for two days following the surgery. When the medication runs out, patients simply take it off and throw it away. Dr. Swenson says: ¡§If we can give [patients] some type of modality that relieves their pain and allows them to go home and be recuperating at home, most patients will jump at the chance to do that. It¡¦s really an amazing technology that we can use ultrasound to safely place those catheters very rapidly with minimal discomfort to the patient.¡¨ The best part about this, he says, is that patients usually don¡¦t need heavy narcotics to control their pain because the anesthetic delivered through the catheter is enough.

The main types of surgery that this is currently used for include rotator cuff repairs in the shoulder, shoulder dislocation repairs, anterior cruciate ligament (ACL) reconstructions in the knee, and major foot and ankle procedures. Dr. Swenson says if you¡¦re having orthopedic surgery, talk to different hospitals about what kind of pain relief you¡¦ll receive. He says: ¡§Most academic centers of anesthesia — probably 50 percent — have already adopted this technology. A much smaller percentage of those are very adept at this new technology.¡¨

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PAIN RELIEF DAY: LIVIA TURCO - OPIATE MEDICINES “EASIER

June 2, 2006

(AGI) - Rome, 25 May - Italy is unable to move from its place as last in line, in Europe and the world, in the World Health Organisation rankings, in the use of opiate medicines” while however the priority is “pain control”. It is therefore necessary to take steps to deal with this for example simplifying the prescription of opiates, writes Livia Turco, head of the department, in the long letter addressed to the president of the Foundation, “Gigi Ghirotti, Bruno Vespa, on the occasion of the press conference for the presentation in Milan of the fifth National Pain Relief Day. Ms Turco said that she was “sorry not to be able to attend the press conference due to unpredicted and unavoidable official commitments. I would have been particularly pleased to have taken part in the event in order to emphasise, at the outset of my appointment as Health Minister, the attention that this Ministry wants to pay to the issue of pain relief and its control, one that I see as a priority”. (AGI) -
251741 MAG 06

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