talk to me about spinal/ epidural meds and options.... - Page 2

[AlexisT]

Well, yes--in fact, patients were even told they were allergic, when they're not. It's been perpetuated by doctors as well as a misunderstanding of the difference between "side effect" and "allergy." But that's why docs are trained to ask about the specifics, so they can try to tell what it was. Big difference between "the Duramorph made me really itchy" and "my throat swelled and I couldn't breathe." Two different complications, two different approaches will be needed for the patient.

Side effects are very real and need to be taken seriously--I don't mean they're irrelevant. But by painting it as an allergy, you may lead the anesthesiologist to take an approach that won't meet your needs. S/he will base decisions on the "allergy" rather than the true problem. Simply saying "I don't want opiates" may not help because the anesthesiologist is going to be extraordinarily reluctant to leave you without a pain management option after major abdominal surgery. By planning ahead and consulting with an anesthesiologist, you can have a much more satisfying plan of care and a much, much better experience. I know someone who had to have a planned C. She was so scared of spinal anesthesia that she thought they would have to do a general. By working with her doctors, she was able to have spinal anesthesia, see her baby be born, and have a really positive experience.

[katelove]

Originally Posted by EdzMommy 

 Valium is long-acting, and it can't be given through the IV.

Just curious to know what you mean by the bolded. Is diazepam not given IV in the US?

[Devaskyla]

Hildare, have you gotten your medical records to see exactly what you were given? That might help you make a more informed decision.

Originally Posted by EdzMommy 

While I never give a patient a medication that they're allergic to, I will sometimes give a medication if the patient describes a common side effect and not an allergy.  For example, itching and nausea are side-effects of opiates, not true allergies. 

How does this not violate the patient's right to informed consent/refusal? This kind of thinking makes me really angry. The anesthesiologist for the cesarean I had with my oldest obviously had the same thinking, because he gave me morphine, despite me saying I didn't want it because it caused extreme nausea. He blew me off with 'that's a normal reaction' and gave it to me anyway. Fast forward 16+ hours to several panicked nurses freaking out because I couldn't even keep water down. If I hadn't had morphine before and known what it did to me, I dread to think what would have happened. And all because someone decided to give me something I specifically said I didn't want because they decided that my reaction was common, without ever finding out details. That is the trouble with ignoring patients who ask to avoid something because of something you consider "common". Not to mention, unless there are no other options, no one else should decide for someone what they should put up with in the way of side effects.

Unfortunately, due to this experience, if I ever have to have surgery again, I know I won't be able to trust that my wishes will be respected. Hopefully it's a moot point & I'll never have another surgery, but if I have to, I will likely be extremely vocal about not getting morphine.

[Storm Bride]

Originally Posted by AlexisT 

Side effects are very real and need to be taken seriously--I don't mean they're irrelevant. But by painting it as an allergy, you may lead the anesthesiologist to take an approach that won't meet your needs. S/he will base decisions on the "allergy" rather than the true problem. Simply saying "I don't want opiates" may not help because the anesthesiologist is going to be extraordinarily reluctant to leave you without a pain management option after major abdominal surgery.

The bolded is where my personal issues come in. Why is it the anesthesiologist's decision as to whether or not I get pain management "options"? How are they "options", if I'm getting them when I don't want them? What does being reluctant to leave me without those "options" after surgery have to do with meeting my needs, if I don't have a need for said "options"?

By planning ahead and consulting with an anesthesiologist, you can have a much more satisfying plan of care and a much, much better experience. I know someone who had to have a planned C. She was so scared of spinal anesthesia that she thought they would have to do a general. By working with her doctors, she was able to have spinal anesthesia, see her baby be born, and have a really positive experience.

I'm glad for your friend, but it doesn't always work that way. I've had three planned c-sections. I was terrified of the spinal when I went for the first of those three. I was more terrified by the second one...and I only got through the third one without a complete breakdown, because the anesthesiologist allowed dh to come into OR while she administered the spinal. They don't normally allow that, but she was a wonderful doctor, and I have that "mother of a stillborn baby" note in my file that makes most care providers actually pay attention to what I say (finally - I'm appalled at the difference in the care I received after going through a personal tragedy, not because there was anything wrong with it, but because there's no reason why every patient on L&D/maternity shouldn't get the same level of consideration). I was scared of spinal anesthesia initially, because it was an unknown. I was far more scared of it once I knew what it was going to be like. There's not a single aspect of spinal anesthesia that doesn't cause me fear...I hate the needle being in my spine. I hate the pain of the needle. (Needles generally don't even make me blink...I can have IVs, innoculations, blood draws, including donation, etc. without batting an eyelash.) And, most of all...I hate the anesthesia itself - the numbness. I was conscious for the "births" of three of my children, and as happy as I was to see them so soon...being unconscious was a much, much, much better experience. For some women, being there for the "birth" trumps being awake for surgery, but it doesn't work that way for me. I can't opt out of the spinal, because general anesthesia confers additional risks to me, which I'd risk in a heartbeat, and my baby, which I wouldn't risk, and don't have the option to risk, anyway. If I could, I would. Being unaware was a much, much better way to have surgery.

Receiving spinal anesthesia is a grotesque, surreal, traumatic experience for me. It's about on a par with the surgery itself. Just thinking about getting the needle makes me twitch. After I typed "I hate the anesthesia itself - the numbness" in the above paragraph, I started to describe what it was like...and had to leave the keyboard twice, started feeling queasy, and had to take multiple deep breaths just to get under control, and had to delete the sentences in question. There is no way to make spinal anesthesia (or a c-section, for that matter) a positive experience for me, because the experience is inherently negative, in every respect, except that I ended up with a baby at the end of it. I summarize my last c-section - the only one I initiated, planned, and went into something resembling willingly, and the one where everybody bent over backwards to make it "positive" for me - as a "less sucky" c-section, because that's as good as a c-section, especially under spinal, is ever going to get.

Anyway...this post was much longer than I intended. Spinal anesthesia has caused me a lot of psychological trauma, and once I get talking about it, I lose my train of thought very easily.

[AlexisT]

How can you possibly know in advance of surgery how you will feel? How can you possibly know there will be no complications, that you will NOT be in extraordinary pain that is beyond what you have planned for? If you exclude all opioids and refuse to discuss them at all, and then you have that one in a thousand horrific surgery, and you've bled too much for Toradol... you've just forced yourself to suffer and have removed your doctors' ability to deal with the problem. This isn't just "Do I get Duramorph in my spinal?" It is not just "this is my pain and I get to decide how to cope with it." With any surgery, you're running the risk of complications. You could be half conscious and unable to make a rational decision. You could have a level of pain that your providers judge to be potentially harmful to you. It is very much the anesthesiologist's job to make sure you have options. Whether or not you have an option available to you is not the same as whether or not you have the right to say yes or no. You can say no to an option.

That is aside from the medical and ethical challenges of doing the surgery itself without opioids in the spinal. Yes, leaving patients in horrible pain is considered unethical for an anesthesiologist. Pain control is considered a right.

[brovie]

Hildare:

to answer your question (finally! :))

"brovie, if you're still around, do you mind one more question? if i ask that i not receive duramorph or morphine, is it likely that i would then have to request an opiate later? or (since i could tolerate the toridaol last time) could i manage without opiates completely? i don't want to walk into a situation with unbearable pain but at the same time, i was pretty high and had a hard time with breastfeeding, etc. and i can stand a little pain rather than the drugged effect. your descriptions were really helpful."

whether or not you decide to refuse having duramorph or spinal/epidural morphine, after a C/S (which is a major abdo surgery as you know) you are likely to need something for pain relief.  Most people need opioids.  Studies show that oral and IV or subcutaneous or intramuscular opioid use is cut down by spinal or epidural morphine.  Studies DON'T show that pain control is worse....but the effect of having to take more opioids by other routes is generally that women experience more side effects like nausea and constipation. 

That being said, the same opioid by different routes (spinal vs IV vs oral morphine) can have a different side effect profile in any given patient.  For example, through experience you might find that spinal morph makes you itch like mad for two days whereas oral morph makes you constipated whereas IV morph does both (note, I'm just giving reactions here to try to make a point, I'm not trying to suggest that that this is what actually happens).  You might find that morphine loops you out but hydromorphone or oxycodone doesn't.  So even if you need opioids after the surgery, being able to decide when and how much to take for yourself will probably sit better with you than having someone put a 48 hour dose in your spinal or epidural space.  For example, you take a small dose of hydromorphone orally, it loops you out but it wears off in 4 -6 hours....so next time you take a smaller dose...or you ask to try oxycodone...or you take some extrastrength tylenol and some toradol and tough it out because that's your preference.  Retaining more control over what is going into your body generally results in great satisfaction...that's the whole premise behind IV patient controlled analgesia, patient controlled epidural analgesia etc etc.  Moms at the maternity hospital I trained at where given a "box of goodies" after their delivery (vaginal or C/S) that contained a whole wack of oral medications with instructions...including tylenol, anti-inflammatories, and a few different kinds of narcotics.  Sure the nurses and docs would answer their questions and help them if asked, but they really were totally in control of their own pain management.

I think its important FOR EVERYONE ON THIS BOARD to remember that you and the anesthesiologist actually have the same goals and I don't see why we can't approach each other with a little less baggage and a little more respect (a little less paternalism on the doctor's side and a little more open-mindedness and trust on the mom's side): 

- freedom from UNwanted pain (note: not ALL pain.  this is patient determined...pain vs pain meds and side effects and is a different threshold for every person)

- the ability to mobilize (get out of bed, lift your infant and take care of your infant, walk to the washroom, etc) after surgery

- the ability to breastfeed if desired (requires both pain control and breastfeeding compatible meds)

A helpful way for you to frame the discussion, Hildare, if you have to have a c-section again would be something like this:

- I had a horrible reaction to what I think was the morphine/ duramorph in my spinal last time and I would like to avoid this medication.  Then describe the reaction...then ask if they have your anesthetic record from your last C/S and what they think may have caused it...

- in general I hate how opioids make me feel.  Is there a way we can minimize my need for them?  Can I try other opioids than morphine to begin with because morphine makes me feel ____________?

- what are the options if I have a bad reaction/ side effect again?

But I wish you a successful and fulfilling VBAC! :)  I'm so pro-VBAC is hurts and I can't believe that the american posters on these boards so often can't find someone who will let them VBAC.  That's a travesty!

[Storm Bride]

Originally Posted by brovie 

I think its important FOR EVERYONE ON THIS BOARD to remember that you and the anesthesiologist actually have the same goals and I don't see why we can't approach each other with a little less baggage and a little more respect (a little less paternalism on the doctor's side and a little more open-mindedness and trust on the mom's side): 

- freedom from UNwanted pain (note: not ALL pain.  this is patient determined...pain vs pain meds and side effects and is a different threshold for every person)

- the ability to mobilize (get out of bed, lift your infant and take care of your infant, walk to the washroom, etc) after surgery

- the ability to breastfeed if desired (requires both pain control and breastfeeding compatible meds)

I have my baggage, because of my experiences. Sorry if that doesn't suit you, but it's the way life works. It would make no sense at all for me to continue to trust doctors, as they have, by and large, repeatedly shown themselves to be undeserving of said trust. I had a good feeling about my last OB, and I'd trust her if I ever needed an OB again...but that doesn't mean that I'm just going to say "oh, okay - that one was good, so the various crap I've had from every other doctor I've seen in the course of my reproductive life doesn't count - doctors are obviously going to look out for me". Quite honestly, it would be completely illogical for me to do so.

My anesthesiologists (at least two of them) did not have the same goals as me. They didn't even know what my goals were. They assumed that I wanted the same things they did, and proceeded accordingly. The fact that they may have been right, if they'd made the same assumptions about most patients, doesn't mean they were right about me, or that we wanted the same thing. This kind of blanket "you and the doctor have the same goals" statement is one of the things that drives me batcrap crazy about the medical profession, as a whole.

Interestingly enough, my ability to mobilize after surgery was best with my last c-section (the one where I put "my agenda" ahead of the anesthesiologist's experise -  apparently - by refusing any post-op pain meds, excpet those I dispensed for myself). And, increased mobility, because you can't feel pain, isn't all it's cracked up to be. While I've had pain after all my surgeries, even with the duramorph, the "pain management" did work reasonably well after I had ds2, which is how I ended up tearing a staple out of my incision, which then got infected, and didn't fully close for almost two months. I'd have done a lot better with less pain management, and a little less mobility, in that particular situation.

Why does breastfeeding post-op "require" pain meds? I've never needed meds for that.

And, re: "unwanted pain" being patient determined. I've never had a doctor (including an anesthesiologist), nurse or any other kind of care provider express any interest whatsoever in what level of pain was acceptable to me. They decided what was okay, and proceeded to attempt to "manage" my pain according to their own bias.

ETA: Before I leave, I wanted to add something about the mobilization thing. After my first, "emergency" c-section, I was badgered endlessly by doctors and nurses telling me to get up and walk, that they "know it hurts, dear, but you have to walk". Not one of them (there at least 10-15 medpros who talked to me about this in the three days it took me to be able to leave my bed for more than an assisted trip across the room to the bathroom) listened to a word I said. I repeatedly explained that the problem wasn't pain. It was weakness.

I hadn't eaten much while in labour, and nothing at all for at least 6-8 hours before I went to the hospital. I'd vomited when labour started, shortly after dinner. So, I had a c-section on Friday evening, and the last real meal I'd eaten was lunch on Thursday, with a small snack that afternoon, and then maybe a cup of fruit/veggies over the course of my 21 hour labour. Then, I'd been given all kinds of drugs in my IV (general anesthesia). Then, I was given morphine in post-op. Then, I was given a sleeping pill (which I'd have refused, but I was still too out of it from all the other drugs). Then, I wasn't allowed any solid food for another 3.5 days, while recovering from surgery, "childbirth", and all those medications. I simply couldn't walk. I could barely stand up (not long enough to change a diaper, for instance, even though I was clinging to the cart the bassinet was on). I was too weak. Not a single person I talked to believed me, and I was repeatedly castigated for, basically, caving to the pain. "I know it hurts, dear, but it's important." "It's going to hurt, but you have to do it." "I'm sorry it hurts, but walking is essential to your recovery." "You have to get moving, no matter how much it hurts." "You're still not walking? You're going to have to ignore the pain." Over and over and over and over for more than three days. And, the pain wasn't the problem, and I told every single one of them that. I can walk if it hurts. I can't walk if I'm physically not strong enough to stand on my own two feet.

Edited by Storm Bride - 8/7/11 at 8:28pm

[Storm Bride]

Originally Posted by AlexisT 

How can you possibly know in advance of surgery how you will feel? How can you possibly know there will be no complications, that you will NOT be in extraordinary pain that is beyond what you have planned for?

What on earth does any of that have to do with what pain control meds are automatically given to me, simply because I'm not allergic to them? What does it have to do with giving me the meds, before there's any reason to suspect complications or an unusually high level of pain?

If you exclude all opioids and refuse to discuss them at all, and then you have that one in a thousand horrific surgery, and you've bled too much for Toradol... you've just forced yourself to suffer and have removed your doctors' ability to deal with the problem. This isn't just "Do I get Duramorph in my spinal?" It is not just "this is my pain and I get to decide how to cope with it."

So, once I refuse any opioids before my surgery, I can't request them later, if I happen to have unusually horrific levels of pain? That seems...very strange to me.

With any surgery, you're running the risk of complications. You could be half conscious and unable to make a rational decision. You could have a level of pain that your providers judge to be potentially harmful to you.

Ugh. Just..ugh. My providers, as far as my personal history shows, have long since decided that any level of pain is potentially harmful to me, and they'll do anything to avoid it. It doesn't matter if I've made it clear that what they want is harmful to me, because I'm not a doctor, and can't possibly know what's in my own best interests. If I'm screaming "make it stop", then it's probably pretty obvious that the pain is too much. If I'm not doing so, or otherwise demonstrating that I can't/don't want to handle that level of pain, then why is someone else making that call for me?

It is very much the anesthesiologist's job to make sure you have options. Whether or not you have an option available to you is not the same as whether or not you have the right to say yes or no. You can say no to an option.

If I can say, "no", then what's the point of your above example of being half-conscious and unable to make a rational decision? In that scenario, does that mean I can say "no"? Or does it mean that I can say "no", but that "no" will be ignored if my "providers" feel that ignoring it is in my own best interests?

That is aside from the medical and ethical challenges of doing the surgery itself without opioids in the spinal. Yes, leaving patients in horrible pain is considered unethical for an anesthesiologist. Pain control is considered a right.

I have no idea what was in my spinal. I wasn't in pain during the surgery, so I have to assume they used opioids, if that's the only way to numb the pain. I'm sure the pain is horrific. What I was addressing in previous posts was post-op pain management. I've been pretty clear about that, I think. And, I don't want it. I don't want anything for pain after a c-section (ie. once I can feel my feet and wiggle my toes again), unless and until I decide the pain is bad enough to require it. Nobody else can make that call for me, whether they're an OB, a nurse, or an anesthesiologist. If I have the right to have pain control, then I have the right to refuse pain control, too. If I can't refuse it, it's not a right - it's a requirement.

OP: Sorry for the total derailment. I've read one too many posts in this thread that have brought back all my anxiety about dealing with the medical profession ever again, and it's triggered me. I'm going to try to ignore this one when it comes up in my inbox (have hit "don't subscribe", but I don't know how that works in the new format), as the entire topic is upsetting on multiple levels.

[katelove]

This is what is commonly offered in Australia; in OT the woman is given a PR NSAID (usually diclofenac or ibuprofen). Once they return to the ward and are able to eat and drink ( usually within a few hours) they are encouraged to have *regular* paracetamol and an NSAID. Depending which one is used, the NSAID is a twice daily dose and the paracetamol is every 6 hours. Research has found that women using this regime require fewer opiates and report better pain control**.

Something else to consider when deciding on how much pain relief you require - in order to reduce your risk of the post-op complications of pneumonia or DVT/PE you need to be able to take deep breaths (almost fully inflating your lungs), cough and move your legs in bed or walk (slow walking is fine) about once every hour or so. Even if you're wearing anti-embolism stockings.

Also, someone mentioned the ethics of pain management. It is absolutely unethical to leave someone in pain *if* they want treatment. But a legally capable adult has the right to choose to decline all forms of treatment, including pain relief. In that case, our ethical obligation is to ensure that it is an informed choice and to make sure the patient is aware that they can change their mind at any time.

**NB. We also usually leave them with a patient-controlled analgesia device (either IV or epidural) which has an opiate (IV) or opiate/local anaesthetic mix (epidural) for the first 12-24hours. There is also research which shows that patients who have PCAs require less opiates than patients who receive intermittent doses which they have to request from the nursing staff each time.

[hildare]

Originally Posted by by-the-lake 

Waaaaaiiiiittt a minute.... Hildaire posts a questions regarding regarding anesthesia drugs. No problem. Then a real anesthesiologist answers, great! A very thorough, respectful answer. Then another poster applies that post to her experience. Derailing here..... then the anesthesiologist defends herself. OK. Of course she was a bit offended. I am confused why you posted a specific medical question, received a medical answer, and then say

"i think you'll find in this particular on line community, there does exist a strong sense of questioning caesarian birth's necessity.  most of us are very well informed here, or else we're seeking to learn more, which is why mdc exists".

and

"but you can bet that i do have probing questions for most people whether they be my mechanic or my ob or the anesthesiologist.  i assume that's rare for you?  but, may i suggest that you not take offense at the questioning... it seemed to me that you were offended.  if you are a person in a position of the holder of knowledge, you shouldn't be too surprised when people do ask!"

Were you looking for answers? Or an argument?

nope; i wasn't looking for an argument and indeed posted seeking answers.  however, i did thank that poster for input but felt the need to address a statement she made, " It bothers me that patients never seem to question the need to go for c-section, but want to tell me exactly how to do their anesthetic. "  i really feel as though that's a very inaccurate statement for most folks here at mdc.  she also DID seem offended that people were asking questions, which i was attempting to point out, is not really something to be offended by.  i understand that it's not fair to lump people of the same profession into one category if they (like stormbride) are bitter about a past experience.  but at the same time, if you have knowledge and other people are interested in or ask questions about it, that's not really something to take affront with, in my opinion. 

i don't think i was disrespectful at any rate, and did thank that poster several times for the input.

 

[hildare]

brovie, thank you so much for your answers, and the framework i needed to have the conversation about medication. 

also, thank you for your viewpoint!  i hope that you're in a position to teach this to interns or students... 

i think this conversation about these questions kind of represent why so many women get so very upset with the medical community at large.. and i think that yes, most medical folks have the best interests of the people they're trying to help at heart, but that some don't see dialogue as a crucial part of the interaction.  i feel like i'm pretty open minded-- i mean if you TELL me i don't have any options but x,y, and z, then i can deal with that.  but for me to state that i don't want X, and to just get a nod and receive x anyway because you felt you knew better and wanted to avoid having to spell it out for me, then, that's a problem.  i think just including a patient in the ideas behind things can go a very long way. 

thanks again for your help and input, not just brovie but everybody who responded.  <3

[by-the-lake]

Originally Posted by hildare 

nope; i wasn't looking for an argument and indeed posted seeking answers.  however, i did thank that poster for input but felt the need to address a statement she made, " It bothers me that patients never seem to question the need to go for c-section, but want to tell me exactly how to do their anesthetic. "  i really feel as though that's a very inaccurate statement for most folks here at mdc.  she also DID seem offended that people were asking questions, which i was attempting to point out, is not really something to be offended by.  i understand that it's not fair to lump people of the same profession into one category if they (like stormbride) are bitter about a past experience.  but at the same time, if you have knowledge and other people are interested in or ask questions about it, that's not really something to take affront with, in my opinion. 

i don't think i was disrespectful at any rate, and did thank that poster several times for the input.

 

Peace,

You did thank her for answering your questions. Then StormBride posted her answers/questions/issues and there seemed to be a bit of dog piling of the anesthesiologist with these statements of yours:

"i think you'll find in this particular on line community, there does exist a strong sense of questioning caesarian birth's necessity.  most of us are very well informed here, or else we're seeking to learn more, which is why mdc exists".

and

"but you can bet that i do have probing questions for most people whether they be my mechanic or my ob or the anesthesiologist.  i assume that's rare for you?  but, may i suggest that you not take offense at the questioning... it seemed to me that you were offended.  if you are a person in a position of the holder of knowledge, you shouldn't be too surprised when people do ask!"

That's all

[1stTimeMama4-4-10]

Just wanted to say that for those of you who got super worked up here, you should probably go back and reread what you have written.  The two medical professionals who posted are members of this community too, and are deserving of the same respect as the rest of us.  I'm surprised and discouraged to see so much hostility on this board.