Where Do You Tilt Your Lance?
by Guest Blogger; Lynn Webster, M.D.

One sunny noonday in the spring of 1990 I received a call from Salt Lake City primary care physician King Udall.  This is the city where I had been practicing medicine since completing my residency in 1980. Dr. Udall was known for treating patients without insurance, many of them destitute. It was one of these patients he was calling me about now, a woman who desperately needed his help and mine.

“Lynn, I have a sixty-two-year-old lady with acute herpes zoster (shingles) involving her left shoulder, axilla, neck, and face. The lesions are weeping, with serous sanguineous fluid, and she is screaming with pain. She can’t tolerate any clothes on the areas and is pleading for mercy. I’ve tried narcotics and they don’t touch the pain. Can you help?”

I said, “Have her come be admitted to the hospital, and I will see what I can do.”

Later that day, at Holy Cross, I met Placida Ramirez*, as well as her husband and two grown daughters, who obviously were quite concerned about her suffering. In her sixties, Placida was heavyset, with light-brown skin and long black hair. She appeared rugged, but she was obviously in severe pain. She was restless, frowning. She paused between words because, as she described it in her broken English, the pain was like an electric shock radiating through her body.

When I began my exam, I quickly discovered that Placida had more problems than shingles. She also had a flesh-eating cancer that had eroded her breast and was invading the left armpit. This was a death sentence already well on its way to being served. I glanced at Placida. She was avoiding my eyes.

I could picture what must have happened. Like many people who come down with symptoms they know or suspect to be life threatening, Placida, instead of getting help immediately, tried to make the symptoms go away by ignoring them. Her lack of health insurance further discouraged her from seeing a doctor…until the pain exceeded her ability to deny it and she went to see Dr. Udall. If cancer was killing her, fear and poverty had joined hands to hurry it along.

I had seen similar types of pathology in the operating room prior to a palliative mastectomy. In those instances I was always able to relieve the pain with a general anesthetic. Not this time. I immediately knew Placida was not a typical patient with an acute pain problem but a patient needing end-of-life pain relief.

I placed an epidural in her upper spine where the medication could block pain originating from the nerves in the armpit, shoulder, neck, and breast. The medication was a local anesthetic like Novocain and small amounts of fentanyl (narcotic). Within a few minutes of my starting Placida’s infusion, she was essentially pain free.

The dying woman rested once the pain was better. Her husband and daughters began to smile and thank me, relieved that their beloved wife and mother was feeling better. Due to the language barrier and some cultural difference, it was not easy for us to communicate, but it was obvious by mannerism and unspoken communication that the family was appreciative. But I noticed that Placida herself didn’t have much to say. She was naturally still weak, but more than that, she seemed to have gone into herself and become more depressed. I think that now that the pain was better, her mind must have begun dwelling on the more serious problem of her cancer. She could no longer ignore the inevitable. She was facing the end.

Placida received the medication for the next three days. It kept the pain away sufficiently so that she could eat and sponge-bathe. For a while, she was able to feel more normal.

I wanted to send her home with the epidural to continue to give her pain relief, but I could not find anyone to provide the service. Since she didn’t have insurance, and since Medicaid wouldn’t pay for home infusion of this type, she was going to be forced to leave the hospital without the epidural. In a short time, she would be plunged back into the same pain she’d had when I’d first met her—a pain that, Dr. Udall had said, no narcotic would touch. Sick inside, I removed the epidural on the third day. She was discharged, to be followed up by Dr. Udall and the oncologist.

A few weeks later she died.

I was afraid to ask if she had died in pain, because I was sure I knew the answer.

Although death is inevitable it should never be insufferable. Unfortunately I have seen far too many people struggle at the end of life and throughout their life to access the type of care that everyone should be able to receive. I have always believed that pain relief should be a right and not only available to those who can afford it. For this to become a reality, people of all interest must unite to demand this level of humanity.  Here is where I title my lance.

*The patient’s name was changed to protect her identity.

Lynn Webster, M.D. is the Vice President of Scientific Affairs of PRA Health Sciences and an industry leader in helping physicians safely treat pain patients, and develop safer and more effective therapies for chronic pain. His latest book, The Painful Truth, will be published in September 2015. You can follow him on Twitter and Facebook.