Exceptional Care: A Case Study, Part 3, The Second Visit

By | May 6, 2011

Jane and her son arrived in the office at about 3 o’clock on Wednesday afternoon, two days after the initial phone call. They met with Melissa and me for about 30 minutes. They wanted to know some more of the details about how the trials were conducted. I explained that the process was similar to the insertion of a labor epidural in a pregnant patient. I told Jane and her son that the procedure didn’t really hurt any more than having blood drawn.



They wanted to know how the medicine from the pump would make her feel. We told her that it would not make her drowsy or cloud her mind the way the Oxycontin and Percocet did. Jane was still apprehensive and asked whether she should give the pills another couple of days. At this point Jane’s son and aide reminded her just how uncomfortable she had been the night before and her son told her that it didn’t seem as though there was much to loose from doing the trial. Jane was curious about how long the trial would last. I told her it would go on as long as she wanted it. I told her that she would probably have a pretty clear idea about whether or not the epidural infusion was working for her by the next day, but that I was prepared to let the trial go on for up to two weeks. I explained that the risk of infection went up every day and that I had never had to let a pump trial go on for much more than a week. By that time it’s usually pretty clear that either the trial is working or it isn’t.

Jane was intrigued, but still uncertain, so I told her the story of a woman, Margaret (again not her real name) who had suffered from the same type of cancer that Jane had. Margaret had been just as apprehensive as Jane was about the trial. Margaret had a very large family and the weekend following the scheduled end of her trial Margaret and group of her daughters and granddaughters were scheduled to go to a Spa out in the desert to celebrate a birthday. They were planning on getting some massages, sitting in the hot tub, having a couple of cocktails and generally whooping it up and Margaret certainly didn’t want my pump to interfere with any of her fun. She made me promise to remove everything by Friday afternoon.

Well Friday afternoon came and Margaret returned to the office and flatly refused to give the Ambet pump back. Margaret was feeling great and definitely wanted the real pump to be implanted as soon as possible, but she had figured out that if we stopped the trial at that point, then the pain would come back and ruin her weekend. I told her that she could keep the pump until Monday, but that it had to come out the day before the permanent implant, because of the risk of infection. I told her that she could certainly have a couple of drinks with the girls and that a massage was fine as long as the masseur didn’t pull out the catheter, but that hot tubs were really not a good idea. Margaret said, “Deal!”

Jane like the story and finally agreed to the trial even though she had no plans for the weekend. We took Jane into the procedure room in the office and placed the epidural trial catheter in about 5 minutes. The programming and test infusions took about another 20 minutes. Jane was then started on a tiny dose of epidural morphine and then observed in the office for another 2 hours. Before she went home Jane said that she felt a little bit better, but not a lot. I explained that this was exactly what I had expected. In the interest of safety I was starting her on an extremely low dose. I told her that more meaningful pain relief would develop slowly over the next 12-24 hours and that in all likelihood I would have to increase the dose on subsequent days to achieve the level of pain relief that we both expected. Hopeful, but still with some misgivings, Jane left for what she was afraid would be another long and painful night.

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