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Postoperative pain in the third world context

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Postoperative pain in the third world context

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    3. Disease Vs Illness

    4. Disease Vs Illness Man, 42 years, manual laborer Cancer of the cheek Lives with wife & two children, 9 and 5 Comes with pain & foul-smelling wound

    5. The disease Squamous cell carcinoma cheek Superadded bacterial infection

    6. The illness Squamous cell Ca cheek & infection Pain! Poor appetite; losing weight, tired Disfigurement, concern about body image Social alienation What will happen to my family? Why did God do this to me?

    7. What is pain? A sensory & emotional experience Pain is what the patient says, hurts.

    8. Treatment of cancer pain: Major modalities In 90% of patients, drug therapy - By mouth - By the clock - By the ladder Invasive procedures only if drugs fail. Never forget treatment of the cause.

    9. WHO Analgesic Ladder Strong opioids + Step 1 Weak opioids + Step 1 Non opioids + adjuvants

    10. Oral morphine All the other oral opioids in India have CEILING EFFECT. Therefore morphine is the mainstay of cancer pain management. It is usually started 5-10 mg Q4H. The dose is increased by 50% SOS

    11. Addiction Addiction is not a probability, so long as oral morphine is used in opioid responsive pain IN DOSES ADEQUATE FOR PAIN RELIEF

    12. Needed: Measurement of pain as the 4th vital sign Numerical scale: 0 = No pain 10 = Worst imaginable pain ONLY the patient can do the scoring!

    13. Treatment of breathlessness Look for correctable cause & correct No ventilator; no isolation. Oxygen only if it helps. Calm presence; explanations. Corticosteroids. Morphine!

    14. Key point 1 Symptoms like pain and dyspnoea Can be and Must be treated. Our aim: Improved patient comfort!

    15. The presenting complaints usually form only the tip of the iceberg

    16. What keeps him depressed even after pain is relieved?

    19. Palliative care is the active total care in incurable diseases.

    20. Key point 2 Quality of life is decreased by physical., Psychological, Social & Spiritual issues.

    21. The whole family suffers!

    22. Remember children If no explanations, they live in fear. Often forced to drop out of school. Long-term social & emotional problems

    23. Key point 3 Remember the quality of life of the family. Remember children!

    24. How does all this apply to your everyday practice? Understanding the persons problems Illness-oriented approach Scientific approach Showing that you care Principles of communication

    25. Reactions to bad news (Dr. Elizabeth Kuebler Ross) D Denial A Anger B Bargaining D Depression A Acceptance

    26. Some basic principles maintain trust reduce uncertainty prevent unrealistic expectations allow the person to adjust prevent a conspiracy of silence

    27. What can you do for him?

    28. Palliative care delivery Care at home whenever possible Outpatient service: low cost to provider Home visits whenever possible particularly for those who are too sick to travel to a hospital/clinic Inpatient service for selected few

    31. Kerala: Predominantly NGO-driven, community-oriented palliative care

    32. Registered charitable trust (2003) Aim: To improve access to palliative care to the suffering millions in the country

    33. Trivandrum Institute of Palliative Sciences (TIPS) 4 weeks course for doctors and nurses Next courses start on 1st Mondays of July & September & November.

    34. What can we do together? Include palliative care in UG education Start a joint OP service supported by home care program Educational program for other staff Educational program for house-surgeons One week posting for house surgeons Interaction with NGOs/LSGIs for support

    35. There is nothing more we can do!

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