Wanted to share this article

i found this on the internet and the story is best "as is", so i figured i would copy/paste it here for you to read.....here goes:

Treating cancer pain effectively

By Dr ALBERT LIM KOK HOOI

A comment on the underuse of morphine in the treatment of cancer pain.

THE first inkling of a toothache was on a Friday morning. It was a throbbing pain, but thankfully, it was intermittent. By afternoon it was worse and the pain free intervals were shorter. I downed two tablets of paracetamol. It worked. It was a busy clinic as it usually is prior to a trip abroad (Murphy’s Law at work?). Patients seen and tiresome insurance forms filled out, I made my way to KLIA. I was to deliver a lecture at an oncology seminar in Hong Kong.

The flight took off on schedule at eight in the evening. With the soothing whirr of the jet engines and a glass of vintage Piper Heidsieck champagne, I settled down comfortably to review my lecture notes.

It hit me hard and without warning. My toothache returned with a vengeance. I tried to will it away, but that did not work. They say pain is just a state of mind. It wasn’t then. It was real enough to consume me. It sat stubbornly in my brain, refusing to budge. It bored down nauseatingly and unpleasantly.

Was the pain in my mouth or in my brain? Wherever it was, it was a “I will give anything to relieve my pain” kind of pain. I ceased whatever I was doing. I was bathed in a searing blinding pain.

I rummaged through my medicine kit. The paracetamol was there but I eschewed it. I found two tablets of tramadol and swallowed them. It took 40 minutes before my pain was dulled to half its intensity. It was still sickeningly bad. I could not concentrate on the seminar proceedings. Food was the last thing on my mind although I was in a gourmet’s paradise. I gave my lecture with half a heart and one-third of a mind. The pain of the toothache clamoured for my attention and was sovereign in my consciousness.

And that was just a toothache!

Now, let us talk about cancer pain. I have never experienced it and neither have most oncologists, palliative care physicians and nurses who treat cancer pain. Nevertheless, from what we learn from our patients, it is terrible and wrenching. A serious and thinking approach to cancer pain is required. It has to be scientific and devoid of folklore. I even tell my young doctors that “untreated or uncontrolled pain is a medical emergency”.

Morphine is very effective in controlling most cases of severe cancer pain not relieved by simpler non- opioid measures. And yet morphine is the most misunderstood, underappreciated and underprescribed drug in the medical pharmacopoeia. Patients and carers similarly have lots of misconceptions and myths about morphine.

The first fear about morphine is that it is addictive. This is unfounded. Morphine is not addictive when used properly in cancer patients who require it. It may be addictive in miscreants who are not in pain and who take it in the mistaken belief they will get a high. Most of the time they only end up drowsy and constipated.

The second misconception about morphine is that it leads to respiratory depression, ie patients stop breathing. I have encountered only one case of respiratory depression after three decades of prescribing morphine. In that case, the patient was easily revived with an injection of naloxone, an antidote of morphine.

The third thing I want to strongly say is that there is no fixed dose of morphine. The dose of morphine in any particular patient is the dose required to keep the patient comfortable and pain free. It may be 10mg every four hours or 100mg or 1000mg or any dose from 10 to 1000mg. The question of “why such a high dose, doctor?” should not arise. There is no low or high dose; only the appropriate and correct dose.

Morphine does not shorten life nor is it only for those who are terminally ill. Many cancer patients live for months and years pain-free because of morphine. In the terminal state, morphine provides a blessed relief from the suffering and indignity of impending death.

Apart from relieving pain, morphine allows the patient a good night’s sleep, lightens her feelings of anxiety, curtails chemotherapy and radiotherapy- induced diarrhoea and makes breathing easier. On the downside, morphine causes nausea and constipation. An anti-nausea pill and a laxative are usually prescribed along with morphine.

In Malaysia, we are fortunate to have available two other opioids (morphine-like substances), ie oxycodone and fentanyl. Morphine, oxycodone and fentanyl differ from each other in small and subtle ways. This is fortunate as some patients do better on one preparation than the other.

Palliative care and oncology trainees are taught that a patient is as much pain as she says she is in. I emphasise and reemphasise this teaching. It is not for us to doubt the truth of the patient’s complaint. We must not allow our prejudices and racial stereotyping to influence our patient care.

Some say the threshold for pain is different in different races and cultures. Don’t you believe it! The threshold is the same. It is the willingness to express the suffering that is different.

To doctors, nurses and carers, I say this: The next time you get a toothache or a headache, think of the cancer patient in severe pain. If your suffering is bad, hers is infinitely worse. Learn about morphine and use it wisely and appropriately. Your patients and loved ones will be so much the better for it.

Having cancer is bad enough. Don’t make it worse for the patient by withholding an elixir such as morphine when it is truly needed.

“The aim of the wise is not to secure pleasure, but to avoid pain.” – Aristotle.

● Dr Albert Lim kok Hooi is a consultant oncologist. For further information, e-mail starhealth@thestar.com.my. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

Jade Goody

though i never really followed her life (she was a UK reality TV star and i live in Croatia and don't like reality TV shows), but this story did astonish me. how someone so young could die from a disease, most doctors will tell you is nothing to worry about. proves them wrong, doesn't it.
she was born on June 5, 1981 and passed away on March 22, 2009..making her only 27 years of age at her time of death. it is upsetting how she had battled with poor health since 2002 and the doctors could find nothing wrong until 2008.
a short outline of the events:
2002- cervical pap test that revealed abnormal cells...possibility of cancer.
2004- tested for ovarian cancer..came back negative
2006- tested for bowel cancer..came back negative
2008- went for hospital tests after collapsing for the 4th time....diagnosis...cervical cancer.

why was she not checked for cervical cancer in 2002? if she was, it is not mentioned in the articles that i have read. perhaps they made a mistake and don't want to admit it. though admitting to ignorance is worse, i believe.
here is a quote from her spokesperson upon the cancer diagnosis in august 2008 while she was on the show Big Boss (Indian version of Big Brother) : "It looks like her cancer is at an early stage but we will have to wait until she gets back to Britain and sees a specialist and has more tests".
i was told that as well, as i am sure a lot of us who were diagnosed were told.
as early as September 1, 2008, she was told that the cancer was in advanced stages and her survival chance was 65 percent. after months of surgery and chemotherapy, she lost her battle and her life.
our hearts and thoughts go out to the family and friends of jade goody and all women who have fought the battle of cervical cancer. i will end this post with a quote from wikipedia:
"When news broke that Goody's cancer was terminal, medical authorities in the UK began reporting a surge in requests from women, particularly younger women, for screening for cervical cancer. This reversed a trend which had seen demand for screening decline overall in the past decade, with the highest decline being among women aged 25-29. As a result of the publicity surrounding Goody's illness, on 13 March 2009 government health ministers agreed to review the NHS's policy of not offering screening for cervical cancer until the age of 25 in England (it is 20 in the rest of the UK). Goody issued a press release the same day, saying that she was "immensely proud" that she had helped prompt the review."

M.S.A.T.H...Part 7

Wednesday morning i was woken up as usual at 6:00 am sharp by a nurse. good news was, i was allowed to finally eat, so i anticipated the arrival of breakfast, which was due at 7:30 am, cracked open my book and began to read. btw..nothing else to do there without a television or radio.
like clock work, my first meal arrived and to my dismay, it was less than typical hospital food. it consisted of 2 pieces of white bread (not toasted) and a bowl of warm milk. ok, i will repeat just in case you think i mistyped or you misread....a BOWL of warm milk, as in, not a cup. now, rather the milk was for me or the vermin, i am not sure. though someone should inform these people that it is a woman's hospital and not a veterinary clinic. the only time i drink milk from a bowl is after i am done eating cereal, which apparently, they forgot to add. they also forgot butter, jam, jelly, or anything else that may go with bread.
at 8:00 am, the doctor came in with about 6 interns to check on us and remove the gauze from my vagina. of course, without curtains, my entire womanhood was there for all to see, including my roommates.
the rest of the day was long, but i did manage to finish my book, and since one of my roommates was sent home, it was just 2 of us, which made it a little more quiet and peaceful.

M.S.A.T.H...Part 6...Tuesday

ok, just thought i would warn you that this will in fact be a long post. this was the day of surgery and my nervous breakdown (to put it mildly). however, you will get 2 pictures and a few links with this post.......so here we go.

Tuesday morning began abruptly and precisely at 6:00 am (as did every morning after that). We were awakened by the nurse (to whom i like to refer to as Brunhilda) flipping on all of the lights and yelling "dobro jutro", though she did not sound as chipper as one normally sounds when saying good morning loudly. She then handed each of us a thermometer and left the room. 10 minutes later, she returned like a drill sergeant, ordering us out of our beds and to line up on the other side of the room. After a long speech to us, which i didn't understand, she made the beds and left. Now, when I say "she made the beds"..I refer to just folding down our blankets to the bottom of the bed (as if we were done with them) and straightening our pillows. I will get into the sanitation of the place later on.
Anyway, 15 minutes after Brunhilda left, I went in to take a shower. I dried myself off with a shirt (there were no towels, remember?) and then laid in my bed waiting for the time to pass. It was a very long morning since I was not allowed anything to eat or drink and that included water. Though the one women in the room, was allowed, so we (Kristina and myself) watched her eat. I will get into the menu and nutritional aspects of the meals later on as well.
Finally, around 10:00 am, Brunhilda came to get me and Kristina and took us to pre-op. As we walked down the halls (there are absolutely no wheelchairs..not kidding), I could feel the anxiety start to build within me. We arrived in a room with pre-made beds and we undressed and laid down in our individual beds (i should be thankful that we didn't have to share one). Brunhilda left and 2 other nurses came in and covered me with a green paper blanket and place my hair in a green paper hairnet (at least I matched) and wheeled me in to a room right outside the operating room. The one nurse gave me a little blue pill, which I later found out was a pain pill called "Ketonal" (though it would have been nicer to have the little blue pill from "The Matrix") and prepped my veins for the IV needle.
They stuck a needle in my hand 1st and it hurt a lot. I'm not sure if they missed or what, but they had to try again. So the nurses (and I actually mean morons) chose a spot directly above the 1st and of course, something went wrong. By that time I was in tears. Let me briefly explain to you my pain tolerance. Last June, I had fractured a rib and still moved about and never took a pain pill. I have had many bad relationships and am accident prone as well. So in the course of my lifetime, I have had broken ribs, fractured ribs, been in a fire (as you will see from the picture of my hand), fell down numerous flights of stairs, had my head put through a window, and have been sideswiped by a drunk driver while I was driving a taxi...just to name a few. So my level of pain that I can tolerate, is pretty high. The needle freaking hurt like Hell.
The 3rd attempt was apparently a charm as they stuck the needle in the inside of my elbow and it was pain free at the time. Then it was Kristina's turn to get the IV needle and they actually broke the needle in her hand. She ended up with the IV in the same place as mine. I then turned to her and said "I hope surgery goes better" and she smiled.
They then wheeled me in to the operating room and I heard a nurse say that they had put something in my IV and I would feel very "drowsy?" I'm not entirely sure what she said after the word "very". All I know is that when I heard her, I was staring at the ceiling in the operating room and then I opened my eyes to another ceiling in the recovery room.
I remember when I woke up, a nurse asked how I felt and I told her that I had to "go pee" and she replied "No you don't" and that was it. She took my blood pressure while I was still in the bed they had used for the operation and then I climbed into my hospital bed (not an easy task after having a chunk of your genitalia removed) and was wheeled up to my room. I then grabbed my glasses from the table and saw my right hand. I had 2 puncture wounds from where they had attempted to put the needle (or was attacked by a vampire) and a lump or knot half the size of a golf ball that was purple, green, and black.
Now a golf ball may not seem all that big, but take a look at your hand and imagine shoving half of a gold ball under the skin. Scary huh? I then located my cell phone and messaged Bela to tell him that I was okay. Within the next hour or so, several nurses came in to check on me (though an English speaking one would have been helpful). I asked 3 times to 2 different people about when I would be allowed to eat, drink, or even use the bathroom (I don't care what the nurse said in recovery, I really did have to pee). One nurse answered "sto"..meaning "what" and the other said I was not allowed out of bed for 3 days. No bed pans and not allowed out of bed..this was not going to be a pretty sight.
Around 3:00 pm, I asked a nurse again, if I may use the toilet. She gave me the "1 minute sign" with her finger and at that moment I felt like raising the "not so pleasant sign" with another finger. But I refrained. I then messaged Bela and told him that I wanted to come home. What was the point of being looked after if communication was impossible anyway? A doctor came in about 4:00 pm and spoke a little English, finally. She asked how I was feeling and I told her that I wanted to go home. She said I was suppose to take it easy for 10 days and I said that would be fine. I told her that I did not work, had a live-in boyfriend and had no kids living at home, so bed rest was completely possible. She responded with "You can still have kids". I repeated that I did not have kids at home so I could get bed rest. I even said that I didn't want anymore kids. She then said "You didn't have a hysterectomy. You can still have kids" I must admit, the thought of jumping up and smashing her head against the wall, did enter my mind.
A half hour later, Bela showed up and I told him everything that had happened that day and showed him my hand. Told him I wanted to leave and go home so he went out to talk to someone. He came back and told me that I had to be there for a few days (not sure why, since I read several articles online that said conization was outpatient surgery). That is when I really lost it. I don't think I cried that much since my father passed away. But the real clincher was when a nurse came in about 5 minutes after and took Kristina to go use the toilet and walked out of the room. At that moment, I knew that I was on my own. I stood up out of bed, which was not an easy task, and walked myself to the bathroom to relieve myself of the urine that was still inside of me since before surgery (roughly 7 hours). Bela kissed my forehead and said he would see me tomorrow and left. The rest of the night, I spent crying until I finally cried myself to sleep.

"Right after surgery, you will be taken to a recovery area where nurses will care for and observe you. Usually you will stay in the recovery area for 1 to 4 hours, and then you will go home."

As with any procedure that is done under anesthesia, you will probably need to fast for 6 - 8 hours. You must sign an informed consent form. The procedure is done on the same day (outpatient) and a hospital stay is usually not needed

The mildew on the wall beside my bed. Note that the wall gets darker but the pole stays white:



Picture of my hand 1 week after surgery:

Happy Valentines Day

as the days get closer to my time of surgery, it is nice to be able to take a step back and look around on this day and see all the people i love and who love me. that is what this day is about after all.
i go in to the hospital on monday morning at 8am and will be in there for at least a few days. we visited the last doctor (anesthesiologist) yesterday and everything is fine for me to get the operation. but like i said, that is monday and today is a beautiful Valentines Day in Zagreb so i plan to live it up. we have plans to go to the mall and do a little shopping for books, so i have something to read while i recover. also going to get some food so i have snacks in there as well. i don't care what country you live in, hospital food is hospital food.
i also plan to quit smoking after my stay. i can't smoke in the hospital so will be without cigarettes a few days anyway....seems like the perfect time and the perfect thing to do. wish me luck as it won't be easy.
ok, going to get going and enjoy this lovely day...hope you all have a great one.

Test Results

well, my tests came back decent. chest x-ray showed no signs of lung cancer (great news). EKG was good and my blood tests came back ok as well. though i am lacking in iron and protein, it is still not major (i just need to start taking vitamins i guess). but maybe i don't. this brings me to the whole "blood test procedure" questions.
why do they advise you not to eat or drink anything 12 hours before a blood test just to tell you that you have low iron and protein in your system? shouldn't we be able to go about our normal routine and intake of foods before a blood test? that would be the most accurate of results i think. my normal morning is 2-3 cups of coffee with milk and sugar, so if i am denied that, then my sugar will be lower than it normally is at 8am. thereby making the results that they got while i was fasting, completely false compared to what my blood results would normally be.
now seeing how i graduated high school through a summer school program, i am sure (insert sarcasm here) that the doctors would know more about my body than i do. i am just making an obvious observation about medicine and how i think it should be performed.
everyone may be created equal, but our bodies are not.

Series of Tests

as some of you might already know, i have to go through a series of tests before surgery (which is set for February 16). today was filled with blood tests, urine sample, chest x-ray, and an EKG. i can think of better ways to spend my time, but i guess we all have to do what we need to to beat this disease.
after only 2 hours of sleep last night, we (my boyfriend and i) arrived at the clinic around 7:30 this morning. first on the agenda was blood and urine, the latter of which has been postponed due to my menstruation and therefore i cannot produce an accurate urine sample. but never the less, 4 tubes of blood were taken so at least that is over with and my arm resembles that of a heroin addicts.
next stop was chest x-ray. this was actually fast, efficient and painless i must say. but there is something to be said about taking your shirt and bra off, leaning against a cold plate of metal and taking a deep breath. i think its the whole "taking shirt off" bit that i dislike. its not that i feel uncomfortable, but lets face it, more people have seen my breasts and genitals this year than my entire time in high school. keep in mind that it isn't even February yet.
last but not least, was the EKG. now the fact that they call it EKG has me somewhat baffled since its real name is electrocardiogram. wouldn't it be ECG? doesn't matter i guess, i just thought it kind of odd to abbreviate with a letter that doesn't even exist in the word.
but the real baffling part is when they hooked two wires up to my legs. now, unless i missed something in science class, the heart is more towards the chest region, right? anywho, i had 1 wire attached to each leg, 1 on each side of my chest, and 3 underneath my left breast. the entire experience is completely painless and as i laid there on the bed, i had to hold back the urge to just burst out laughing. i'm not sure if it was the lack of sleep or the fact that i felt like keanu reeves in the matrix shortly after he took the red pill (hairy legs and all), but it was the perfect ending to the first series of tests. although next time i think i might take along a camera so as i can get pictures of the idiocracy that i felt at that moment.
tomorrow, we get results from tests, so i will keep everyone posted. i just wanted to share this unforgettable experience and try to shed a little bit of light on what is a dark moment known as cancer.

Doctors and Algebra

i have to go see another doctor (doctor B) today about my cervical cancer. this is the one who is covered by insurance, but he doesn't speak english, which is why i was going to the private doctor (doctor A) to begin with. Now hopefully doctor B will just write the referral i need to go see yet another doctor (doctor C) on Thursday. doctor C is the oncologist/gynecologist. he'll be the one performing the surgery.

upon all these doctors and doctor visits, the question is posed: how many doctors does it take to screw in a light bulb? i have been seeing so many doctors lately, i feel like i'm at a singles mixer for the rich and famous. call me old fashioned but i prefer to be tied down to one doctor and not play the field. to have just one doctor that does everything and not have your medical journal look like an algebra problem.

if A+B=C, then why can't i just go to C? is it just like in school when you can't just write down the answer, but have to show your work? my teachers always said that i would need all of that information i learned sometime in my life. i just never thought it would be that.

maybe life really is an arithmetic problem. death is "the answer", "showing your work" is life itself.

Worried About Surgery

its been a few days since my last post and for that i apologize. i spoke to my doctor on monday and i have an appointment tomorrow to go over the steps we are going to take with my cancer.
i have been depressed and didn't want that to come out in my blog, so i stayed away. as i said in earlier posts, i am an american living in croatia and right now i am worried about the communication difference, among other things. will i be able to talk to the nurses or doctors in the hospital? will they understand me if something hurts? will i be able to understand them when they tell me of my progress?
it may not seem like a big deal to most, but to me it is.
then there is the recovery period. i have never been pampered and i am guessing that that will not change. though, from what i have read, i will be out of commission for a few weeks. i will have to limit physical activity. problem is, i don't think i can. and if i do, then i will have weeks worth of dishes and cleaning to catch up on. should i pamper myself and play catch-up later, or just ignore doctors orders and go about my normal routine?
what would you do?

The Right to Live vs. Insurance

not sure about everyone out there, but i reside in zagreb, croatia. i am a united states citizen, born and raised for 35 years, so i know how the US health care system is. i currently have insurance to which we (my boyfriend actually) pays every month. it is expensive but mandatory here.
it is extremely difficult to find a gynecologist that accepts insurance that is taking on new patients. let alone trying to find one that speaks english. so everything so far has been out of pocket expense and quite frankly, we are going broke because of it.
if paying for insurance is required, then the government should be required to provide adequate doctors.
when i go into the hospital, fortunately (i guess), it will be covered by insurance. however, the cost of the operation is 4,000 kunas and 150 kunas per night, roughly 4 nights, in the hospital. those figures are our co-pay of 10%. so the entire process will cost about 4600 kunas or $1000 our expense and 46,000 or $10,000 totaled.
why does a procedure that they consider to be "routine" and only takes about 2 hours cost $8000 to begin with?
and why does the person who is needing the surgery have to pay? haven't they been through enough? when will the bureaucrats get off their asses and start helping civilians? do we not have a right to live or does that just pertain to the elite?