Dr. Susan Hardwicke interviews Pain Management Expert Maureen Carling
May 19, 2009
Maureen Carling RN has more than forty years experience in nursing and teaching, and has become an expert in pain management through her past experiences as the President of the Virginia Cancer Pain Initiative in 1996 and as the Pain Management Coordinator for Riverside Regional Medical Center in Virginia for almost three years, up until April 1998, during which time, taught program of Pain Assessment and Management to nursing staff, physical therapists, pharmacists, medical students from EVMS, OB/GYN and Family Practice Residents." She has authored multiple articles published in the journals" Analgesia," International Journal of Pharmaceutical Compounding, and theInternational Myeloma Foundation Journal. Read her impressive story in this one-on-one interview with Dr. Susan Hardwicke:
1. You are well known for your expertise in" pain management, and an assessment algorithm. What sparked your interest and how did this become your life's work?
My interest arose from both personal as well as professional experiences. My father died from" multiple myeloma in 1969. He died with both femurs fractured from the disease and he died in agony, because his pain was not well managed. My mother never recovered, not from his death, but from the manner in which he died." She would say "You wouldn’t let a dog die like that." I was a young nurse and couldn’t help my own dad. I felt utterly powerless. I vowed I would never allow any patient of mine to die like that if I could do anything about it. In those days pain was managed using mostly opioids and there were no long acting opioids then, so the patient had to ask for medication each time and wait for the nurse to bring it. Oftentimes, if it was prescribed 4 – 6 hourly they had to wait until it was ‘due.’Dame Cicely Saunders, the founder of the modern hospice movement had opened St Christopher’s Hospice in South London, England in 1967, but the development of other hospices was still some time away. It was she, who argued for the giving of mediation ‘round the clock’ to keep the pain ‘controlled’ rather than treated as and when.
Following the loss of my husband in 1984 in horrendous circumstances, I found myself being repeatedly invalidated by" health care professionals. It was the worst thing that has ever happened to me, because once again, I felt powerless. I was extremely well known within the community, broadcasting live one a month with the BBC, yet this was happening to me. I thought that if this is happening to me, what about others who turn to us for help and can’t stand up for themselves? What about the elderly who regarded us with such respect?" Who listened to them? I became very angry and spoke out about it. I was contacted and asked if I would be willing to be a member of the management committee that were trying to set up and open the first hospice in the area and I agreed – mainly to speak up for them. Then I was asked to serve on the" Advisory Committee for the Care of the" Terminally Ill for that region. Again, my main reason was to speak up for those who could not speak up for themselves.
What I saw in that hospice changed my life. I saw patients coming in a great deal of pain, sometimes delirious and their family torn apart with anguish having to watch this. I remembered my dad. Within 24 -48 hours, these patients were sitting up in bed eating their meals and watching TV – pain free. I kept on asking. "What on earth did you do?" Because of that experience, I went back to college and with the help and guidance of our" Medical Director who was a Consultant in Palliative Medicine, I learned how to manage pain effectively.
When I came to the USA, I started working with a hospice. What I noticed was that they were using the 0 -10 scale as their assessment tool, whereas, I was assessing pain the way I had been taught in England. 0 – 10 only gives you a measure of the effectiveness of medication, but its quick and objective and that makes everyone happy. Except it’s the wrong tool, or it’s the right tool being used incorrectly." It was noticed that my patients did very much better, so eventually I was asked "What are you doing that we are not doing or what are we doing that you are not doing?" I replied "You are using the wrong assessment tool". That was the start of me designing the Pain Assessment Algorithm and being asked to speak at conferences all over the USA. I was constantly asked about books and CDS etc which led me to develop the" Pain Management Workshops. Eventually, I established my own consultancy and went out on my own in 1998.
My interest arose from both personal as well as professional experiences. My father died from" multiple myeloma in 1969. He died with both femurs fractured from the disease and he died in agony, because his pain was not well managed. My mother never recovered, not from his death, but from the manner in which he died." She would say "You wouldn’t let a dog die like that." I was a young nurse and couldn’t help my own dad. I felt utterly powerless. I vowed I would never allow any patient of mine to die like that if I could do anything about it. In those days pain was managed using mostly opioids and there were no long acting opioids then, so the patient had to ask for medication each time and wait for the nurse to bring it. Oftentimes, if it was prescribed 4 – 6 hourly they had to wait until it was ‘due.’Dame Cicely Saunders, the founder of the modern hospice movement had opened St Christopher’s Hospice in South London, England in 1967, but the development of other hospices was still some time away. It was she, who argued for the giving of mediation ‘round the clock’ to keep the pain ‘controlled’ rather than treated as and when.
Following the loss of my husband in 1984 in horrendous circumstances, I found myself being repeatedly invalidated by" health care professionals. It was the worst thing that has ever happened to me, because once again, I felt powerless. I was extremely well known within the community, broadcasting live one a month with the BBC, yet this was happening to me. I thought that if this is happening to me, what about others who turn to us for help and can’t stand up for themselves? What about the elderly who regarded us with such respect?" Who listened to them? I became very angry and spoke out about it. I was contacted and asked if I would be willing to be a member of the management committee that were trying to set up and open the first hospice in the area and I agreed – mainly to speak up for them. Then I was asked to serve on the" Advisory Committee for the Care of the" Terminally Ill for that region. Again, my main reason was to speak up for those who could not speak up for themselves.
What I saw in that hospice changed my life. I saw patients coming in a great deal of pain, sometimes delirious and their family torn apart with anguish having to watch this. I remembered my dad. Within 24 -48 hours, these patients were sitting up in bed eating their meals and watching TV – pain free. I kept on asking. "What on earth did you do?" Because of that experience, I went back to college and with the help and guidance of our" Medical Director who was a Consultant in Palliative Medicine, I learned how to manage pain effectively.
When I came to the USA, I started working with a hospice. What I noticed was that they were using the 0 -10 scale as their assessment tool, whereas, I was assessing pain the way I had been taught in England. 0 – 10 only gives you a measure of the effectiveness of medication, but its quick and objective and that makes everyone happy. Except it’s the wrong tool, or it’s the right tool being used incorrectly." It was noticed that my patients did very much better, so eventually I was asked "What are you doing that we are not doing or what are we doing that you are not doing?" I replied "You are using the wrong assessment tool". That was the start of me designing the Pain Assessment Algorithm and being asked to speak at conferences all over the USA. I was constantly asked about books and CDS etc which led me to develop the" Pain Management Workshops. Eventually, I established my own consultancy and went out on my own in 1998.
2. What experiences in patient care motivated you most?
Seeing patients in needless pain and knowing that I knew how to bring it under control. I felt duty bound to speak up. Physicians began to ask me to do Pain Consults, and of course when I got the pain under control, they started asking me how I did it and it spead.
3. How did you develop your pain assessment method?
Initially, I did a literature survey and found that all the many of the methods used were very lengthy - some as long as six pages long. It was impractical and I knew they would not be used. Also, those lengthy ones were not designed for the bedside, but for" pain clinics. I asked myself "What information is absolutely essential for" effective pain management?" I decided that duration, description and response to opioids were the most important. I then added what types of pain those descriptions suggested and along the bottom the treatment options for each type of pain. I then had to design a Pain Assessment Sheet to record the information collected during the Initial Pain Assessment. This is the data I take away and do an analysis, report and plan of care – specific to that patient, to bring the pain under control.
4. What are the eight types of pain that you mention in your article?
Visceral (internal organs) and" soft tissue pain, bone pain, nerve compression, pleuritic, colic," muscle spasm and neuropathic pain.
5. Can people have more than one type?
Yes, in fact multiple concurrent pains are common. According to Robert G. Twycross and Sylvia A. Lack only 1/5 of patients have one pain, 4/5 have two or more and 1/3 have four pain or more.
6. If control is possible, why are so many people still living with chronic pain?
Pain has been a low priority within the health services, medical and nursing schools. The" Joint Commission for Accreditation of Health Organizations (JCAHO) carried out a 2 year study to try to identify why pain was management so poorly. They issued new rules for pain management and stated that pain would now be the" fifth vital sign. Those organizations who failed their surveys in the area of pain management could be refused accreditation." The first survey following these new rules was in 2000. To date no organization has been refused accreditation, yet we are still seeing the same problems now.
Physicians are diagnosticians. They tend to see pain in terms of stimulus and response i.e. Pain as a warning that something is wrong. They seek to find the cause, treat it and would expect the pain to go away. For many years an acute pain model was used for" chronic pain patients, yet the physiology behind it is entirely different. When Xrays, scans MRIs etc are negative, the patients are sometimes told; "You’ll just have to learn to live with the pain," "You have a low threshold for pain," "Its’ all in your head." Invalidation. Worse than that, if left with uncontrolled pain, neurological changes begin to take place, new synapses are formed, new pathways develop which can lead to the development of other conditions, eg hyperangesia, allodynia, chronic pain and the spread of pain to other parts of the body.
7. Do you treat your own patients?
No. When a patient is referred for a Pain Consult, I do a very detailed Initial Pain Assessment." Then, I take that data away and do an analysis, report and plan of care for bringing the pains under control. This too is very detailed. Then, together with a" covering letter, I fax it back to the referring physician." If he accepts the plan of care, he prescribes the medications and I monitor the patient, reassessing him/her and write a follow-up letters to the physician regarding the patient’s progress until the pain is under control.
8. How can people get in touch with you?
The best means of reaching me now is email.
E-mail:" " " " " " " This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Thank you, Maureen!
Next interview with Maureen: examples of successes in pain management
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