We broke open the Cold Pack last night...
...although we, gratefully, didn't have to use it. Last night my mother experienced an episode of sudden, extreme, unusual pain which started at about 2215. It was immediately obvious to me from her movements in the rocking chair and the expression on her face that something was horribly wrong. She had jerked herself into a leaning position on the bedside table in front of her and she was wild eyed. In an instant her breathing had gone from easy and quiet to labored and loud. I did not have to ask her what was happening. She fairly shouted, "My back! It hurts!"
    In less than two minutes I had determined that the pain was across her lower back, it had begun suddenly, although she'd been mentioning, throughout the evening, a minor lower backache, her "usual" (I asked her this earlier), but she'd refused a regular strength acetaminophen with dinner. Sometimes she'll take acetaminophen, sometimes not. Sometimes I can tell, even in the face of her refusal, that her "minor lower backache" is a higher degree of minor than normal and will not ask if she wants acetaminophen, I'll insist. I did not believe this condition existed last night. Once the surprising, hard pain struck, in the above mentioned span of time I gave Mom an extra strength dose (500 mg) of acetaminophen and called Hospice. The on call RN (one with whom I'm very familiar and with whom I enjoy working; I discovered last night that she is always on call at night, Monday - Friday, which pleases me) returned my call at 2229. Within that 14 minutes it occurred to me to have Mom attempt to rise from her chair with assist to see if she retained the use of her legs and/or if this kind of movement affected the pain. She rose, and sat, without difficulty. The attempt had no effect on her pain...it neither lessened it nor increased it.
    As the phone call began, Mom reported that the pain remained, steady and harsh. The acetaminophen either wasn't working or hadn't kicked in. The RN could hear my mother's distress over the phone while talking to me. She quickly had me assess the exact location of the pain: lower mid back, just below her rib cage, about waist level, extending from about 5 inches on either side of Mom's spine across the spinal column. "We can say it's in the lumbar region," said the nurse. She had me ask Mom specific questions about the nature of the pain. The only one I remember was whether it felt like something was tightening and loosening, in order to determine if it was a muscle cramp or spasm. Mom's answer was, no, it was steady and of the same intensity throughout. Time to break out the Cold Pack and access the Morphine Sulfate Oral Solution (Raspberry Flavor: Funny what you notice in an emergency...my immediate instinctual thought was thank the gods it isn't cherry flavored. Mom hates cherry flavored medicine!). I had anticipated this. It was why I called Hospice.
    The first thing I discovered, which did much to alleviate some of Mom's distress, was that in her twisting and turning and bending attempts to lessen the pain she had dislodged one of her cannula spouts completely out of one nostril, which put the other into a tilt that blew most of its oxygen past her other nostril. Fixing this flooded what was a previously pale face rimmed in Distress Red with a more normal shade of pink, although the Distress Red did not disappear.
    By the time I had been given full instructions on how to administer the morphine, my mother announced, with astonishment, "The pain's gone!"
    Apparently, the acetaminophen kicked in and did the trick. The nurse cautioned me, though, that, if it should return at the same or higher intensity later in the evening, it might not be a bad idea to attack it with morphine instead of giving Mom another acetaminophen. If the pain is going to recur with acetaminophen, it may not with morphine.
    I recorded, of course, on the spot, the detailed instructions, caveats and observations the Hospice RN gave me regarding the use of oral morphine. I've placed them in a post over at The Dailies. I feel bound to mention that I have not published this information in the spirit of global "how to" instructions. My purpose in publication is threefold, listed in descending order of importance:

1. For my reference;
2. As a continuation of my effort to record my mother's medical history as concisely and meticulously as possible;
3. In the interest of the kind of curiosity to which I am prey and which, I imagine, I share with many people, the desire, when reading something, to wonder about the hows and whys and the need for ever more information until my curiosity is satsified.

    So. We've passed yet another First in our journey. I have seen my mother in strong pain, before. The last time was when she hurt her back in October of 2003. I have vivid memories of the duration and intractability of that pain. It was months before she was completely free of it. I remember how the pain showed in her face and in her movement; how OTC analgesics, which, aside from a short-lasting Rx for some innocuous pain reliever/muscle relaxer, the type of which I can't remember, didn't fully address the pain. Ever. Acupuncture did, but it took a series of appointments. Despite this, my mother endured the pain like a trooper. She complained, but not more than I would expect and usually only when I asked after her pain. Most of the time I didn't have to ask. It's presence and quality were obvious. At any rate, the reason I'm recalling that experience, here, is that I can say with certainty that this pain was different: Stronger, harder to bear and completely unexpected. I'm not sure if it scared my mother...that's hard to determine. It's possible that very little, if anything, scares her. It certainly surprised her and the shock registered on her face. It's sudden disappearance also shocked and relieved her.
    After the RN and I closed out our conversation, Mom announced that, "I think bedtime is order." Her voice and manner were even a bit jaunty, which did much to relieve my reactions. I agreed. We took it slow, administered a much needed breathing treatment, used the wheelchair (of course), into and out of which she transferred with ease. Bedtime prep proceeded as usual. I obsessively asked her, as each movement was performed and sometimes when none was being performed, if she was feeling any pain. Her constant response was, "No, not at all." At one point, on the toilet, probably while she was having a bowel movement that I didn't detect until she arose, she mentioned, "I'm feeling a little discomfort back here," reaching around with her hand to indicate her lower back. The area, though, was a few inches lower than where the hard pain had been. She labeled the discomfort as "normal" and noted within a minute or so that it had disappeared.
    Even though her day began at 1400, she was clearly ready for sleep at 0030 this morning, when she was finally abed. Pain is exhausting. It had exhausted her so much that she decided to put off watching the rest of a PBS program, Born to Be King: Charles at 60, I'd taped for her and with which she'd been inordinately enchanted when the pain struck. That's exhaustion, folks. Nothing gets between Mom and her Royals; well, as it turns out, almost nothing. She's slept peacefully through the night. I stayed awake until 0200, tense and waiting for what I feared would be a return of the pain once the acetaminophen wore off. Didn't happen. Her breathing, too, has been even and easy throughout the night and morning. She is not sleeping in any kind of an odd position.
    The RN and I briefly discussed possible causes, mostly in an effort to prepare me, should any other related symptoms (discussed in the Dailies post) appear that suggest that a further look was in order. Mostly, though, as the RN reminded me, Hospice is much less interested in the genesis of pain than in its relief. I'm pretty fairly indoctrinated into this philosophy, by now, but, I have to say, I had a few moments, last night, when I was rabid with the desire to know why this was happening. I no longer feel that way. I'm just glad the pain is relieved. I was surprised and pleased, in fact, to discover that I have so incorporated Hospice's Palliative Care philosophy that when the RN mentioned that if the problem is a compression fracture of the spine a hospital visit might be in order, I was careful to mention that, if such a visit could be avoided, if, for instance, nothing could be done, considering Mom's current health profile, other than confirming the existence of such a fracture and if that information was not necessary to handle its presence, I'd rather not put my mother through a "twisting and turning" hospital visit.
    I was cool, and, of course, very focused, not only through the episode but through the rest of Mom's evening. I allowed my demeanor to sway in accordance with Mom's levels of distress and relief: Intense, when treatment was needed, relaxed when it was no longer necessary. My focus continued as I remained awake after she'd retired and peripherally attended to the monitor. When I retired I immediately fell asleep. Good sign that I'm taking this new development in stride.
    This morning I had a short episode of sudden weeping as I reviewed the events of last night. It was sort of like someone shaking their hands after witnessing something they'd never imagined, "good" or "bad". When it started I expected it to last for several moments and, perhaps, set the tenor for my day, but it came and went and left me settled and sturdy in its wake. I'm surprised to discover that I was never frightened. I experienced, certainly, an extremely heightened level of attention and concern but didn't experience even a hint of freaking. I was able to easily move back and forth between my discussion with the RN and Mom's distress in a highly appropriate, timely and functional manner. I guess I've learned a thing or two in these last 12 years of caring for my companion, my mother.
    I have been concerned about how I would react if and when my mother experienced unusual, hard pain. I'm satisfied, now, that I'll be absolutely present in her moment, which will be necessary, and able to maneuver through it with clear thought and fortitude, no matter what the result. I even found myself thinking, after the weeping session, Pain happens. It's a part of life. Endurable or not, agonizing or not, at some point, for one or more of many reasons, it ends. We have no choice but to deal with it, in whatever manner makes sense to us. I want to make graceful sense in my mother's life...I want to validate her experiences, always, and tend to them as necessary in order to make sure she is able to negotiate through the rest of her life with as much interest and spirit and will as she cares to summon. I want her to do this in comfort. I'll use this as a yardstick to determine my actions in her life.
    Sounds like a plan.
    Later.

P.S.  [Some hours after I published the above post] I just realized that perhaps I need to define an eccentric term. What I refer to as "Cold Pack" is normally called a "Comfort Pack"...but, it's kept in the refrigerator, so, for some reason, probably because we have yet to use it and it's been in our refrigerator since a few days after June 29th, I call it a "Cold Pack". Just wanted to clear possible confusion in case anyone on Hospice is reading.
- posted by Gail Rae @ 13:00   email  this post