Lee Webber, a CRNA with Horizon Health, in Paris, Illinois, with the latest treatments involving Pain Management.
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Ke'an: Hi.
I'm Ke'an Armstrong, your host for Being Well.
Thank you so much for watching today.
Today I have Lee Webber, a CRNA, joining me
today and we are going to be talking about
pain management.
Something that most people deal with but maybe
don't know how to live with.
We're going to be discussing a few different
things and a couple of different types of
pain management.
Thanks so much for joining me today.
Lee: You're welcome.
Ke'an: Let's start off with you're with Horizon
Health in Paris and you're a CRNA, is that
right.
Lee: Correct.
Ke'an: Can you explain to folks what a CRNA
is?
Lee: Sometimes CRNA will be on our badges
or you'll meet a CRNA but nobody's really
sure what that is.
We're anesthesia providers.
It's stands for certified registered nurse
anesthetist and again we're the anesthesia
providers for most rural health communities.
Most of rural health America, we're the sole
anesthesia providers in those facilities and
we're able to bring anesthesia services, pain
management services, obstetrical services
to those areas simple because there's not
enough anesthesiologists or physician anesthesiologists
to, they're located more in the cities where
there's higher, more acuity types of surgeries
being done.
Lee: We do a lot of the rural health stuff
and often, like I said, are the sole providers
and that is the case at Paris.
There are four CRNAs at Paris and we all do
surgical anesthesia as well as some chronic
pain management outside of the clinic.
Ke'an: No anesthesiologists on staff but four
CRNAs.
Lee: Correct.
Ke'an: Yeah, that's interesting.
A difference between rural and city type of
providing health and different services.
Lee: And you'll find CRNAs as well, you'll
find them in any facility or place where there
is anesthetics being provided.
Dentist's office, podiatrist office as well
as in the traditional OR suite setting.
But in the larger areas, bigger hospitals,
cities, you'll find it more of what they call
team care models.
You'll have some anesthesiologists as well
as multiple CRNAs on site.
You'll likely run into an anesthesiologist
working your preop interview and then in the
room during your anesthetic for the case,
will actually be an CRNA sitting with you
and checking your vitals on the monitor and
making the adjustments there.
Lee: A lot of people are just unaware that
we're kind of around.
We've been around for a long time.
A 150 years.
Ke'an: Really?
Lee: We were the first ones doing anesthesia
on the battlefield in the Civil War is where
they really first kind of came about.
Primarily in World War I and then it sort
of became a real credentialed type thing around
the 1950s.
Ke'an: That's interesting because when you
think of anesthesiology, you just think of
going into surgery and someone putting you
to sleep.
You don't think about all the different things
we're going to discuss today.
Ke'an: We're here to talk about pain management.
We're going to be talking about acute as well
as chronic.
Which would you like to start talking about?
Lee: Let's start with acute.
When someone's coming and they're going to
be having surgery, you're talking about that
acute pain that they're going to be dealing
with.
Acute meaning short lived.
We know exactly what's causing it and we're
expecting it.
You're coming in for a shoulder surgery, you've
hurt your shoulder, we know you're there to
get it fixed and we know you're going to have
some pain surrounding this shoulder surgery
and getting through the recovery of that especially
in that first 24, 48, 72 hour period and so
what can we do as anesthesia providers to
help control your pain to get you through
that experience in the best way possible so
that you have a nice comfortable experience
and you're also maintaining range of motion
of your shoulder and the things that the surgeon
is wanting in order to expedited your healing
and make sure that the shoulder heals in the
way that they're wanting it to.
Lee: A shoulder surgery, a lot of times and
this is what they'll find still at some facilities
which is kind of mind boggling to me but you'll
go and just get put to sleep, have your shoulder
surgery and wake up.
You're going to have a lot of pain if you
do it that way.
Shoulder surgery is one of the most painful
surgeries that we do.
Ke'an: Yes it is.
I have had it and it's not, yes there's a
lot of pain involved.
Lee: There's a lot of pain with shoulder surgery
and it takes a long time to recover.
You don't want to move it very much.
Some things that we can do, the biggest of
which would be a peripheral nerve block.
We can insert a shot of some numbing medicine
around the nerves above the level of the shoulder,
turn those nerves off for a while so that
you're not feeling pain or anything in this
whole arm that we're working on here.
What we like to do.
Ke'an: We going to show a little example of
something here?
Lee: Yeah, I brought this catheter.
If we give you just one shot for your shoulder
surgery, you'll typically get pain relief,
good pain relief for about 12 to 24 hours.
That gets you through.
It's great.
It gets you through the first 24 hours but
a lot of times that it's going to be wearing
off in the middle of the night when you first
go home if you're doing it outpatient and
shoulder surgery is really painful past the
first 24 hours.
Lee: What we like to do is before we take
that needle out we go ahead and we thread
a little catheter and we leave that catheter
in right by the nerves, hook it up to this
tubing with a little regulator that we can
control how fast how fast it goes and then
we fill this more of that numbing medicine
in this ball and then you go home with this
in a nice little fanny pack that you just
wear and carry around with you and it will
continue giving you that numbing medicine.
Dripping that on that nerve, keeping that
nerve turned off for the length of however
long we have medicine in this which usually
lasts about three to four days.
Lee: We use this a lot as a tool as anesthesia
providers to really help with pain control.
We find when we use a peripheral nerve block,
we give way less narcotics, way less pain
medicines both intra-op, during the procedure
and postoperatively when they wake up in recovery
room.
If they have a nerve block, especially with
a catheter, a lot of times they wake up and
they don't need any pain medicine at all.
They go home, maybe they take one or two and
some patients take none at all and they get
through that first three days.
Lee: That's a really, really good tool for
us.
Ke'an: Is that something new?
Lee: No.
It's been around for a while.
It's just not, you have to have anesthesia
providers that know how to place the block
and so there's some training and skill involved
there and so some centers will have providers
that know how to do that and other places
won't.
Ke'an: Okay.
I have a note here that says that you have
SIUE clinical site.
Are you teaching other people how to use things
such as that then?
Lee: Yes.
Our site in Paris is a clinical site for the
anesthesia school at Southern Indiana University
Edwardsville.
Just at the north side of St. Louis.
They will send their senior anesthesia students
who are just about to graduate through different
clinical rotations.
Ours is specific for them learning how to
do different types of peripheral nerve blocks
because they don't get that a lot at some
of their other clinical sites.
They come and we try to get those many blocks,
learning how to do these blocks as they can.
We use ultrasound so we can image and see
where our needle's going.
See where we end placing our catheter.
It's just kind of, it takes a little bit of
practice to utilize the needling techniques
and using the ultrasound and knowing what
you're looking at on the screen.
They come specifically for that and that's
what we try to get them.
Ke'an: All right.
Will the patient need to go back to have it
removed?
And also, can that be put on different parts
of your body?
Say your back or hip, knee?
Is it something that can be used more so on
other body parts?
Lee: Yes.
To your first question, the patients I would
say, remove the catheter themselves about
95% of the time.
We tell them on discharge if they don't feel
comfortable removing that catheter, absolutely,
they can come in, we'll do it for them.
It's usually depending on what site of the
body we place that catheter, it could be anywhere
from two centimeters to 10 centimeters and
it's again a really, really small catheter
and you just sort of pull it out.
There shouldn't be any bleeding.
There might be a little back leaking of some
of this numbing medicine that we put in there
but you can just put a Band-Aid over it and
that's about it.
Lee: To your question of parts of the body,
yes, we can do different types of blocks.
Ones that we're going to be using these catheters
for that the patients we'll send home usually
have to be on an appendage of some sort.
On an arm or a leg so that would include ankles
and knees and hips.
If you're talking about a truncal surgeries,
a laparoscopic surgery, we can also place
those block but they are typically not patients
that are going home.
Those are typically going to be your inpatient
surgeries and then the nurse would remove
the catheters at that point.
Ke'an: All right, so how do you treat chronic
pain?
Lee: If we're moving to chronic pain, we're
talking now about some patients that are having
pain.
Lower back pain's a big one that we deal with.
So many people have lower back pain.
Knee pain is probably the second largest one
we get referrals for.
Pain that's not associated with a particular
insult, a particular surgery you just had
or an injury that you just had.
Pain that you've been dealing with now for
months, years in a lot of cases.
You've tried multiple things to try to help
that out and you're just not getting anywhere
with that.
Lee: These are the patients we'll see in our
chronic pain clinic.
Paris has a chronic pain clinic that started
about nine years ago.
Started very small and there was just two
anesthetists there at the time.
They mostly just treated some disc bulges
and sciatica type symptoms.
Chronic lower back pain and pain into the
legs starting from the back.
They would do a few injections in the back
and it started very small.
Lee: Now we're on a much bigger scale.
We do a whole lot more interventions.
There's different types of injections that
we can do and so we usually just start with
seeing how long they've had their pain and
where it started.
Ke'an: All right.
We're talking about lower back hurting and
you hear a lot people say, "Gosh when my back
hurts I just hurt all over and I just can't
get any relief."
How do you talk to that patient about what's
going to happen?
Lee: We usually get these patients into our
clinic.
They usually are coming from some sort of
primary care provider.
Their family practice physician, their internal
medicine physician and they'll show up in
our clinic and they'll usually already have
an MRI, some sort of imaging that shows on
their back what's going on.
We use that information as well as just working
with those patients in the office.
Putting them through a few different exams
in the office to try to, back pain is very
difficult to diagnose.
There's a lot of things that can cause back
pain, a lot of different things so we have
to use a combination of our exam skills and
the imaging to try to do some detective work
to try to figure out what's actually causing
that pain.
Ke'an: Well especially if they've had it for
a long time too.
Lee: Right, right.
I have another little model here of the back.
We've got different …
Ke'an: Take a look at this.
Lee: Portions.
Just a model of the spine that we're using
and we've got different things.
These are the discs that lie in between the
vertebra of the spine.
Those are our shock absorbers and our cushion.
They're normally supposed to be set up with
a little bit of jelly like substance on the
inside and then there's sort of an annular
ring of a tougher substance on the outside.
Lee: As we get older this disc can degenerate
or sort of just kind of wear away and the
other thing you can see happening in this
one is this inner substances, don't pay attention
to the color, that doesn't really matter,
but you can see it's starting to kind of push
its way out over here.
And then you get to the point here where you
may have this inner jelly like substance squirting
all the way out.
Lee: You can go all the way from just having
a simple disc bulge where the disc is just
sort of pushing out of where it's supposed
to be.
It's been irritated and it's pushing backwards
on the spinal cord and on the spinal nerve
roots that are coming out.
All the way to an extrusion or a herniation
of that inside substance.
Lee: All of those different things can cause
you some back pain as well as just this little
joint right here which is called the facet
joint and it's just where these stack on top
of each other.
You'll have some pain in that bony area right
there.
And right here.
Those are facet joints and you'll have arthritis
as you get older into those areas.
Lee: The pain from those areas is usually
just achy, chronic back pain.
The pain from a bulging disc or something
that pushing on a nerve root, you're probably
going to have symptoms on down your leg.
You're going to have either numbness of a
lower leg extremity or pain shooting down
the backside of your leg and so we need to
tease out what is the source of your pain.
Often patients, I have multiple sources of
their pain so then we work on trying to tease
out what is the most irritating part of their
pain at that moment or the most important
to fix interventionally at that time.
What's the biggest risk towards them?
If you keep pressure on that spinal cord for
a long time, that's not a good thing.
We want to make sure that we take care of
that first before we work on just the arthritis
in the back.
Ke'an: Okay, so talk about some options that
patients can receive treatment or pain remedy.
What do you do?
If it's something that is like that bulging
or the pressing on a nerve or the little joint
there, talk to us about some of the different
things that you actually do to help that patient
deal with that pain.
Lee: Again, typically by the time they've
seen us, the primary care provider has already
put them through some sort of course of physical
therapy.
That's a good thing to start at the beginning.
Ke'an: Create mobility.
Lee: Create mobility.
A lot of times with some particular exercises
that they put them through, a lot of times
laying on the stomach and doing some extension
of the spine exercise you can kind of get
that disc bulge to go back if it's not a really
big one.
Hasn't been there for very long and it's still
fairly mobile.
Lee: Other things that we'll like to see them
to have tried is an over the counter antiinflammatory
of some sort.
Not just pain meds.
A lot of times we'll get pain patients who
are just on pain medicines but they've never
tried an antiinflammatory.
The order if you're having back pain would
be to get mobile, ice, rest in between your
mobility and stretching.
Try an over the counter antiinflammatory.
Lee: From there, which is typically the point
that we receive these patients, then we can
look at doing something a little bit on down
the pathway.
We can give them a prescription strength antiinflammatory.
Try that for little bit.
We can give them some other types of medicines,
anti-spasmotics or muscle relaxant type medicines,
other neuropathic medicines like gabapentin
or Lyrica are good to try at the beginning.
And then if they're still not getting relief
then we usually take them to the OR and do
some sort of spinal injection like an epidural
steroid injection or an ablation injection
or something like that to try to help that
disc bulge to get better or that arthritis
to get better.
Ke'an: All right.
Looking at a timeline of folks who come in
and say, "Gosh, I've lived with this for so
many years.
I just want this to go away."
Going through these different varieties of
options, what kind of timeline can you give
people an idea of okay, we're going to start
out with this.
We're going to do the physical therapy, leading
up to where you hear a lot of people actually
getting those shots.
Kind of how long on average?
Lee: The first thing to help patients understand
when they first come in is that if you're
coming in and you've had back pain, chronic
lower back pain for 10 years, I'm not going
to be able to fix it in a month.
I can't give you one injection, one pill and
you're going to be good to go for the rest
of your life.
Sometimes it's just helping them get a realization
of these are the things we need to do.
And really the interventional tools that we
use, both the medications that we use, the
pills and the injections in the back, they're
all to try to help get the patient over not
so much pain that they are right now so that
they can feel better to then do the things
that they need to do to continue their back
health for the rest of their life.
Lee: Maybe they try to go to PT but they just
couldn't even finish the four weeks of PT
that they're primary care provider prescribed
'cause they were just in so much pain.
They'll end up with us.
We'll do an epidural steroid injection.
That'll give them some good pain relief then
they'll go back to PT. then they'll do their
home exercises and they'll continue on that
path.
Usually again, at the way that it works at
our facility and our primary care providers
which are a big referral source for us, I
would say patients are probably getting their
injections within a first couple weeks of
seeing us.
Lee: But a lot of times, one or two injections
is all they need and if we can get them to
a point of understanding that to carry this
on, this isn't the solution.
This is just something to kind of get you
over the hump and we're trying to get you
to feel better so you feel good enough to
go out and exercise.
To do the home exercise stretching and a little
bit of weight lifting, weight bearing exercise.
Doing those types of things that PT is suggesting
and their primary care is suggesting.
Maybe lose some weight if they've got a really
high body mass index and they need to just
get that there 'cause otherwise you're just
going to continue having, putting pressure
on those discs and they're going to continue
to herniate.
Lee: Smoking is another big issue.
There's multiple studies.
They redo them all the time and they always
come out with the same result that smokers
have a much higher risk of disc herniation
than nonsmokers.
Ke'an: Really?
Lee: It changes the makeup of the disc in
the spine and it makes it much more easy to
slide out and cause disc bulges and disc herniations.
That's a big one we try to get our patients
to realize that you need to really work on.
Work with your primary care provider.
There's lots of options available now to try
to stop smoking.
We can really look, we're looking at, how
are we going to control your back health five
years from now?
10 years from now?
15 years from now?
Doing epidural steroid injections all the
time, that's not going to be the right answer.
Ke'an: It's more about learning how to change
your daily habits once you can get the pain
under control to start changing your normal
daily activities?
Ke'an: All right I've got something here called
a P and B. Have we discussed that?
Lee: That is peripheral nerve block and yes,
that's what we were talking about with both
the acute pain and every once and a while
we'll use that in chronic pain.
Sometimes there'll be a part of the body that's
just, they call it a wind up phenomenon.
It doesn't sound very medical but the nerves
have just gotten themselves in such a rut
where they are firing all the time even though
they shouldn't be firing.
Lee: If I pinch my arm, I should have a nerve
fire there that tells me, oh that hurts if
I do that.
But if I just lightly touch my arm I shouldn't
have a severe pain but some patients will
all have, they'll have developed this already
where you're just barely touch their back
and they're just moving like … yeah, it
feels like I'm pinching their back even though
I'm just barely touching it.
We have to get those nerve to break out of
that and sometimes we will use the peripheral
nerve blocks that we use for surgery in a
chronic pain situation to just kind of turn
those nerves off for a while and that combined
with some other oral medications will kind
of reset the nerves and let them start over.
Ke'an: To settle everything down for a little
bit.
All right well let me change gears here for
just a second.
We've got about five minutes left in the show.
I want to ask what are you doing to help with
the opioid crisis in our area?
Lee: As you know, it's a big deal everywhere
in the country.
This opioid epidemic has taken over.
There's a lot of different reasons for it.
Some of it is the amount of pills just available
out in the community.
That is a lot of leftover pills from surgeries
that people had.
You had your shoulder surgery and maybe they
prescribed you seven to 10 days worth of opioids.
Taking those three to four times a day, maybe
one to two pills three to four times a day,
that ends up being a large pill bottle.
You may, especially if you've had a peripheral
nerve block or your pain control was really
good, you may not have taken hardly any of
those pain pills but now you still have them
and we need better ways to get rid of those
because we're finding that the younger generation,
they're finding these pills and people are
using them that they're not intended to be
used for.
It's not for the person that they were prescribed
for.
Lee: That's number one.
If we're able to control their acute pain
in the surgical setting, those surgeons don't
need to prescribe these long, huge doses.
Long lengths of time of huge doses of these
medicines so there's less of it in the community.
Lee: Number two, we're exposing patients to
less narcotics intraoperatively and after
surgery.
We've gone through for instance, a breast
surgery, there's evidence that if you use
opioids or narcotics, the risk of reoccurrence
of breast cancer is much higher.
All of those surgeries will go through a completely
nonnarcotic experience.
We'll do a block ahead of time, a peripheral
nerve block and we use all nonopioid medicines
through the entirety of their stay so their
body has never been exposed to the opioids
and they never even know what that's like.
It doesn't turn on any of these receptors.
Lee: Some of the things they're studying right
now, why certain people have different responses
to opioids and why we have some addictions
in people that just didn't even know that
that was something.
A lot of times it's just in hereditary wise
and you don't even realize that's a gene that's
running in your family.
Lee: We can patients a favor if we're not,
anytime we can not expose them to opioids
and get around that another way, still controlling
their pain but doing it via all of these other
receptors and these other tools that we have,
we're doing the community a service.
Ke'an: All right, well that's so interesting
and we didn't get to the iPad there but was
there anything that you wanted to talk?
We have just a couple minutes left.
Was there anything that you were going to
show or talk about that?
We have just about a minute left here.
Lee: Yeah, I can show what we use, this is
what we use in the clinic a lot and again
it's just a way to show patients.
Ke'an: See if we can get this on camera.
Lee: What's going on?
There we go.
What's going in their spine.
We can show them the back and different spots
that we're working on.
That's the hip, there's the sacrum there and
so if we're looking a sacroiliac joint or
if we can zoom in we're going to work it doing
an injection in between this level and this
level and we can show the connective tissue
on the back.
All those little arthritic areas they have
this little joint capsule around them so that
we can go in there and inject.
We can do things on here and we can add the
nerves and we can show patients specific nerves
that are troublesome to them.
It's a really neat tool.
We can look at their MRI and then we can,
MRIs are hard to read for patients I find
and so you can throw the MRI picture up but
that doesn't always mean a whole lot.
This little app that we use means a whole
lot more 'cause we can make that very individualized
for the patients.
Ke'an: Well how neat.
That is technology is so cool these days.
You can show the patient exactly what's going
on.
They can understand it, get their pain under
control hopefully and start to live normal
lives.
Well it's been a pleasure talking about this
with you today.
Lee: Thank you very much.
Ke'an: Thank you so much for getting this
information out.
And thank you for watching this episode of
Being Well.
Please tune into our website for more information
at weiu.net and click on Being Well.
We'll see you next time.
Lori:
Sarah Bush Lincoln Health System supporting
healthy lifestyles, eating heart-healthy diet,
staying active, managing stress, and regular
checkups are ways of reducing your health
risks.
Proper health is important to all at Sarah
Bush Lincoln Health System.
Rameen:
Meeting the ever changing in healthcare needs
of our communities.
Paris Community Hospital/Family Medical Center
is now Horizon Health, with the same ownership,
management, providers and employees.
Horizon Health provides patient care and promotes
wellness to the communities of East Central
Illinois.
Jeff:
At HSHS St. Anthony's Memorial Hospital we
are at work transforming heart care, rebuilding
knees and hips, delivering new generations,
and focused on providing healthcare to you.
We are HSHS St. Anthony's Memorial Hospital.
Male Voice: Carle combines clinical care,
health insurance, and research in a way that
solves problems today, with an eye toward
the future.
Supported by a deep philanthropic spirit,
and dedicated to making life better, for as
many as possible.
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