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17 October 2010 @ 08:34 am
I Wrote My Doctor A Letter  
I don't understand the strange, legalistic system I got thrown into by asking member services a simple question about pain management, but as a result I got back some legal sounding response about IV meds and no mention of what I really talked about--needing much more time to become numb with local anesthetic.

I am terrified to come back if I ever need a cortisone injection for fear that I'll end up once again having that needle inserted when I'm not numb. All I want for myself and people like me is a system to give us more time to get numb, test us to see if we are, and then proceed. People like us are only 1-2% of the population so I understand things are not set up for us normally.

It takes 30 minutes in the dentist's office for me to become fully numb. I had given you all that info in advance. I don't know what more I need to do to communicate my needs. I'm happy to wait outside the treatment room while the anesthetic takes effect.

There are studies you can find.

--Tapati

(I got cut off by the limit with that last sentence in their message center.)
 
 
 
Warrior of Worrywarriorofworry on October 17th, 2010 06:54 pm (UTC)
That's annoying, especially because I thought that was a good letter. Send a cc to the doctor?
Tapatitapati on October 17th, 2010 11:14 pm (UTC)
This one is to the doc himself but I should send a copy of what I'd sent the official folks at managed care because it was longer and went into more detail and I'd included the research on people who are resistant to local anesthetic.
milimodmilimod on October 17th, 2010 11:22 pm (UTC)
Not even sure how you would do this...
...but it seems to me that much of the healthcare establishment's policies trickle down out of medical schools and other institutions such as the CDC or the WHO. So if you were to, perhaps, request your medical records where a practitioner would have had to make notes recording the fact that your response to anesthetic was much slower than the norm, and then relay all of this in detail to one of the aforementioned institutions...maybe they would follow up with you (I'm thinking they might even invite to take part in a study) that would eventually lead to a revision in these standard procedures. Nothing is quick, naturally, especially if as you say this is not typical for most patients. But I could see some research on this topic being published first in one of the higher journals and gradually making its way into the mainstream press. Once it gets there, the medical boards and insurance companies have to pay more attention.
Tapatitapati on October 17th, 2010 11:49 pm (UTC)
Re: Not even sure how you would do this...
There is research on this already. That's part of my frustration--I included copies of some of the studies in my letter to the managed care people after they first contacted me to tell me that the report had been received. A gene has even been identified that is involved in this resistance. Red heads and some people with dark hair were proven to have this gene and be resistant to local anesthetic. I only learned what works for me because a dentist had read this research and applied it. First painless dental procedure I ever had.
Tapatitapati on October 18th, 2010 12:10 am (UTC)
Re: Not even sure how you would do this...
http://www.painphysicianjournal.com/2003/july/2003;6;291-293.pdf

^Excellent study of patients who were resistant to some local anesthetics but not others, evidence of genetic link.

-----


http://www.biomedcentral.com/1471-2253/4/1

Excerpt:

The patient was taken to the operating room and routine monitors applied. The patient did not appear overly anxious and was cooperative and coherent. She was placed in the sitting position for epidural insertion. After sterile skin preparation, three milliliters of 1% lidocaine from the epidural kit was infiltrated. After allowing time for the anesthetic to take effect, an attempt was made to insert a 17-gauge Touhy needle into the skin. The patient complained immediately of pain, indicating inadequate skin analgesia. Again, the patient was not anxious or uncooperative and gave a clear, reasonable account of pain. An additional 3 milliliters of 1% lidocaine from a second vial of lidocaine, not supplied in the kit, was infiltrated at the same site. Again, the patient did not obtain skin analgesia and complained of pain on insertion of the Touhy needle.

The epidural needle was never inserted past the subcutaneous tissue. The decision was made at this time to perform a single-shot spinal. It was felt that this single needle stick would be preferable to continued attempts at local infiltration followed by epidural placement. The patient remained in the sitting position. A 24-gauge, 90 millimeter Sprotte spinal needle via an 18-gauge 1.25 inch introducer needle was inserted at level L3-4 with mild patient discomfort. The needle was directed slightly cephalad with the eyelet of the needle pointing cephalad. Free flow of cerebrospinal fluid without aspiration was obtained on first attempt. A syringe containing 1.2 cc of 0.75% bupivacaine with 50 micrograms of fentanyl and 0.25 milligrams of additive free morphine was attached to the spinal needle, easy aspiration of fluid with swirling of syringe contents was performed, and the medication was easily injected. The bupivacaine used was from a vial of local anesthetic not included in the epidural tray. Clear cerebrospinal fluid was aspirated in a volume of approximately 2 milliliters without difficulty prior to the injection of local anesthetic. An additional volume of cerebrospinal fluid of approximately 0.5 milliliters was aspirated and then reinjected at the end of the injection of intrathecal local anesthetic.

The patient was placed supine almost immediately. After five minutes, testing for sensory level was performed with an alcohol swab (for temperature) and light touch. The patient did not have any sensory level at this time. After an additional three minutes, testing for sensory level was again performed with an alcohol swab and light touch. Pin-prick testing was also performed including the lateral ankle (S1 dermatome) with the patient reporting no sensory changes. The patient had no signs of motor blockade.

Ten minutes after injection, the patient was asked if she felt any difference compared to before the spinal anesthetic was performed and the patient noted warmth in her feet and buttocks. The patient reported no sensory level or motor block. After twenty minutes, there were still no signs of sensory or motor blockade. The decision was made to proceed with general anesthesia. At this point the patient stated that the same sequence of events (inability to numb her skin, failed regional block and general anesthesia) had occurred with her previous cesarean section. The patient received an uneventful general anesthetic. At the conclusion of surgery the patient was examined again for evidence of sensory level or motor blockade. None was evident.

On questioning, the patient described repeated failures of local anesthetics associated with skin infiltration for placement of intravenous lines, including the intravenous line that had been placed preoperatively. She also stated that she was unable to obtain analgesia for dental procedures. Reportedly, her dentist had attempted to use three different types of local anesthetics without success. She did not recall the names of the medications used.

----continued below

Tapatitapati on October 18th, 2010 12:11 am (UTC)
Re: Not even sure how you would do this...
Part two

comment in response:

Adrian Woollard (18 June 2007) North East Wales NHS Trust email

Dear Authors

I thought your article was well written. We have recently had a similar case of local anaesthetic resistance. It was a patient presenting as an emergency for a caesarean section. The patient had a history of failure of local anaesthetics for dental procedures and dermatological procedures. The spinal also failed despite good practice. We never found a reason for it to fail. Other reasons we suspect would include subarchnoid cysts which although rare in the lumbar regional could explain the aspiration of CSF and the ability to inject 2 mls without detectable resistance. A review article in the BJA could explain where a mutation in the channel would cause resistance to local anaesthetics. It would be interesting to find the incidence of failure to produce a spinal despite the end point of aspiration of CSF.

Reference:

A Scholz. Mechanisms of local anaesthetics on voltage-gated sodium and other ion channels British journal of anaesthesia 2002;89:52-61

----

Pain Physician. 2003 Jul;6(3):291-3.
Local anesthetic "resistance".

Trescot AM.

The Pain Center, 1564 Kingsley Ave, Orange Park, FL 32073, USA. amt57@aol.com
Abstract

The incidence of inadequate analgesia despite technically well performed injections led our clinic to prospectively test patients for response to a variety of local aesthetics. Skin testing was performed on the skin of the forearm away from the site of pathology. Patients were asked to identify "which is the most numb" of the skin wheals. Although most were equally numb to all three local anesthetics (lidocaine, bupivicaine, and mepivicaine), 7.5% of the patients consistently chose mepivicaine as the local anesthetic resulting in the most hypoesthesia. For patients who had previously undergone an unsuccessful procedure with bupivicaine (the standard local anesthetic used in our practice), the same procedure with mepivicaine provided good relief. Patients are now questioned on their initial evaluation about a history of difficulty getting numb, for instance at the dentist, and preemptively skin tested prior to any invasive procedure.

http://www.ncbi.nlm.nih.gov/pubmed/16880874

-----

The Pain of Being a Redhead

I have redheads in my family tree and had red highlights in my hair so maybe I have the resistant gene. Sigh.

"A growing body of research shows that people with red hair need larger doses of anesthesia and often are resistant to local pain blockers like Novocaine. As a result, redheads tend to be particularly nervous about dental procedures and are twice as likely to avoid going to the dentist as people with other hair colors, according to new research published in The Journal of the American Dental Association."

The MC1R gene belongs to a family of receptors that include pain receptors in the brain, and as a result, a mutation in the gene appears to influence the body’s sensitivity to pain. A 2004 study showed that redheads require, on average, about 20 percent more general anesthesia than people with dark hair or blond coloring. And in 2005, researchers found that redheads are more resistant to the effects of local anesthesia, such as the numbing drugs used by dentists."


http://jada.ada.org/cgi/content/abstract/140/7/896 (study referenced in above article)
carmy_wcarmy_w on October 18th, 2010 07:51 pm (UTC)
WOW-I don't blame you for being cross over it.
From your first paragraph, it sounds like you got caught in the verbal equivalent of a form-letter loop (where someone heard one word of your question, and it opened a verbatim reply on an entirely different subject).

I am a firm believer in being very proactive and down right pissy with medical people if necessary. If I was you, (in addition to your letter) the next time, I'd tell them to double their wait time, period. If they gripe-hey, you are paying them, not the other way around. And I'm not afraid to repeat myself twice, or even three times, just to make very sure the message gets across. I repeat it until at least one person confirms that they read the file note about it, and then usually let it rest.