Replacement and Post-Op Discomfort

Hi Everyone,

I was puzzled when I did not locate a thread regarding pain medication after battery replacement.

I had my battery replacement yesterday and was directed to take Tylenol or Ibuprofen for discomfort.

*I was disappointed that they did not prescribe a day or two of Vicodin (as needed for postop pain.)


(Vicodin was just an example of a milder prescription pain medication.)

This was not offered as an option instead discharge instructions stated:

Notify your Primary Care Practitioner for:

"Pain unrelieved by Medication."

How is my Primary doctor going to direct postop pain management for battery replacement? What?

Were you guys offered an option of pain medication other than Tylenol or Motrin?

(I have a rail-thin chest wall, and it was difficult for the Doctor to manipulate the placement.)

Today I can feel bruising, and I have ice on my chest right now. The ice is helping me somewhat.

*So I am feeling grumpy and uncomfortable. Offering Tylenol as the only option seems odd.
(Let's dig in your chest wall and give you Tylenol *if you need it.)
;-)
However, maybe this is standard pain management for this procedure?

(*One other quick comment, although the battery/generator does not require a new pocket, it does not just fall out like a hen egg.
;-)
It entails the initial incision followed by incising around the indwelling implant to effect extraction.)

Any feedback you can give would be helpful.

Thank you.




11 Comments

I think that's standard

by SaraTB - 2016-01-30 09:01:52

Replacement procedures are generally very straightforward and ideally shouldn't require more than OTC painkillers. Bear in mind, a replacement doesn't require a new pocket made, so it's unusual to cause bruising compared with the original implant.

I was told to take acetaminophen (paracetamol in Europe) or ibuprofen, if needed (it wasn't). I'd be concerned if a doctor was automatically prescribing strong stuff like Vicodin, frankly for what should ordinarily be simply the incision wound.

I would say the instructions are sensible: if you are in pain, take OTC painkillers. If you are still in pain, ask your primary care doctor for something stronger. You have said you have bruising, but you have no said whether you actually are in pain that is unrelieved by OTC meds.

Hope this reassures you that the instructions are normal.

I agree with Sara

by IAN MC - 2016-01-30 10:01:38

I ,too , would be quite concerned if Drs routinely dished out powerful pain-killers such as Vicodin for a minor procedure such as a PM replacement.

Vicodin, which you use as an example, contains hydrocodone which is an opioid and is reserved for severe levels of pain. Would you be happy if your dentist gave you morphine after a minor dental procedure.?

Just because paracetamol and ibuprofen can be bought O.T.C doesn't mean that they are ineffective for the level of discomfort that you are likely to encounter. Many people don't need any painkillers at all.

I don't understand the point you make about GPs; they are accustomed to having to manage all levels of pain.

Ian


pain management

by Tracey_E - 2016-01-31 02:01:24

I've had 4 pacer surgeries. I was not sent home with pain meds after any of them. When I had the last one, a plastic surgeon cleaned up the scar tissue and reconstructed the pocket and they ran a new lead through a different vein and tunneled it to where the others hook up, so I was pretty sore after. My instructions were to call my primary if I wanted more than otc, I did and she immediately called in something. I filled it but only took one, Tylenol and ice took care of it by the second day. Replacements are considered pretty minor, but that doesn't mean everyone is ok with just otc, however I can see the potential for abuse so it makes sense to me that they don't automatically prescribe it.

Final Update from communication with Interventional Cardiologist (Surgeon)

by mchokozi - 2016-01-31 07:01:33


I followed up with an email to the Interventional Cardiologist (Surgeon,) who I like and is highly competent. I addressed my issue with pain control.

She responded very rapidly and was thorough and caring with her answers. She was glad to hear that I was going to receive Vicodin, as the on-call doctor had prescribed it.

She gave wider parameters than the on-call physician, including two pills and more frequent dosing to effectively manage my pain (as necessary.)

We exchanged a couple of emails, and I feel so grateful for her open-minded approach to discussing my concerns. She listened and communicated collaboratively and patiently.

Bottom line:

*She is rethinking her routine practice to include offering patients prn (as needed) pain medication.
(This type of prescription would be written based on the variation in pain tolerance.)

*She is aware that access to a prescription medication may be difficult for someone who cannot drive.

If not initially obtained, one may have to see a doctor followed by a trip to the pharmacy to access a pain medication at a later time.

This process would require finding transportation as one may have early driving restrictions. Obtaining transportation can be challenging and costly for some people. Waiting for public transportation can be difficult when you are in pain.

These variables would make an initial offering of pain medication optimal.

She did indicate that my new pacemaker is a different shape and larger than my last one. She said that she had to perform some dissection to create capacity for inserting the new one.

She also said my thin chest and an unusually low amount of sedation likely contributed to inadequate pain control.

I hope my challenges may be helpful or relevant for someone else.

I appreciate people weighing in with their experiences.

Thanks to each of you.

Definition

by BillH - 2016-01-31 12:01:10

The problem is that people don't understand the difference between minor and major surgery.

Minor surgery is brain surgery done on someone else.

Major surgery is the removal of a splinter from you.

Following up

by mchokozi - 2016-01-31 12:01:20

So here is the follow up that I have.

Even though the pocket is already there, the pacemaker itself has to be extracted. It is necessary to excise it away from the muscle and chest wall to perform an extraction. In sum, this is not merely an incision wound.

There is a degree of manipulation required for insertion of the new pacemaker. Then the connective tissue and muscle are drawn up adjacent to the pacemaker and secured in place.

Any other procedure requiring this degree of tissue manipulation would automatically entail a short-term prescription for pain medication as needed.

As to the Dentist, they commonly give a couple of days of Vicodin (or similar RX) for a painful and invasive procedure.

Vicodin (as an example) is one of the weakest prescriptions medications and is *not morphine. Although it contains a synthetic analog of codeine, it is in no way equivalent to the administration of morphine. It is not in the class of Morphine *at all.

The oral (by mouth) equivalent of morphine is Oxycontin. Oxycontin is a triplicate drug and far different from Vicodin (at a higher level of narcotic control.) One must go in as an individual to pick up an Oxycontin prescription and pick it up in person from the pharmacy.

In contrast, a friend can go to the pharmacy for you to pick up Vicodin.

Prescribing an "as needed" prescription is typically considered appropriate management of postoperative pain. This practice is why I am puzzled by this surgeon's order.

Although General Practitioners are competent with pain management, it is not routine for them to address postoperative pain.

At least, in the United States, that type of pain is commonly considered in the domain of the operating surgeon (or on-call surgeon.) Refractory pain is not rolled over to a Primary Care doctor.

Transitioning pain management to a PCP has not been standard practice (in my experience as an RN and patient.) Perhaps patient management is adapting to a new model, but I do not think this is the case.

To answer your question regarding my pain, I have been taking Tylenol, Relafen, ice packs, etc., and I am still hurting. There appears to be soft tissue swelling around the dressing. My chest wall is remarkably thin, so apparently operating on me is relatively challenging. I heard the surgeon discussing how difficult it was for her as she was working on me.

(I sustained a pneumothorax with my original implantation, in part related to my anatomy.)

I am happy to hear that many people suffer minimal to no pain and do not require pain medication.
However in my case, OTC treatment has not been fully effective. I am sure I am not alone in experiencing this level of discomfort even if it is not "normative."

I did contact the On-Call doctor for the PCP (Primary Care Doctor.)
When I reached him, he was stunned that there was no order for any pain medication (such as Vicodin.)

He described it as:
"a laceration with excavation,
with no pain medicine.

He gave an order for Vicodin, which my husband will be picking up for me.
I appreciated this physician's willingness to address the issue and wanted to share this outcome.

Again, I understand this does not reflect the experiences of the people who have responded to me thus far, and perhaps the majority of people.

BTW, thanks to Bill who clarified "minor" vs "major" surgery. That made me chuckle!

Thank you for all of your responses, as they are helpful in giving perspective. Perhaps this is considered a "niche" where pain management is a "different animal" (one that I do not like.) ;-)

In this day & time I'm...

by donr - 2016-02-01 02:02:22

...surprised if ANY physician not directly associated w/ performing a surgical procedure would prescribe any controlled pain killer for a patient.

I am especially surprised that a surgeon would tell a patient to go to another Dr to ASK for such meds.

To me as the patient, I hold that surgeon responsible for management of my situation until I return to normal. That includes PAIN - because pain is an indication that something is not going the way the surgeon expected.

MOF, I have never had any surgeon who performed any sort of invasive procedure even suggest going to another physician for help in this sort of situation - the post-procedure WRITTEN instructions have always included a phone number for their practice in such events.

As to my opening line including "...in this day & time..." - Our #2 daughter is an MD, just opening a private practice (Turned on the "OPEN" sign the end of Nov, 2015) after 13+ yrs as an ER Doc. She will not give a non-patient (of hers) controlled pain meds w/o a very probing investigation of their situation - including a call to the primary Dr. responsible for the existing cause for the pain. She has seen too many druggies trolling for support of a habit in her ER's.

Don't know about other states in the US, but Mississippi has a centralized system that collects data on physician's controlled substance prescription practices - if they find an "unusual number" of prescriptions to the same patient, there is a quick inquiry asking for justification for them.

Her first question of a patient asking for pain meds when she is not responsible for the procedure causing the pain is "Why didn't you go to your Dr. who performed the procedure?". You should hear the convoluted reasons given in response.

Pain management is a complex & individualized situation. We all respond differently to pain & its relief meds because of our differing tolerance of pain.

Dave: Just read your polemic on pain killers & Heroin.

Table talk w/ ER Doc Daughter is interesting on this subject. I can remember from 1956 when I had my first surgery by Henry VIII's headsman using his ax to repair a torn cartilage. I was 19 at the time & the pain PO was excruciating. The only pain killer then was morphine & it sucked as to side effects. How anyone could become addicted to that stuff amazed me! But they did.

You are correct about the sad situation in monitoring pain meds prescriptions, but the addiction situation out there is horrific! According to Daughter, Heroin is not the real problem today. W/ the Oxy family of synthetic opiates & the spectrum of strengths, she has seen a lot of people who become addicted to those meds. I cannot handle the side effects of any of therm, so I am not a risk for addiction. But there is a significant number of people who enjoy the feeling they create, & they are apparently legion! There are even those who are resistant to the effects of the narcotics & have to eat them like candy to get any relief.

The plus side to all the pain meds is that Dr's can treat pain much more efficiently w/o having to go right to the silver bullets. Unfortunately no action is w/o its unexpected consequences. Addiction to legal pain killers is one of those consequences!

The ER's get a LOT of druggies looking for their next fix, & they are exquisite in their schtick for conning unsuspecting Docs into supporting their habits. The real challenge for the Docs is to sort out the people who are really in pain from the druggies. That requires real probing questioning & some extremely tough love - and sometimes in the end some harsh ultimatums.

MOF, the really proficient druggies learn quickly who the sucker Docs are & learn to recognize their cars, so check the physician's parking areas to see who is on duty. Realize, I am talking about rural areas where the smaller hospitals only have 1 ER Doc on duty.

Compassion: can sometimes be unfriendly. Like the time daughter was going to perform a minor injection of a hand problem I had. Just before doing it, she looked up at me & says "Dad, sit down, shut up & quit whining!" There were several ghoulish family members witnessing the scene, all gathered around the kitchen table, who were shocked. Daughter looks over at her sister & said "Susan, you have no idea how many times I've wanted to say that to a patient!"

Donr





Vicodin ( hydrocodone )

by IAN MC - 2016-02-01 04:02:46

Interestingly when I expressed the view that Vicodin should not be offered ROUTINELY for post-pacemaker discomfort I wasn't even thinking about addiction.

A total of 661 other drugs interact with hydrocodone, 143 of these drug interactions are major and can be serious.

It is not a drug which should be routinely dished out just in case you get post-operative pain in my opinion. If OTC's don't work, and you need something stronger, fine but a doctor who knows your medical history should be involved in the prescribing decision.

David , you say " Shame on the folks who think the poster should not need any pain-killers " . I have re-read the replies and no-one expressed that view. We are all different and no-one should be made to endure pain if it is avoidable . The only point being discussed was what the prescribing process should be post-operatively.

Don , I played golf today with a retired GP and I quizzed him on his role in pain management . He told me that he has often had to substantially increase the levels of analgesia particularly for some cancer patients. Maybe the UK is different to the U.S ?

Ian

Hello again David

by IAN MC - 2016-02-01 06:02:57

When I commented on the need for Vicodin , I said that it should not be " routinely " dished out. I think my inclusion of the word "routinely" was fairly important.

Both Sara and Tracey similarly questioned the "automatic" prescribing of powerful pain-killers.

I agree with you that anything which causes people to be denied adequate pain relief needs to be looked at.

I guess I should apologise for my own " soap box" which is the unnecessary use and the over -use of prescription drugs ( ironic really as my pension is provided by a pharmaceutical company !)

Cheers

Isn

None for me

by valley01 - 2016-02-01 08:02:47

I didn't receive any type of pain medication upon leaving the hospital after receiving my pacemaker (haven't needed a battery replacement yet). Post-op directions were very vague - ice, Tylenol for pain, no lifting arm, no shower, etc. So I drove myself home - 45 minutes away from the hospital because I didn't want to be without my car (I was taken to the ER from work so my car was 1 mile from the hospital - my dad drove me to pick it up and I even gave him a tour of the place I work). Nobody told me I couldn't drive. My dad followed me home and we even stopped and had lunch about halfway (I wouldn't recommend this because my energy level died while waiting for our food and I was miserable the rest of the drive home). But I never did need any pain medication other than the Tylenol. I think everybody is different and every surgeon is different so some will feel more pain.

Let's talk....

by donr - 2016-02-02 05:02:17

....druggies for a moment.

Drug addiction is a real problem - but we cannot solve it by forcing addicts into rehab.

Rehab only works if the addict WANTS it to work (See 4 below). Therein lies the problem. The typical addict who trolls the ER's for a fix knows exactly what they are doing. They come at night when staffing is lowest. They come at night when the social work staff is off duty. They find out who the "Candymen" are & come when they are on duty. They come at night when the staff may be harried & not have the time or inclination to talk rehab. ER work tends to be a bit more engaging than four 15 minute appointments per hour - trauma injuries & ER grade illnesses eat time - why do the snotty nosed kids get pushed to the end of the line & wait multiple hours w/o getting seen? Are these people "Throw-aways"? Depends on the person - if they don't want help, there's nothing that society can do for or about them.

I just walked to the next room & asked our ER Doc daughter about the subjects we have been discussing. Actually, I inadvertently jerked her chain & got a memory dump about painkiller scripts & Dr's. I think I hit a raw nerve!

1) Any Dr. who turns a patient loose after ANY procedure that MAY result in pain at a later point in time - w/o making provisions for addressing that pain is guilty of "Bad doctoring." Plain & simple.

2) Any surgeon who turns a patient loose after a procedure w/ instructions to see their PCP for pain is guilty of "Dumping." You do the job, it's your responsibility to follow up till the patient has returned to near normalcy.

3) People are all different in their reactions to pain meds. Dilaudid, PO, makes me hallucinate. Not good, even though it kills the pain. Any opiates make me loopy, hung over & legally drunk. She had a patient who could take percocet & it did nothing for his pain after about 2 hours. He could eat them like candy w/o any real relief.

4) She once treated a young woman for an overdose - she survived. Her parents went bankrupt putting her through rehab for several repeat tries. She eventually died from an another OD.

5) She reinforced Ian's comments about neither over or under prescribing pain meds. Any competent Dr should be aware of the pain management needs of the patient. It is a very personal issue & varies widely among people.

6) Dr's need to control the use of narcotics & tailor the script quantities to the patient. It is bad medicine to hand out scripts for bottles of thirty (or more) willy-nilly.

Face it, they quickly learn who the narcotics "Abusers" are. If they don't know how to spot them, they need to learn.

7) Pain management requires a conservative approach - unless it is known to be severe, intractable pain, start w/ a low level pain killer; if it fails, go to the next level of strength. Where to start is a judgement call.

8) Pain management is part of doctoring for every MD, PA & NP. They must make time for it & listen to patient's complaints seriously. As I said this AM, unusual pain is a sign of something gone/going astray.

9) Treating pain is part of treating the patient's head as well as their body. (This line is mine, not Daughter's. It goes back to that ancient physician, Napoleon Bonaparte, who said "In battle, the mental is to the physical as three is to one." It's also true in things medical - he just didn't know it when he spoke.)

Ian: I do not know of the situation w/ cancer patients in severe pain requiring greater analgesia. Not even via second or third person experience. I've read about it. Daughter has never cared for these patients. Severe burn patients in a hospital burn unit at a trauma hospital - yes, & she has talked about their pain management needs. Patients w/ 2nd & 3rd degree burns over 50% of the body define intractable pain. They have acute pain that lasts almost like chronic pain in duration - literally months on end. How they keep from becoming addicted is beyond me.

Back in the mid-1960's I had a young soldier working for me who had an accident while white water canoeing. He was thrown out of the canoe & somehow wound up in front of it, facing it. He took the keel of the canoe in his mouth & lost several teeth. He spent several weeks in the hosp & had very severe pain. Lots of morphine - standard in those days. Got addicted to the stuff. So I had a true morphine addict working for me. The difference was that he did NOT want to be addicted & fought it tooth & toenail, all the time.

This is a worthwhile thread - pain management & addiction to prescription meds is a serious problem.

David: I respect your comments on druggies being throw away's. While discussing it w/ daughter, I parsed her words & can best sum up her attitude as "I can't save them all. If they want help, it's there; if they just want a fix, there's nothing I can do for them, except abet their cravings, & that I refuse to do." I call it triage at the point of service. You tend to get a bit unsympathetic toward the druggies when you match it against a mother bringing in a dead baby; a man with a .45 round that went in the right chest, transited all the major vessels at the top of the heart & stopped against the left ribcage; a man who is having a heart attack & you have to get him stabilized for a 30 min flight to a major hosp; a woman suffering a major snakebite from a venomous variety of reptile; an auto accident that delivers two DOA's & three severely injured people - & there's only one of you.

The first time I learned about triage, it was in a class in the Army on mass casualties in the event of nuclear attack. The discussion seemed heartless & inhumane. But upon further cogitation, it was/is a necessary action when medical assets are exceeded by casualties. That's the case in most hosp ER's.

Nowadays, the first person you see in an ER is the "Triage Nurse," who assigns you a priority for treatment. Chest pains go to the front of the line, as do symptoms of a stroke. Snotty-nosed kids sit & wait.

Donr

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