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อัพเดท: 21 พ.ค. 2007 09.46 น. บทความนี้มีผู้ชม: 8243 ครั้ง

คำเตือน: ผู้แต่งต้องขออภัย ที่จำเป็นต้องแต่งเป็นภาษาอังกฤษ เพราะต้องการให้คำเตือนเรื่องสุขภาพนี้เป็นประโยชน์กับคนทั่วโลก จึงได้ส่งไป CNN.com และสื่อต่าง ๆ ทั่วโลกด้วยแต่ยังมิได้รับการตีพิมพ์แต่อย่างใด นอกจากมีนพ.ผู้อำนวยการรพ.ระดับอินเตอร์ที่ใหญที่สุดในประเทศไทยแห่งหนึ่งที่เกี่ยวข้องกับการผ่าครั้งนี้เขียนมาขอบคุณและบอกว่าจะนำไปใช้ในการฝึกอบรมแพทย์และบุคลากรต่อไป หากท่านมีญาติมิตร คนรู้จัก ที่ต้องการผ่า LASIK หรือ ป่วยเป็นไทรอยด์ ควรอ่าน


ได้ธรรมะมาสอนใจจากการไปผ่าเลสิก

Executive Summary

Who

An unsuspecting LASIK patient with Hypothyroid problem

What

Went through preventable “near-death”24 hours of shockingly painful post-LASIK experience plus 7-day slow recovery,

an internationally unprecedented case

Where

at a leading international Hospital in Bangkok, Thailand.

When

Aug 25, 2006.

Why

Underwent LASIK while having unusually low level of Cortisol hormone (3.9 mcg/dcl) without receiving Cortisone (steroid) injection before operation.

How

Insufficient communication between “home hospital” that handles on-going Thyroid treatment and “host hospital” that performs LASIK surgery.

To What Effect

Unprecedented case: nurse unprepared & not knowing how to handle, making matter worse.

Purpose of Article

*To prevent others to go through same painful experience

*�� To create more awareness of Hypothyroid and the importance of regular health check up for all.

*To stimulate more research in Cortisol & postoperative pain

N.B.

No names of the hospitals are mentioned in this article as it is not the objective of the author to discredit any hospitals or doctors.


Not only Agassi Needs Cortisone Injection:

A Thai Patient’s Post-LASIK “Near-Death”

Painful Experience

by Nash Siamwalla

����������� Bangkok, September 2006 --�� Although the tears Andre Agassi was shedding as he was bidding farewell to tennis fans during this week’s U.S. Open were from his emotion and not from his chronic back pain, we were also aware that he would not have made that far into third round of the U.S. Open without his rounds of Cortisone injections to treat his painful sciatic nerve. (“Intense Back Pain”, 2006)

����������� In his own words, he was quoted as barely able to stand after the first-round win over Pavel, (“Hurting Agassi faces tough Baghdatis”, 2006) and had to lie down on the pavement while waiting for his limousine to pick him up for his Cortisone injection to help alleviate the pain. (Clarey, 2006)Such was the level of pain when Cortisone is required in the picture.It brought even the world’s top athlete to tears.It reduced the most dexterous man on court to immobility.

����������� Half way across the globe here in Bangkok, Thailand, barely two weeks earlier, a Thai Hypothyroid patient with an alarmingly low level of Cortisol, a hormone that, among others, helps you tolerate pain (Scott, 2006), was also lying down awaiting the same Cortisone injection as recommended by her physician before a LASIK surgery. With Cortisol so low, her regular physician suspected she would not be able to tolerate the trauma from surgery.

����������� Not that the patient was someone who was likely to fear pain.About to take the blackbelt exam in Chanbara, a new-age sword-fighting Japanese martial arts and a current holder of Tae Kwon Do’s brown belt, the patient was also a veteran mindfulness (vipassana) meditator with thirty four one-week meditation retreats listed on her resume.Those are classic training in physical and mental pain handling.But this time, the level of Cortisol in her blood sample was too low to take the risk.

The optician, however, decided not to give the Cortisone injection to her as recommended two days before by her Thyroid physician from another hospital and went ahead with the LASIK surgery.

Post-LASIK Hell

After the anesthetics’ effect ran out, the 24 hours of Post-LASIK agony would put any torture chamber to shame.For it felt like your eyes are being poked by hundreds of thousands of needles continuously while sandpaper is being rubbed brutally on to the delicate surface of your retina.Left, right, up, down.There is no escape from that.The pain was suddenly there and everywhere.

����������� And once the intimidating postoperative pain began, there was no way to reverse that. What was supposed to be a quick, painless LASIK operation (Center for Devices & Radiological Health, 2006) turned out to be an extended nightmare despite the perfect vision that would follow that nearsightedness corrective surgery.

Tears continued to gush down the cheeks of the shocked patient like waterfalls through both eye covers, soaking them right into the early hours of the next day.That was simply the body’s final, losing battle against the ruthless agony.Ironically, it was very sad to discover first-hand that our own body has that desperate SOS function to produce a continuing flow of tears without one’s emotional need to cry.

Your body was mourning its failing self.Isn’t it pathetic to observe this natural fight of survival happening to your body as you lay there without the slightest need to sob?

����������� How did I know all this?I was that patient.


�����������
That pain was the drive behind my determination to do this research from a patient’s perspective and write this article so that no other person would ever have to go through what I went through ever again.��


Pain? What Pain?


�����������
Yes, I agree that pain is indeed a subjective experience.I found that out bitterly when the nurses and staff at the hospital at first expressed disbelief that someone who just had a LASIK operation could have gone into so much pain.They simply would not believe me.They insisted that no patient has ever gone into this much agony after the anesthetics’ effect ran out.


�����������
As proof, until the day of this article writing, they still do not take me seriously.No warning has been put on their web site regarding possible risk for patients with similar symptoms such as myself, i.e. hypothyroid or low Cortisol level.The U.S. F.D.A.’s web site, however, makes it very clear that among people at risk for LASIK are those with hormone fluctuations (Center for Devices & Radiological Health, 2006).


���������� LASIK, according to the hospital staff, is such a minor operation that most patients do not even bother to check themselves in at the hospital’s room for observation in case of emergency during the 6-8 hours mandatory postoperative rest period like I did.


�����������
Their denial alone in fact would have driven my Cortisol level even lower (“Cortisol”, 2006, Physiology, para 1) (Priyasombat), hence lowering my ability to tolerate pain even more.If there should be people of any profession that are better-informed about Hypothyroid patient’s lower sensitivity to pain, it should be post-operative nurses!One familiar sentence from popular Thai tabloid press sprang to my mind, “…And the victim died because of her inability to tolerate the wound…”


Facts on Pain Perception

In the case most similar to mine I could find on the web, doctors indeed have done experiments on pain perception while monitoring Cortisol level of patients who went through cataract surgery based on self-report.Subjective as it may have been, none of the patients went through their surgery experience (before, during and after) with their Cortisol level lower than 8.7 microgram per deciliter of blood (Gozum, Altan-Yaycioglu, Gucukoglu & Arslan, 2003).�

According to the U.S. National Library of Medicine, the normal level of Cortisol should be between 6-23 mcg/dcl (Hurd, 2006).That is, anything lower than 6 would likely to be too painful to handle, I figure.

Mine?Two days before LASIK, my regular Thyroid blood test at another hospital showed that my Cortisol was as low as 3.9 mcg/dcl.�

In Japan, even with patients who were qualified as clinically depressed, none of them went through their surgery for research on Cortisol with their Cortisol level lower than 19.2 mcg/dcl. (Kudoh, Takahira, Katagai & Takazawa, 2002).

While it may sound like I stand for the new world record as the patient who went through surgery with the lowest Cortisol level in history, it also means I was exposed to the level of pain previously inconceivable to mankind on the operating table.Personally, I do not want to be remembered in the Guinness Book of World Records like that. ��And I am equally confident that Mr. Agassi would not want to be remembered as the tennis legend who suffered the most severe back pain during a Grand Slam event either.


����������� While Cortisol is better-known to be related to stress, hence the nickname “Stress Hormone,” research into correlation between Cortisol and pain was not new.Even without access to exclusive medical database, any internet user can perform search on Cortisol and pain like I did.If Thailand wants to be a medical hub of the world, I think our medical team as a whole should at least promote more awareness of this kind of basic knowledge.

The Help That Would Not Come

����������� “Try not to worry.It would make your pain become worse,” said one nurse.At that time of such excruciating pain, you don’t have time to worry about anything else in the world, believe me.All you wanted was to get rid of the pain.

Twisting and trashing about in bed with pain at that time, tears flowing incessantly from both covered eyes, I temporarily lost all my meditation training and felt I had the patient’s right to feel that the two words were not interchangeable.Stress was psychological, I reasoned, while pain was very much physical.Therefore, through my gritted teeth, I seethed out my answer, “I-AM-NOT-STRESSED.I-AM-IN-PAIN.COULD-YOU-JUST-PLEASE-GET-THE-DOCTOR?”

The Failed, Attempted Pain Relief

This she did try, but it took such a long time before she got back to me.At least that was how it felt to my burning eyes.There was even one occasion that she returned to say that she couldn’t reach the doctor on his mobile phone.Imagine how Mr. Agassi would feel if he was lying in pain on the burning pavement in a hot New York summer during this U.S Open and they told him that they could not find someone to help him with his pain.

At the end, following the optician’s instruction over the phone, they had to risk my post-op eyes’ infection and open my eyes which were supposed to rest closed for another 8 hours to put in more anesthetics drops.Frightfully as it may sound, during the crucial first 24 hours after the operation, no doctor came to physically visit me despite my obvious urgent need for one.

With my body in spasm with pain and my eye still covered, rendering me helpless, I repeatedly made a desperate plea for the nurse to call my thyroid doctor at another hospital to report the situation and request some advice.I was to find out later at the time of this writing that no contact attempt was made.In plain words, my highly unusual pain was left undiagnosed and untreated by any doctor until the next day.

The anesthetics relief attempt mentioned earlier helped only for less than half an hour, then the torture started all over again.They could only repeat this treatment twice altogether, meaning less than one hour of temporary relief during the 24 hours’ inexplicable agony. ��After that all you could have was an ice pack which you could not put directly on to your burning eyes either.It would be too painful even for that.So I had to put four ice packs around my eye sockets to try to use the freezing temperature to trick the sensation around my eyes to turn its attention away from the trauma inside.It did not really help as tears still continued to roll down underneath the ice packs.A big messy affair it was.

Children in Pain

As far back as the year 2000, The European Journal of Pediatric Surgery has published a research result of Cortisol level and postoperative pain in children (Solak, Ulusoy, Sarihan, 2000).This report confirms my case.The children’s self-reported postoperative pain score corresponds with their Cortisol level.��

But if I as an adult was having a lot of problem convincing medical professionals at a leading international hospital to understand and believe the level of my pain, I wonder what methodology those researchers would have to use to make the experiment valid and credible to the global medical community.

Pain Measurement

After more serious search, I did find out there were many medical standards to gauge the level of pain.Beside patient’s self-report and obvious biological measures such as heart rate and blood pressure, there is the standardized behavior test.

Three behavioral scales have been developed for measuring post-operative pain in infants and children. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) rates six behaviors including crying, facial expression, verbal expression, torso position, touch and leg position(International Association for the Study of Pain, 1995).

����������� And my own level of pain according to this CHEOPS pain scale?Many eyewitnesses would be able to testify for me, perhaps with horror, that, from the postoperative morning hours well into the night, they saw my upper torso convulsing up from bed by itself with pain as if I was trying to do a sit-up exercise before falling heavily down again, not to mention the automatic leg-kicking and sheets-grabbing whenever I drifted out of sleep enforced on me by the strongest medicine they could give without jeopardizing my health even further.

Covering Up the Problem Rather Than Solving It at Its Root Cause

����������� It took three doses of two different sedatives to finally put me to sleep. After the first dose of Xanax failed to make me sleep, they told me to hold another dose right under my tongue for faster, more effective effect.But my pain was far greater than two doses of Xanax, even if you hold it under your tongue.

����������
Finally two more tablets of a very strong sleeping pill arrived on top of 2 tablets of Xanax and 13 other prescriptive medications I was taking at that time for my hypothyroid, stomach ulcer, etc.With virtually empty stomach, that finally did the trick.But I still woke up regularly because of the pain.


�����������
Looking back, I would suggest that they did send a doctor to try to look at this unusual problem at its root cause and try to solve it from there rather than trying to cover it up by putting me to sleep and hope that the problem would be able to go away by itself.

����������
If I did not have my extra dose of strong medication from my thyroid doctor from another hospital with me to take twice daily during the post-operative period, my pain problem would definitely NOT go away by itself and my excruciating pain would last much longer and its root cause would never be explained.More unsuspecting patients could have ended up like me!

Mother’s Instinct: The Most Trustable Source

����������� It must have been especially hard for my mother who was there originally to offer to drive me home but end up having to stay overnight to give me moral support.Being my own mother she must have known by instinct that the twisting and trashing body on the hospital bed in front of her was really in highest level possible of pain and was not just acting to draw her attention.

I am, after all, a psychologically healthy grownup who never acted like that even after my tonsils removal surgery at 5 years old or my appendix removal surgery at that same age! I still have vivid memory of both surgeries.While the tonsils removal was more painful than the appendix’s, neither was as bad as this LASIK ordeal. My mother did not need a standardized pain scale to gauge my pain score.

���������
Grasping her hand, I told her in my shaking voice that my eyes were burning.She knew instinctively that this pain magnitude was raw and real because I never reached for her hands because of pain before in my adult life.

This is life, after all, not a medical experiment.


Flirting with “Near-Death” Sensation

Put it this way, if I was not educated enough, I would really believe that I was about to die because of that nonstop pain.The level of pain convinced me that the imminent result could not be otherwise.The shocking, to-the-flesh-and-bone kind of pain literally ripped out any human dignity you think you may have.I was reduced to a mere creature trashing about with teeth gritting, fists clenching, legs kicking and upper torso in spasm.�

Please keep in mind that all through this period my level of Cortisol, the hormone that helps you tolerate pain, has hit an all-time low and I was not given any proper treatment to handle this chronic pain hypersensitivity.

Unlike Mr. Agassi, I did not get my Cortisone injection
.

With your eyes closed, your other sensorial perception is normally heightened.But at that time I did not even recognize my own eerie grunts.As tears continued to gush down, I struggled to keep my mind intact and focused and tried in vain to use different meditation techniques to pull me through.The breathing technique, mindfulness technique, loving-kindness meditation, empowerment prayers, Zen’s “no mind”, Theravada’s absolute forgiveness, I have tried them all.

���������� But I was not in the state to pull off any of the technique I used to be able to master.I was Harry Potter without the magic wand and on top of that I was also badly injured by Lord Voldermort’s most intimidating spell.In this kind of situation, I needed help.


��������� Alternately, without my religious training, I would also say that there were indeed moments that I would prefer to die.That was the first time ever in my whole life that pain has driven me that far.

Personally, this was my own near-death experience.Driven by pain to the point that I was on the verge of giving up on life itself, I felt I have physically been to Hell and back.I got a first-hand experience how dreadfully painful it is like over there in Hell.I know I don’t want to be there ever again.

I emerged from that ordeal a whole new person with a broader perspective of life.Other problems seem less trivial comparing to what I just went through.What I am also happy to find is that I could find peace of mind after the excruciating painful period was over because I knew it was my Karma.

Quintessentially, this has been the greatest Dhamma learning experience for me.It has been truly “eye-opening.”Yes, the pun was well-intended.It helps reaffirm my determination to try to achieve Enlightenment one day, this life-time or otherwise, so that I would end my cycle of sufferings, meaning birth and rebirth, in this Samsara for good. Because of my existence, there was that horrible suffering.That insight came up repeatedly during those fateful hours.

What Actually Went Wrong and What Could Have Been Done

By this time, many of you may wonder what actually went wrong and why was I not given the Cortisone injection?It should have been a simple procedure enough, shouldn’t it?

By all means, it should have!

Two days before LASIK, I went for my regular blood test.That was the day my physician discovered that my Cortisol level was unusually low at 3.9 mcg/dcl.That was more than enough to send her into alarm.Learning of my upcoming LASIK at another hospital, she asked me to inform my optician to inject me with steroid before the surgery and prescribed me with additional doses of prednisolone for postoperative period.� She did no want me to go into shock ant lost consciousness like it is supposed to be.� It could complicate the other medications I was already taking at that time.

Karma aside, this is how I saw how things started to go wrong.First, I should have asked for the Cortisol Lab Result to carry with me to the hospital that performed my LASIK.Second, I should have insisted for a written recommendation for the Cortisone Injection.Although I did call my Eye Hospital and informed them, at the end, they still believe that the amount of my regular oral Thyroid prescription would still be enough to handle the LASIK ordeal on me.�

And I have to thank my Thyroid doctor for her foresight in giving me the extra dose of prednisolone to handle my post-op ordeal for the next 5 days, without which I wouldn’t want to imagine how much longer my pain would last or how much more painful I must have felt.

The Recuperating Week

Even after I went home to recuperate, the first week was still haunted with sporadic pain and unsuspecting event.�� Living in a condominium, an elevator ride was inevitable.And even that caused so much pressure on my eyes that both my hands instinctively went up to cover both eyes as I went down to the elevator floor squatting.

����������
That was my body’s automatic reaction to a normal elevator ride because both my hyper-sensitive eyes felt as if there has been a heavy weightlifting iron pressuring swiftly on both eyelids.My eyeballs felt so squeezed as if they are on the verge of jumping out of my eye’s socket.

During that first week, I would also feel hyper-sensitive to anything that would come into contact with my eyes.A waft of cologne from someone walking by even not in a close range was enough to make my eyes producing a flow of tears again automatically.I still could not resume normal walking rhythm in the first week because that would be too painful.Moving around slowly like an aging person who was ill, I patiently nursed myself back to health before I researched and wrote this article.


Learning

1.������������������ If you are using more than one hospital for your health maintenance, make sure the authorized person a.k.a. chief physician from each hospital communicates regularly with each other in writing.

2.������������������ If you are a nurse, try a more psychologically practical approach in handling patients in pain.Telling a patient not to worry while the patient is in so much pain did in fact accentuate the patient’s anxiety thus increasing the pain even more.

3.������������������ If you are considering a LASIK surgery or any surgery at all for that matter, consider an overall health check up to see first if you are a Thyroid patient.It is more common than you think! (“Hypothyroidism”, 2005)Knowing about your thyroid condition could also help you improve your overall quality of life even though you are not planning any surgery.������

4.������������������ If you are in any medical profession, by all means, please spread more information and understanding of Thyroid patient’s lower sensitivity to pain and stress.Definitely more research is needed.It would help your work much easier also at the end of the day.

5.������������������ If you have never experienced the same kind of pain the patient is experiencing a.k.a. postoperative pain with extremely low Cortisol hormone, it is a better idea to observe and try to learn as much from the patient’s experience with respect than just to comment on them or try to make the patient adjust to your own pain’s threshold.Usually, it makes the matter worse, not vice versa, no matter how much good intention you may have.�� Because even if you are a trained professional with a proven technique that you thought would help lessen the pain, you still lack the unique insight of the patient.Do help with compassion, not with your own blind passion to have things your way.


���������� This article is not copyrighted.Please feel free to pass it around to people that may benefit from it as much as possible.And let us hope that no one should be left in pain or was hurt unnecessary from miscommunication or misunderstanding regarding the seriousness of correlation between low Cortisol level and pain sensitivity again.

May you all be healthy, happy, and free from physical and mental sufferings.

**************

BIBLIOGRAPHY

Center for Devices & Radiological Health.U.S. F.D.A. (July 12, 2006). What Should I Expect? Lasik Eye Surgery.Retrieved on September 8, 2006 from http://www.fda.gov/cdrh/LASIK/expect.htm

Center for Devices & Radiological Health.U.S. F.D.A. (July 12, 2006). When is Lasik Not for Me? Lasik Eye Surgery.Retrieved on September 8, 2006 from http://www.fda.gov/cdrh/LASIK/when.htm

Clarey C. (September 4, 2006), One Last Kiss From Agassi, and It’s Over, The New York Times on The Web.Retrieved on September 6, 2006, from http://www.nytimes.com/2006/09/04/sports/tennis/04tennis.html

Cortisol. (2006, September 4). In Wikipedia, The Free Encyclopedia. Retrieved 08:33, September 5, 2006, from http://en.wikipedia.org/w/index.php?title=Cortisol&oldid=73781605

“Hurting Agassi faces tough Baghdatis: Soon-to-retire U.S. star says he could barely stand after beating Pavel” (2006).Associated Press.Retrieved on September 6, 2006, from http://www.msnbc.msn.com/id/14588023/

Hypothyroidism.(2005).�� Norman Endocrine Surgery Clinic.Retrieved on September 8, 2006, from http://www.endocrineweb.com/hypo1.html

“Intense back pain leads to another injection for Agassi”.(September 1, 2006).CBS Sportsline.ComRetrieved on September 6, 2006 from http://www.sportsline.com/tennis/story/9632806

International Association for the Study of Pain. (July 1995). Pain Measurement in Children. Pain Clinical Updates. Volume III, Issue 2.Retrieved on September 5, 2006, from http://www.iasp-pain.org/PCU95b.html

Kudoh A., Takahira Y., Katagai H., and Takazawa T. (2002).Cortisol Response to Surgery and Postoperative Confusion in Depressed Patients under General Anesthesia with Fentanyl.Hirosaki, Japan, University of Hirosaki School of Medicine, and Hirosaki National Hospital, Department of Anesthesiology, Neuropsychobiology 46:22-26. Retrieved on September 5, 2006 from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12207143&dopt=Abstract

Nilfer G., Rana A., Ahmet G. and O. (2003). Does Topical Anesthesia Increase Patient's Serum Cortisol Level? The Internet Journal of Ophthalmology and Visual Science. Volume 2 Number 2.Retrieved on September 5, 2006 from http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijovs/vol2n2/cortisol.xml

Priyasombat, Chavalit, M.D. โรคของต่อมหมวกไต, , Adrenal Glands, Lecture for Fourth Year Medical Student, Mahidol University’s Faculty of Medicine,Retrieved on September 5, 2006 from http://library.ra.mahidol.ac.th/Lecture/Adrenal.htm

Hurd, R., M.D.(August 11, 2006).Cortisol Level.Medical Encyclopedia. U.S. National Library of Medicine. Retrieved on September 5, 2006 from http://www.nlm.nih.gov/medlineplus/ency/article/003693.htm

Scott, Elizabeth. (May 15, 2006).�� Cortisol and Stress: How to Stay Healthy.Stress Management.Retrieve on September 5, 2006 from http://stress.about.com/od/stresshealth/a/cortisol.htm

Solak M., Ulusoy H. and Sarihan H.(Aug 10, 2000). Effects of caudal block on cortisol and prolactin responses to postoperative pain in children. European Journal of Pediatric Surgery (4):219-23.Retrieved on September 5, 2006, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11034509&dopt=Abstract


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