PAIN When the subject of âpainâ can be completely understood, then we can understand âlife,â too. That the medical profession has many effective anti-pain medications, and excellent anesthesia for both surgery and non-surgical cases, is a testament to increasing understanding of pain. The fact that pain can also be effectively managed without medication and without other physical manipulations such as acupuncture or pressure, should add to the measure of success which we, as a species, have amassed in the management of pain. Instead, however, this has only added to our confoundment on the subject. Patient walks in with a deep laceration of his upper lip. Sutures are needed. But before sutures, local anesthesia is necessary to numb the area surrounding the wound so that the wound can be stitched. Patient says, âNo way, local anesthetic injectionâ Why? Because the patient is literally âmortallyâ afraid of needles (actually, needle sticks). I suppose an option is the use of general anesthesia (which means, putting the patient out completely); but the risks of general anesthesia far outweigh the benefits in this case. The other option would be to NOT stitch the wound at all (I shudder when I imagine the potential cosmetic results, and the risk of infection!). But, he has a suggestion: an answer. âDoc, how about hypnosisâput me under hypnosis and stitch me up?â What? I placed the patient under hypnosis, and thus placed myself in the land of amazement and marvel. Stitch after stitch, patient remained pain free. There were a few drops of tears in his half-closed eyes. There was no winceâcorrection: I was the one doing all the wincing for both of us: do you know how sensitive the upper lip is? I brought him out of hypnosis after the repair was completed; he was no worse for the wear. How is it that one can be so afraid of the pain of a needle stick, yet be able to undergo wound suturing without anesthesia under hypnosis? Life can be deep: so can pain. There is phantom pain where the brain is fooling one, but the pain is still real. There is psychological or emotional pain, even psychic pain, whose depth no one can plumbânot yet. And, there is vicarious painâa father-to-be feeling some of the labor pains of his spouse (of course, it canât be the same: he does not have it in him). Pain, Just like life. I tried to feel the pain of my patientsâenough to empathize and understand a little more of what they were going through. I once thought allowing it all the way might impair my professional judgment as to what needed to be done for the principle pain-sufferer. I found out later that it did not. Such practice of feeling one's patient's pain only enhanced the therapeutic relationship. Yet, I couldnât get myself to feel vicarious labor. Too painful, I decided. If to understand pain is to understand life, consider this: there seems to be no pain at all when in the active phase of the death and dying processâthat is, well before death occurs. In summary: even though there are effective options for pain control, pain is not well understood. There is a tremendous opportunity to manage pain effectively and completely using innate and inner personal resources as opposed to external agentsâif we can come to know how to tap into this. Can you imagine a world, or life, without pain?

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Influenza or the âFlu.â ...Fine one moment, next moment, rapid development of sore throat, headache and fever, and before long (actually, in almost record time), a feeling of the throat and chest being on fire, along with difficulty breathing, and body aches: Influenza has struckâthat quickly. Actually, the virus which causes Influenza âwormedâ its way past many barriersânormal body defense mechanismsâby treachery and stealth, homing in on susceptible tissue (the respiratory track), while its presence was not yet felt. Having gained control of the âfactoriesâ of the tissues, the virus makes large numbers of copies of itself; when these copies suddenly burst out of the tissues and into the body, the complaints described above startâand become worse, very quickly. The patient was brought into the clinic from work. From work? Yes; because, it was just a normal work day for him, with no inkling that anything was wrong or would be wrong. Suddenly, at work, he had taken ill, and now, he felt like he was going to die because his throat hurt really bad, his chest hurt, it hurt to breathe, and he had a fever; his head hurt, and by this time, all his body was aching. And, all of that happened so suddenly. It was the first influenza case of the season. âYou have the flu.â âBut Doc, I do not have any intestinal problems like nausea or vomiting or diarrheaâthat sort of thing.â âPrecisely. The flu or influenza does not go there.â This patient had come in within the window of opportunity for the anti-(Influenza)-viral medication to be considered effective. He had not received the vaccine earlier. âBut, will the pill workââ his eyes questioned: âdonât I need to be put in the hospital?â In many circumstances, the doctor is moved to use antibiotics at this phase, although these would be useless. Save them for the second phase. By the second phase, the patient reports that having battled the flu and gotten back to almost normal (took 1 week or so), he now has new problems with congestion and runny nose, cough and headache, and maybe, even feverââis the flu coming back?â No. What is actually going on is that, the body, having won over the virus by destroying it along with the infected respiratory tissue, now is faced with two problems: healingâgetting rid of dead tissue, replacing the damaged tissue;âand maintaining the original (normal) function of the now destroyed tissues while waiting for fresh tissue to come on line to take over. It is this delay in plugging this gap in function which allows the âsecond roundâ of complaints for the post-influenza patient. Now, he or she may be susceptible to bacteria infection, which responds better to antibiotics than the influenza virus does to the antiviral medications. The reality of the flu, though, is the capacity to make millions of people all sick at the same time. Looking at history, when, in the past, this has happened, many people perished. For the most part, there was not informed treatment; and even when we became informed, it was not easy to fashion the treatment. If millions of people can get sick at the same time with the same bug, it offers a chance for prevention using vaccines. We have done it with other diseases. Here again, the wily influenza bug appears to have read the book: it âchanges its colorsâ so fast that recognition, needed for vaccines to work, is lost. The best we can do now is to make an informed and educated guess as to what âcolorâ it is going to wear next season so that we can use the vaccine ahead of the season to prepare the bodyâs ambush against that color-flu virus. If the virus actually is a different color, it will not be challenged by the bodyâs ambush team. Scientists are trying harder to target other than the âcolorâ of the virus. The reality of the flu is also the reality of fear. In general, of course, fear is the âdis-easeâ in disease. Predictions of a huge influenza pandemic (world-wide affliction) and warnings that the world may not be ready for a deadly incarnation of such flu which could kill a lot of people have probably aroused more fear in us than given us information to prepare us or motivation for protective actionâthe latter being the intended goal. This year we saw how doomsday-type predications of natural disasters actually came trueâmore or less. Through it all, we survived. There were serious casualties, butâit could have been worse: we survived. Hopefully, we learned, too. Did we learn--enough? If we can send space crafts to land on Mars and also orbit it, you would think that we could take care of ourselves on Earth? Yes, here on our Earth, we are too busy with other things to notice that the same bold and courageous thinking that put us on Mars, is, when it comes to Health and Medical Science and Technology, being stifled for fear of offending certain âsensitivities.â Experience and facts have shown that such âprotectedâ sensitivities have never prevented our feared calamities, never took away our vulnerabilities, nor even lessened our suffering when victimized and afflicted. In summary: the flu attacks quick and furious (this makes it easier to recognizeâpromptlyâthan other respiratory ailments): âwatch out for the wake following initial improvement. Fear of influenza pandemic is in the air, but we shall survive. Turn fear into action: ask the question: what is directly and indirectly hampering Health and Medical Science and Technology? In the meantime, take Public Health Influenza-related offerings seriously. Oguchi Nkwocha, MD oguchi@mbay.net Doctors Log 121305

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Menopause I am amazed at how underestimated the condition called "Menopause" is. To most, it is simply a physiological condition of aging resulting from a change in hormonal productions, fluxes and balance in the female gender. That clinical mouthful is reduced in lay terms to: unpredictable hot flushes in afflicted women, irritability and loss of interest in romance and related activities. Menopause is most likely a leading cause, if not the leading cause, of relationship problems and failures in the age groups affected. Divorce and marital separations are the result. When the term "Midlife Crisis" is used to summarize these problems, the fact that it is Menopause that may be causing the problems is somehow overlooked. I was moved when once a patient who had earlier started taking Estrogen to improve the symptoms of Menopause was recalled to re-assess the treatment after a new scientific study implicated such Estrogen treatment as presenting a risk for certain types of Breast Cancer. The patient flatly refused to stop taking Estrogen. Why? Because without Estrogen, her marital relationship would be over for sure. That was not an option for her. What a choice to make--between Breast Cancer risk and Divorce certainty. The relationship-burden of Menopause is huge. If better understood and properly taken care of, such a burden may not, and should not result in the wrecking of the relationships and lives of those affected. These relationships are not just important: they also define the essence of life and well-being for the affected; and perhaps, the way most people see themselves--their roles and place--in the larger society; that is, their whole identity. Since every woman, if she lives long enough, will undergo Menopause, and her relationships will thus be "touched," some focus should be directed towards managing and maintaining relationships. The typical man's reaction to Menopause is to feel rejected just because his partner does not respond to sexual cues any longer, nor does she appear to have any interest in romance. It appears that no amount of education, professional or otherwise, can convince the man that this is not really about him per se, therefore, the issue is NOT REJECTION. I believe that most men are reasonable, especially those men who are interested in protecting and preserving a hard-won, valuable and indispensable relationship, which most such relationships are. When a man can be led to understand that he is not being rejected, that this is a condition beyond the control of the woman, an "issue" wherein his partner finds herself a victim, too, then, the man will naturally swing into the role of an understanding partner-helper, just as he would were his partner to be diagnosed with a serious long-term ailment. A woman going through Menopause, besides putting up with all the usual problems, often feels guilty for "being accused of rejecting" her partner; then, she is saddled with being rejected herself by a partner reacting to perceived initial rejection. The vicious cycle does not end; and this is at a time when what the woman needs most is understanding--by her partner, and also by her own self. For, many women going through menopause actually believe that the loss of interest in sex and romance is their own fault--maybe they are not trying hard enough, maybe they actually made the choice... Is there an element of "shame" there, perhaps? I think that even Nature itself groans under such a burden, because, some women are spared in the sense that not every woman will experience all the symptoms of Menopause; the seriousness and how many years the symptoms persist vary, too. Not every relationship will be stretched and stressed and torn apart. When the effects of menopause are interpreted as REJECTION by the man, the results can be disastrous to a relationship. This interpretation needn't be so. When Menopause is seen as an undesirable but nevertheless a natural "change-event" which has the same effects as an ailment afflicting a loved and dear partner, the Compassionate power and role of the man can be brought out to maintain and nourish the relationship. Guilt, shame and any sense of rejection on the part of the woman going through Menopause can only add to the destruction of relationships. While medical and folk-remedy treatments continue for Menopause, I wonder if it can be seen as a form of "aging," or at least, "unavoidable change," hence, placing it among the long list of other life-management issues, that way, its brutal bite on relationships can be stopped? In summary: Menopause wrecks relationships, among other problems; it does not have to when it is remembered, especially by the man, that it is not about REJECTION; and by the woman, that it is not about shame and or guilt. This aspect of help does not require medication. If the new medications coming down the line can actually restore normal feelings and attitude toward romance even during Menopause, and not carry the risks of Estrogen, that will be great all around. Until then, remember...and protect your relationships. Oguchi Nkwocha, MD. oguchi@mbay.net Doctors Log 121005

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