Pain, pills and prunes

Pain management is tricky! I was sent home from hospital with paracetamol, Naproxen (a stronger NSAID than ibuprofen) and codeine phosphate. The nurse said as he handed me my party bag, “Your GP may be able to get you something stronger if you need. This is all we can prescribe from here”. I was intrigued and a little nervous, this already seemed like a lot.

No point in being brave

I know from previous experience what it’s like when regular painkillers are not enough. When I bruised my rib a few years ago they told me two things of interest.

  • Take whatever painkillers in safe quantities and mixtures for as long as you need to control the pain. There’s no value in ‘being brave’.
  • NSAIDs have a cumulative effect. That is, for as long as you keep taking them the pain-masking builds up to a certain level. If you miss them or drop some doses you lose this buffer. So again, no point cutting down ‘to be brave’, you are simply not getting best benefit from them.

It’s very important however not to overdose on the various painkillers. Taking more than recommended can do irreparable internal damage. In the case of codeine you also have to consider its addictive qualities. You are advised not to take for more than 72 hours, however in the case of acute need like a fracture there doesn’t seem any problem with getting a week’s worth to see you through the worst of it.

So if you’ve taken as many paracetamol as you are allowed in 24 hours and still in pain, the answer is to mix up different types of painkillers across the day. To explain further, it’s worth understanding how the different types of painkiller work:

Paracetamol relieves mild to moderate pain and reduces fever. It doesn’t reduce inflammation or address the cause of the pain, but it works fast. It’s usually the first resort. But you should only take up to 4g a day (four doses of up to 1000mg).

Non-steroidal anti-inflammatory drugs (NSAIDs) equally address mild to moderate pain but also work to inhibit inflammation. Example types are Ibuprofen, Naproxen and Aspirin. Aspirin is also used to prevent blood clots so is taken preventatively by some people. NSAIDs have side effects though – they can cause thinning and erosion of the stomach lining and bowel, so recommended dosage is limited to 1.6g a day (4 doses of 400mg).

If you are clear to take ibuprofen you can alternate doses with paracetamol to give you good mild to moderate pain cover over the entire day and night and continue this as long as you need. A slight complication is that ibuprofen ideally needs to be taken with or after food to help prevent irritation of digestive system.

A note about anti-inflamms and fractures

There is some evidence that taking NSAIDs in the first fortnight is counter-productive because inflammation is part of the natural healing process. I asked the consultant about this at my two-week appointment and he agreed, but said it was too late as it was more than two weeks gone. I guess we’ll see at the next fracture clinic/x-ray whether the union process has begun as it should. I think the nurse and doctor in A&E should have let us know about this when we were discharged.

Opioids are the next step up. These are divided into weak and strong types: you are only likely to need the stronger ones at the outset of treatment, or at moments where enhanced pain management is needed over a short time-frame, eg if your broken limb needed to be manipulated for some purpose. Hence being given Oramorph by mouth just before my first x-ray.

Codeine is a mild opioid. So it’s available on prescription to help augment your pain relief if paracetamol and ibuprofen are not enough. Downsides of codeine are sleepiness, and that it makes your digestive tract sluggish too… So you are bound to get constipation.

So, managing the pain day-to-day becomes a juggling act of scheduling paracetamol, ibuprofen and codeine. A system is good for this. If, like me, you’re also taking other supplements and unrelated medication it becomes tricky to remember what you’ve taken when. More on this later.

What’s the pain like?

To be honest, there is very little pain for most of the time. In the first week there’s the pops, crackles, jolts and spasms of the raw break and inflamed muscles shifting around. Then things settle down and as long as you don’t move wrongly, or too fast, and remember to relax your shoulder and elbow downwards and not tense up, the painkillers keep everything at bay.

Where do the prunes come in?

After three weeks, I wanted to give up the codeine. I’d moved from prescription codeine phosphate to over-the-counter Solpadeine to help me  get through the night. It felt wrong to be on it for so long. Although it was helping me to sleep I didn’t much like the thought of dependency. I’d started to notice feeling headachey with it, a bad sign… And then there was the constipation. I’d been tackling that pre-emptively since day 3 with fruit, dried apricots, and tinned prunes. I was drinking plenty of water too. Later I tried adding in Senna capsules overnight. But the clogging power of codeine is all-powerful. In the end the only way to overcome it was to quit. The effects continued for a week after stopping it. I’m also taking Dulcolax stool softeners and overnight caps now and finally getting back to normal but still can’t take anything for granted. So prunes and fruit it is, whenever I can.

2017-07-31 10.34.36

Back to pain. This sounds really stupid but the weird thing I realised after three weeks was that the painkillers had  been working effectively all along (duh!). All the time I thought the broken arm didn’t really hurt much it was because the pain was masked successfully. So as I left the codeine behind and tried extending periods between paracetamol and ibuprofen doses, I would suddenly notice that my arm felt ridiculously sore, stiff and heavy. It felt especially sore along the forearm and at the wrist where it was resting on the cuff of the sling. I would try to relax to no avail. Only paracetamol would relieve the feeling. Of course without codeine I am now down to juggling just paracetamol and ibuprofen all day, and the real trick here is to space them out and not miss doses. If I go too long I get what I now recognise as the ache of the broken arm, but also the referred pain of ligaments and muscles, not just along my arm and in my elbow, but elsewhere… Neck, shoulder, hips and back from sleeping in the same position so much, and now also sore knee ligaments, from inactivity I presume.

Keeping track

A good way to manage this regular and effective dosing without going over the top is to make yourself a chart to tick off. Or perhaps a tray with a sheet of paper on it, laying out your meds at the beginning of each day so you can see what you’ve taken so far. I’m at day 27 now so this is what I’m going to be doing from now on.

2017-07-31 10.40.52

Now, tell me about your pain and how you’ve coped with it.

Bracing myself…

I had been really looking forward to day 17 – Thursday 20th July was my first appointment at the fracture clinic at Frimley Park. I say looking forward; I suppose there was an element of trepidation mixed in with the curiosity. I hoped I’d find out how my arm was progressing, if the bones were lining up, and above all that I’d be offered a more robust brace of some kind to give my wobbly arm more protection. I was also slightly nervous that there would be pain, that they’d try to manipulate my arm in some painful way (why, I have no idea?) or that fitting a new brace might hurt. Also that they’d look and say ‘I’m sorry, your bones are not going to meet up’. Totally irrational but that’s the nature of fear and the unknown!

Waiting room

We arrived in good time, not really sure what to expect. There were signs up warning people that if they needed both x-rays and plastering they could be in clinic for two to four hours. I knew I wouldn’t be getting plastered but settled in with a puzzle book in my bag, ready for a lengthy visit. The other clinic visitors appeared to be ankle and lower leg breaks at different stages of repair. One lad and his mum emerged smiling from the consultation rooms and went to the desk to hand in his crutches and leg brace. Job done! A few ladies with lower leg fractures were in wheelchairs. Once again I thanked my lucky stars.

In the event it was all quite quick. We were called in promptly and the doctor took a quick look and organised a chitty for an  x-ray and a brace to be fixed (relief!), promising we could come back to ask questions afterwards. We moved into the plaster room as instructed but a nurse asked me to climb into a chair with a raised armrest and I stared at in fear, saying “I don’t think I can lift my arm onto there!”. She quickly realised we were in the wrong place and the consultant came back to see us again to explain he’d only been at Frimley a week and he’d got it wrong – an x-ray today was too early to see improvement. I needed a moulded plastic brace fitting though – so we were sent off to occupational therapy to get one sorted.

Before we left I checked a few things with him – pain relief, swelling, likely timescales. I don’t think we learned anything new. He said we’d have to experiment with the pain meds to get it right, and gave 10 to 12 weeks before I’d be able to have the brace removed. He said there was a possibility the union wouldn’t be perfect but up to 30% displacement was normal and my arm would regain full functionality. I was to return in two weeks to get the update x-ray.

20108301_1907254362822331_8367183052961138024_nGetting the brace

In occupational therapy we walked past the rooms full of crutches, stools and wheelchairs and found our way to the therapist, Jane, who was to fit the moulded plastic brace to my arm. She was very calm and gentle and put me at ease. First she measured and cut the plastic to a paper template. Then she put the plastic sheet into the warm water machine (like an electric bain marie) to soften it up. She pulled the tube stocking carefully up over my upper arm. It hurt at first with the pressure, but then felt snug. Her colleague Fiona came out to pull my elbow downwards in slight traction while they wrapped the plastic sheet warmly round my arm and then fixed the velcro round. The two velcro straps were pulled tight in opposite directions. It felt nice and secure and reassuring.

Jane suggested I try from time to time removing my wrist from the collar and cuff and gently lifting my hand up and down, supported, to ‘oil’ my elbow joint and stop it completely stiffening up. I also need to squeeze a ball and flex my wrist up and down.

I’ve spent two nights in it the brace now and it feels fine. We’ve only had to loosen and readjust it once so far. Tomorrow we will attempt to shower with it ON, but covered by a plastic bag or shield. In future we can try removing it to shower.

Two weeks on

Today is day 14, two weeks on from splat day. Where does it go, eh?

I can report that things feel a little better in some ways, but are just as bad in others. There are still a great many things I can’t do – see below. Things that have improved or changed:

• I can move about more easily. Standing up, sitting down, stepping up and down are all more natural. I even managed to carry a cup of tea upstairs to my husband this morning.
• The involuntary spasms in my arm are fewer and painless now – a few sudden twitches. My arm still ‘clicks out’ from time to time but is less painful when it does.
• I’ve cut down a bit on painkillers. However my arm is getting heavy and achey. I guess the painkillers were masking that but I’m trying not to take any in the middle of the day, especially codeine which I am leaving to 3 times a day – evening, bedtime and early waking 5 to 6 am.
• I can put on my own proxy sling made out of a cotton scarf and tie it with my teeth. I can take off and put on my own dress and underwear.
• I can bend a little lower to pick up things from about knee height, as long as I bend my knees and keep my back quite straight. So crouching slightly with one foot in front of the other, or squatting in a ballet plié – style move. With ninja moves I can plug something into a wall socket by sliding my back down the wall. I can pick up things from the coffee table using kitchen tongs!
• I can lightly grip things in my left hand if careful.

Things that are still difficult

• I can still only sleep in my monster chair
• I can’t stand up from the normal sofa without assistance
• I cannot pick up anything from the floor. I’m sure somewhere I have a litter-picker-upper that I got as a prop for work but it can’t be located right now.
• My arm is in the sling 24/7. I don’t dare release it except supported by a cushion while I swap to the makeshift sling. It feels very vulnerable.
• I am still very wary of others’ movements near me.
• I can only type one-handed…. Slow and full of typos which keep needing correcting. I can’t type accented letters using the number keypad because the alt key is left of the space bar. I have to gently hold a pen in my left hand to keep ‘alt’ depressed. Tricksy. Scrolling and selecting on the laptop touchpad is challenging.
• Washing under my left arm. Still can’t lift my arm away from my side so poor left armpit only gets a gentle wipe with baby wipes – no chance of deodorant!
• I can’t completely close my fingers on the left hand yet – they are too swollen.

How’s it all looking?

• My upper arm still looks a bit concave
• Some bruising – it took a week for any to show and it wasn’t as dramatic as I thought it would be – but I noticed this evening it’s a bit ugly and green underneath my elbow, where the blood pools I guess.

• My left hand isn’t as swollen but I still can’t make a fist or grip anything
• My feet, lower legs and upper legs are still rather swollen but much better if I spend time with my feet raised. I’m not looking forward to having to wear shoes.
• My tummy is still bloated. I’ve gained 6 pounds, wah!

The other thing to report is itching. Argh, the skin is dry and it gets sweaty under my elbow where my arm is resting. One good time to not be wearing a cast. At least I can have a gentle scratch.