By John Kelly
Wednesday, November 18, 2009
It should tell you something about Dr. Julia Finkel that when I asked if she had one of those charts used for ranking pain -- you know: On a scale of 1 to 10, how much does it hurt? -- she had to think for a moment before getting up from her chair and retrieving a tiny laminated card . . . from the trash can.
Dr. Finkel does not have much use for that familiar "pain ladder." Nor for what was on the back of the card: the Wong Baker Faces Pain Rating Scale. Used with children to gauge their pain, it features six crude drawings of a person's face ranging from a smiling "no hurt" face to a weeping "hurts worst" face. Children are asked to point to the face that best describes their "pain intensity."
But, of course, pain is incredibly subjective. All you know is it hurts, and you want it to stop.
As the director of pain medicine at Children's National Medical Center, Dr. Finkel is responsible for making the hurt go away.
I met her recently during a reunion of sorts. For years, 13-year-old Francesca Petrizzo had lacerating abdominal pain. Schoolwork was hard, sports were out. "It was frustrating," said Francesca, whose family has just moved back to the District from Florida. "I couldn't play outside or eat -- and I like to eat. I couldn't do things other kids can do."
I asked Francesca whether the pain ever went away. Sometimes, she said, she could lean forward, her back parallel with the floor, and it didn't hurt quite so much.
This is not a way to spend a childhood.
"We take a mechanistic approach to treating pain," Dr. Finkel said. It starts with diagnosing the cause. In Francesca's case, scar tissue had formed around the site of a hernia repaired when she was 3. By the time she was 7, the scar had entrapped a nerve, causing neuropathic pain.
"Pain is a symptom," Dr. Finkel said. "What really causes it needs to be determined so that you can manage the pain, not simply put a Band-Aid on it."
In a perfect world, a surgeon could free Francesca's entrapped nerve from the thicket of scar tissue. But that would come with its own risks, chief among them creating more of the scar tissue that had started the pain. Instead, Dr. Finkel proposed shutting the nerve down.
To get a sense of whether that approach might work, Dr. Finkel carefully injected the anesthetic lidocaine into Francesca's abdomen in April, turning the nerve off temporarily.
For the first time in years, the youngster was pain-free. But as with Cinderella, the clock was ticking. Francesca and her family -- parents Nicole and T.J., younger brothers Zachary, Nate and Josh -- tried to pack as much as possible into two hours: lunch at the Capital City Brewing Co., a visit to ESPN Zone. Then the pain returned.
But the method had worked. Later that month, Dr. Finkel injected alcohol in the same area. It ended the pain for three months. In August, she brought out the big gun: phenol. Francesca has a numb spot about the size of an index card around her belly button, but she'll gladly take that over the sharp pain she once suffered.
Meanwhile, Dr. Finkel continues to ponder pain. She's studying the genetics of pain and the pharmacogenetics of pain medication: Why do people react to pain-relieving drugs differently? She's developing compounds that, it's hoped, will prevent the occurrence of tolerance to pain medications and the withdrawal that can come from their use. And she's developing an algometer: an instrument that measures pain.
The device is a small, noninvasive probe that's placed against the affected area, detecting which types of pain fibers are activated and with what intensity. If successful, it could replace those subjective 1-to-1o scales, which have the effect of confusing the emotional reaction to pain with the physiological reaction.
" 'It hurts' isn't enough," Dr. Finkel said.Helping children
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