Over the years I've come up with my own clinical pearls which have served me well. One of them which came up recently in my mind was: you can't treat the wound if you haven't treated the pain.
I thought of this epiphany because we had two patients with intractable wounds needing advanced wound care which was hard to do because the patients were in pain. Both of the patients had been in significant pain for a long time with these wounds, seen by various clinicians along the way who didn't see the necessity of addressing the pain as a critical issue.
In fact one of the patients had been debrided and unsuccessfully grafted without anything in place, and when this individual came on service with hospice was out of their mind in misery and couldn't be touched. We were not initially able to adequately do what we needed to do because the pain was preventing us from moving further.
It almost seems counterintuitive, because logic would dictate that in trying to treat the wound, as these patients had sought to do over time, the wound and therefore the pain should improve, theoretically making pain-control essentially moot. But perhaps this is the problem of current traditional medicine, that we are always looking to cure, and forgetting that that the ancillary issues that arise may really be the problem. Perhaps if we took a palliative approach first, rather than a "curative" approach, we would quickly see that the symptom management of pain was the critical issue to address first.
We in medicine need to address pain as much as woundedness. In fact, in addressing the pain in both these patients the wounds were finally able to improve, as we were better able to access and treat them. We need to discuss treating all forms of pain in medicine, from the physical to the psychological to the emotional. We need to make sure the modalities we use fit the situation, using the full armementarium of our drugs and non-drug options to find a tailored way to help calm the sufferer's misery. Remember my clinical pearl: you can't dig deep into a wound that you cannot touch.