About 12 years ago, I took a body sculpting class at my gym. The class was taught by a lovely, incredibly enthusiastic woman. Her husband owned a local, popular restaurant, but she had zero excess body fat. She was prone to cheer leading as we huffed through her punishing routine of crunches, butt squeezes, tricep curls, leg lifts and push-ups. “You can do it!” “Almost there!” and this is the one that got me: “Work through the pain!”
Silly me, I did work through the pain. That caused a minor tear in the rotator cuff tendon of my right shoulder, beginning a year of ice packs, pain killers, MRI imaging and physical therapy.
The shoulder is mostly fine now, but it acts up occasionally. Of course, it acts up just before I start chemotherapy. My primary care doc theorizes that I might be holding that shoulder in a tense position because of the surgery on the left side. She prescribes a muscle relaxant and a painkiller, just enough to get me through the two days until chemo starts. By infusion one, my shoulder is fine.
Last weekend, the nausea and fatigue keep me in bed for most of the time, sleeping, tossing, turning. By Sunday afternoon, I start to feel a twinge in my right shoulder. By Monday, the pain is extreme. Even after two Vicodin, the pain is still severe. I am fit to do nothing except read a book my brother brought by, “How Doctors Think,” by Jerome Groopman, the Harvard Medical School professor and New Yorker writer. (How do people like Groopman, and his colleague Atul Gawande, manage to operate at the top of TWO fields at once?)
The thesis of Groopman’s book is that doctors are people, and that most medical mistakes or missteps occur because of faulty reasoning with roots in human weaknesses: emotions, stereotypes, a tendency to reach for the easy conclusion, overwork, distractions of all kinds. Groopman also writes about “frames.” Doctors, like all people, to see problems within a certain context, Groopman says. They put this kind of problem in one box, that kind in another. It takes real and conscious effort to think outside those boxes. No one manages to do this all of the time.
On Monday afternoon, I call the nurse practitioners at the Breast Care Center.
Jean-Anne, the whip smart NP who taught my chemocare appointment, gets on the phone. I tell her I have an old rotator cuff injury that’s acting up and that I need a muscle relaxant if that’s safe to take with all the chemo-related medications. Jean-Anne is thinking in a chemo frame. How are the chemo drugs interacting? How can the common chemo side effects be minimized?
“You don’t have any tingling in your hands, do you? (This “neuropathy” is a common side effect of chemo.) It’s just one shoulder? Has this acted up since the beginning of chemo? Are you taking the drugs we prescribed for neuropathy?”
I repeat that it comes and goes, and that I think I just slept in a weird position and that it’s related to an old injury and I just need a muscle relaxant if that’s OK.
“I think we should watch it for a couple days. Take some hot baths. Do some stretches to open up your chest and shoulder muscles. Get your husband to give you a massage. Start taking 600 mg of ibuprofen and one Vicodin every six hours.”
Over the next two days, I do all those things. I also pound my shoulder with a therapy ball, a gadget that looks like a meat tenderizer with a rubber ball on the end rather than spikes. It performs basically the same function. Still, the pain wakes me up at up at night, so severe that my whimpering wakes my husband Pete at 4 a.m. Thursday morning. He reassures me, massages my shoulder, runs off to get both ice packs and a heating pad. He makes me promise to call both my primary care doc and the Breast Care Center.
When morning breaks, I leave messages at both places.
Midday, one of my best pals from college comes by for lunch. She’s a doctor, a geriatric specialist who focuses on the behavioral problems of dementia. She’s been my medical lifesaver on many, many occasions. But, of course, she thinks in a old people frame, i.e. don’t prescribe too much, start slow, beware of drug interactions.
“Well, the drug you’re taking for neuropathy isn’t what I would choose,” she says. “I’d suggest you take this new drug, Lyrica, for neuropathy.”
By this point, I’m tired of the pain and really frustrated. “I don’t need a drug for neuropathy! I just need a muscle relaxant! And nobody at UCSF Primary Care or the Breast Care Center is calling me back!”
“OK,” my friend says, a little reluctantly. “Just in case they don’t get back to you today, I’ll write you a scrip for Lyrica and for a small amount of muscle relaxant. I’d suggest you start with the Lyrica, give it a couple days. If that doesn’t work, then try the muscle relaxant. You’ve got so many drugs in your body right now, you don’t want to overdo it.”
What is the deal with doctors not liking muscle relaxants? Why is no one really listening to what I’m saying?
Later that afternoon, I get a call from Tara, another Breast Care Center NP who’s done a couple of my pre-chemo check-ups. She’s thinking in a cancer frame. Is this persistent pain a sign of a metastasis?
“I’m sorry that you’re still in pain,” she says. “Normally, this kind of pain would make me worry (breast-to-bone is the most common breast cancer metastasis, so all aches and pains are red flags). But you had that PET scan before chemo and it didn’t show any cause for worry. Since the pain is so severe, even after you take Vicodin, I’m wondering if you might have a pinched nerve. You’re not claustrophobic, are you? I’m thinking maybe we should order a spine MRI. Maybe we should do that just to be sure.”
I start to plead. “Look, I’m happy to do the MRI if you think that’s indicated. But this has happened to me several times before. I think that what I really need is a muscle relaxant for a couple days. I haven’t heard back from Primary Care, but a doctor pal came by today and she called in a scrip for a muscle relaxant.”
“You don’t remember what relaxant Primary Care gave you last time?” Tara asks. “Well, I could call Walgreens and research that, but it’s late. Why don’t you just use what your friend called in. Call me back tomorrow and let me know how you do.”
As I’m having this conversation, the mom of one my daughter’s classmates comes by. She’s an urgent care doc, and she thinks in a practical, urgent care frame. How can we solve this problem quickly? How can we stabilize the patient?
“You know,” she says. “If you were my patient, the thing I would key in on is that this has worked for you before. Muscle relaxants only work for about 50 percent of people, and they’re addictive. So docs are reluctant to prescribe them.”
In the early evening, I run up to the pharmacy. It turns out that UCSF Primary Care called in the prescription after all: Flexeril (cyclobenzaprine). Hallelujah.
I take one Flexeril that night, and two more for the next two nights. I get the first good night’s sleep in about five days. Today, as I type this, there’s a little twinge in that right shoulder, but it’s basically fine. The muscle relaxant stopped whatever crazy pain-tension-pain feedback loop was tormenting my shoulder.
There are good reasons to think in a chemo frame, a cancer frame, a geriatric frame, an urgent care frame. But sometimes a banana is just a banana.