Pain relief.

We expect it to be painful when someone slices your tummy open. I remember seeing a war film once where the soldiers hit the ground when showered with machine gun bullets. After the shooting stopped the sergeant told his men to start moving out, only to be greeted by one of his men asking, "What shall I do with these?" as the camera panned down to his abdomen where he held several coils of intestine in his hand. The very thought makes many people squirm, but it is just what an abdominal operation involves.

Naturally, some form of pain relief is necessary, and the best form is an epidural which stops the messages from nerve to brain, for although it seems as though we feel the pain in our tummy, in reality it is the brain that really does the feeling. Almost all other forms of pain relief involve impairing the function of the brain, sometimes so much that we are rendered unconscious.

It is also true that most forms of pain relief have serious side effects. Morphine and other opiates induce nausea and vomiting, suppress the cough reflex, slow down the bowel causing constipation and in large doses suppress the respiratory center causing one to stop breathing. The non-steroidal anti-inflmmatories can cause mucosal ulceration and depending whether they are cox-1 or cox-2 inhibitors affect the clotting mechanisms, either by leading to bleeding (cox-1) or thrombotic (cox-2). The one drug that is pretty free of side effect is acetaminophen (paracetamol), but overdoses (greater than 15 g or 30 tablets) are fatal, causing liver damage. Standard hospital guidelines allow a safety margin and require anti-poisoning measures after 24 tablets, but strangely the maximum permitted therapeutic dose in hospital in 8 tablets.

Since normally the required dose for pain relief is 2 tablets every 4 hours, this leaves anyone who is kept awake by pain with nowhere to go in the middle of the night. This happened to me. My pain was adequately controlled by paracetamol, but at 4 in the morning I needed another dose. The nurse informed me that I was not allowed any more paracetamol for another hour, but I could have some morphine.

I didn't blame the nurse, she was only obeying her instructions, but I do blame whoever wrote the instructions. It was not a local decision it is a central NHS decision. The maximal allowable dose is just one third of the toxic dose - even when there is a built in safety margin - and did I mention that there is a perfectly adequate antidote for paracetamol?

Had I been at home I could have taken paracetamol with impunity. As it was I suffered for another hour.