Module 6v2

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@@.whitetext; !!!VA_Pain training_6 Welcome to the sixth in a series of interactive scenarios to support learning during pain training. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */

@@.whitetext; !!!VA_Pain training_6: Cancer pain Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "therapy" "audio/therapy.mp3">> <<set $history to []>> <<set $started to 0>>

!!@@.greentext;2021 Curriculum learning syllabus@@ !!!@@.greentext;Stage 1 Pain learning outcomes@@ @@.greentext; ''//Recognises, assesses and treats acute pain independently Differentiates between acute and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * Can recognise, examine, assess and manage acute pain in the surgical and non-surgical patient * Is able to safely and appropriately prescribe medication for pain management * ''Demonstrates effective communication skills regarding pain management with patients, relatives and carers'' * Demonstrates the basic assessment and management of acute on chronic and chronic pain in adults * ''Describes the concept of biopsychosocial multi-disciplinary pain management'' * Describes the special circumstances in assessing and managing perioperative pain in specific patient groups including children, pregnancy and breast feeding, the elderly and frail, those with learning and communication difficulties, autism, dementia, renal and hepatic impairment and substance abuse * Demonstrates the safe use of equipment used in pain management !!!@@.greentext;Stage 2 learning outcome:@@ @@.greentext;''//Understands the aetiology and management of acute, acute on chronic and chronic pain//''@@ !!!@@.greentext;Key capabilities@@ * ''Utilises a multi-disciplinary approach to the management of complex pain within a biopsychosocial model of care'' * Can confidently manage acute pain in the whole perioperative pathway in a timely manner * ''Is able to assess patients, interpret investigations and initiate management of chronic malignant and non-malignant pain in a timely manner under distant supervision'' * Can assess and manage acute on chronic and chronic inpatient pain in adults and recognise when referral to specialist pain services is appropriate * ''Identify barriers to effective pain management including those related to patient beliefs, society, culture, and healthcare provision'' * Explains the risk factors for persistent post-surgical pain including measures to minimise its occurrence !!!@@.greentext;Stage 3 learning outcome:@@ @@.greentext;''//Able to initiate complex pain management for in-patients and to sign-post to appropriate pain management services//''@@ !!!@@.greentext;Key capabilities@@ * ''Applies knowledge and understanding of assessment and management of pain in a multiprofessional context'' * Demonstrates safe effective pharmacological management of acute and procedure pain in all age groups * Acts as an effective member of the inpatient pain team * ''Effectively engages with multi-disciplinary primary and secondary pain services and palliative care when necessary'' * ''Recognises the need for and complications of interventional pain procedures'' * Prescribes appropriately in the perioperative period and recognises the long term implications of not reviewing patient analgesia in the post–operative period following discharge * Plans the perioperative management of patients for surgery who are taking high dose opioids and other drugs of potential addiction [[Next->Core clinical learning objectives]]

!!!@@.greentext;Scenario learning objectives:@@ * Describe the assessment of a patient with pain related to cancer * Appreciate the need to communicate with multi-disciplinary primary and secondary pain services and palliative care when necessary * Know the important basic science underpinning the management of cancer pain * Explain the importance of effective communication skills regarding pain management with patients, relatives and carers * Develop an individual pain management care plan for a patient with pain related to cancer * Identify barriers to effective pain management including those related to patient beliefs, society, culture, and healthcare provision * Recognise the need for and complications of interventional pain procedures in the management of cancer pain [[Credits and certificate|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VApain6">> <<set $result1 to "-">> <<set $result2 to "-">> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

<p style="text-align:justify">@@.console; !!!Our patient 8 months ago: "Dad are you OK?!" "Fine, absolutely fine." "You don’t look fine. It would be a massive downer if you choked to death while we were on holiday!" "No honestly, I’m fine, just indigestion, that’s all. Anyhow, you were saying that you and Tony were looking at that reception venue on the coast?" [[Next|patient2]] @@</p>

It's half one and you are just enjoying a well earned lunch break. Might just check a few emails while you have the chance? [[take a look|email2]]

<p style="text-align:left"><img src="images/gplogo.jpg" style="max-width: 20%;"/></p> <p style="text-align:right"> Valley Medical Practice Valley Road St Elsewhere LL12 6LL</p> Dear Dr Jones ''RE: Mr Dennis Sanderson, DOB: 07/09/1959, NHS No: 0000 666 7777'' Diagnosis: Adenocarcinoma PDAC Medication: MST 90 mg BD, 225 mg Pregabalin BD, 150 mg Amitriptyline noct. Oramorph 10 mg PRN, Creon with meals. <p style="text-align:justify">Mr Sanderson has recently completed 12 cycles of Folfirinox chemotherapy for stage 4 adenocarcinoma of the pancreas with a poor response. As he understands further chemotherapy is not an option and he is not elligible for the existing clinical trials at his center. He was reluctant to discuss his current symptoms with me but does report significant abdominal pain, radiating to his back with nausea and vomiting, hiccups, and painful bloating, especially at night. This is interfering with his sleep. He also has some symptoms suggesting peripheral neuropathy which may be related to his chemotherapy. Mr Sanderson was extreamly reluctant to explore further palliative care options and does not consider himself to have a palliative diagnosis. He has a number of significant life events in the coming months including his daughters wedding and can not countenance the idea that he may not live to be there. He attended the appointment today with extensive information about experimental 'curative' treatments he has been researching. I discussed a referral to the pain service as one option to potentially improve on his current symptoms. He has agreed that the referal would be helpful so please can you see this gentleman as soon as possible.</p> Yours sincerely !!!@@.writing; //D Ried//@@ Dr Ried MBBS MRCGP Dip Av Med [[Next|complexMDT]]

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio therapy play>> [[Transcript->transcript1]]   [[Next->audiopost1]] @@.whitetext; If the audio doesn't play automatically press @@ [[PLAY|https://www.virtualanaesthetics.com/Module%206/audio/therapy.mp3]] @@.whitetext; (opens in a new screen).@@ <img src="images/therapy.jpg" style="max-width: 100%;"/> </center> <<set $therapy to true>>

<center> !! @@.greentext;What is pain for this patient and how can we help manage this?@@ <img src="images/cancerpain.jpg" style="max-width: 100%;"/> ''Figure 1: Biological, psychological and social aspects of cancer pain'' </center> If you have undertaken our other modules you will already know about the biopsychosocial model of pain and may have some idea of the complex biopsychosocial interrelations in cancer pain. So let's break it down with what we know so far... <div class="notes">''Biological''</div> Most cancer pain includes a combination of one or more of the following +/- an inflammatory element: ''Somatic pain'' — stimulation of nociceptors (e.g. bone metastases, wound or incision pain, myofascial or MSK pain). ''Visceral pain'' — stretching, compression, distension, or infiltration of viscera (e.g. liver metastases, pancreatic cancer, intestinal obstruction). ''Neuropathic pain'' — injury to the peripheral or central nervous system (e.g. infiltration of nerves, nerve roots or the spinal cord, trauma from surgery, chemotherapy or radiotherapy). and pain can result from: * Direct tumour effects * Treatment for the cancer * Procedure related pain * Other non-cancer conditions @@.greentext;''Interventions:'' Pharmacological interventions including analgesics, chemotherapy, and drugs for symptom control (e.g. laxatives, antispasmodics, antiemetics, bisphosphonates), interventional techniques (e.g. coeliac plexus block, paravertebral blocks, neuraxial therapies), surgery (e.g. defunctioning ileostomy, stents, curative surgery), palliative and curative radiotherapy and non-pharmacological modalities (e.g. heat/cold, physiotherapy, aquatherapy).@@ !!!<p style="text-align:justify">@@.typing;Dennis has symptoms of somatic, visceral and neuropathic pain and these are a result of direct effects of the tumour as well as the treatment he has received. He has had palliative chemotherapy recently and finds the side effects of his current analgesic regime burdensome. We should actively enquire about side effects such as constipation and nausea. @@ </p> <div class="notes">''Psychological''</div> Somatization, catastrophizing, depression, anxiety, distress, helpful or unhelpful coping stratergies, the individual's understanding of the meaning of pain, and general quality of life are all associated with pain levels. @@.greentext;''Interventions:'' Individual/family/group counselling, cognitive behavioural therapy, meditiation, relaxation, guided imagery, antidepresants or anxiolytics, pet therapy, music or art therapy.@@ !!!<p style="text-align:justify">@@.typing;Dennis has high levels of psychological distress. He is using denial and distraction as coping strategies. He also has signs of low mood and depression with his changing role in the family and profound sense of loss.@@ </p> <div class="notes">''Sociological''</div> Higher levels of cancer pain are associated with lower levels of social support and <<link [[avoidant or anxious attachment styles|audiopost2]]>> <<set Dialog.setup("Attachment styles")>> <<set Dialog.wiki(" ''Avoidant:'' discomfort with closeness and interdependence in relationships. ''Anxious:'' worry about the availability and responsiveness of others")>> <<set Dialog.open ()>> <</link>>. Access to services, socioeconomic status and ability to communicate all influence resilience in this area. @@.greentext;''Interventions:'' Culturally sensitive educational materials and information on relevant services and benefits, peer support groups, pastoral support.@@ !!!<p style="text-align:justify">@@.typing;We don't really know Dennis enough at this point to work out his attachment style, however it is clear that he has high expectations of himself as a father and husband. His concerns about being 'weak' or worrying his family cause him to remove himself from their care and support. He may still be in employment and face financial difficulties if unable to work. @@ </p> [[Next|audiopost3]] [[show me the evidence|ref2]]

<center> !!!@@.greentext;Practice review: Evidence-based and effective management of pain in patients with advanced cancer@@ <img src="images/cancer.jpg" style="max-width: 100%;"/> </center> The scope of the problem: * Cancer causes more than one in four of all deaths in the UK^^1^^ * More than half of people with advanced cancer have moderate-severe pain * Pain is one of the most common causes of hospitalisation in patients with advanced cancer <div class="notes">''Practice recommendations - 'Do'''</div> <p style="text-align:justify">@@.greentext;''- Screen for pain''@@ NICE recommends use of a validated structured pain assessment tool e.g. a numerical rating scale 0-10 or visual rating scale 0-10. Mild pain: less than 3. Mild to moderate pain: 3–6. Severe pain: more than 6. Differentiate between the usual level of pain, breakthrough pain, incident pain, and 'end of dose' failure of regular around-the-clock analgesia.</p> <p style="text-align:justify">@@.greentext;''- Assess the components of the pain''@@ Remember to ask about: Functional loss, effect on activities of daily living, effect on sleep and the person's thoughts about the likely cause. Neuropathic pain is a predictor of poor pain management in people with advanced cancer. When investigating pain in palliative care limit investigations to those likely to significantly affect treatment decisions.</p> <p style="text-align:justify">@@.greentext;''- Treat moderate-severe pain with a strong opioid''@@ NICE recommends Step 3: Strong Opioids, on the WHO analgesic ladder for patients with severe pain in advanced cancer. The dose depends on the person's comorbidities and their existing analgesia. Actively manage opioid adverse effects: ''Drowsiness'' frequently occurs when starting or increasing doses of strong opioids. Tolerence usually developes within a few days. Warn people they MUST NOT drive if they feel drowsy, dizzy, are unable to concentrate or have vision disturbance. It is now an offence to drive if you have more than a specified amount of opioid in your body whether your driving is impaired or not. ''Nausea and vomiting'' usually also subside after a few days but can be an ongoing so prescribe an antiemetic. ''Constipation'' can be prevented with a stimulant laxative and a softening laxative. ''Dry mouth'' can be managed with simple measures e.g. cold drinks, sugar free gum or sweets, ice lollies. Give patients information on how to safely store and dispose of unused strong opioids.</p> <p style="text-align:justify">@@.greentext;''- Consider opioid switching''@@ Seek specialist advice, or consult local guidelines (where available), when selecting the opioid and dose to switch to. Monitoring and dose titration is especially crucial when switching between opioids at high doses or when there has been a recent rapid escalation of the first opioid. Avoid Methadone unless under specialist advice due to long unpredictable half-life.</p> <p style="text-align:justify">@@.greentext;''- Treat metastatic bone pain with radiotherapy, bisphosphonates or both''@@ Seek urgent advice from an orthopaedic surgeon if there is evidence or suspicion of an actual or imminent fracture.</p> <p style="text-align:justify">@@.greentext;''- Use self-management strategies''@@ Including strategies on managing breakthrough pain. </p> @@.greentext;''- Agree a tailored pain management plan''@@ @@.greentext;''- Consider epidural or intrathecal opioids''@@ @@.greentext;''- Consider physiotherapy-based interventions'' ''- Consider non-pharmacological approaches (e.g. music therapy)'' ''- Regularly review''@@ <div class="notes">''Practice recommendations - 'Do not'''</div> <p style="text-align:justify">@@.greentext;''- Routinely use oral paracetamol in patients on strong opioids''@@ Paracetamol is a first line drug for mild-moderate pain and many people will already be on this agent. Pragmatically once strong opioids are established for severe pain paracetamol can be stopped if the drug is of no benefit.</p> <p style="text-align:justify">@@.greentext;''- Routinely use ketamine''@@ Ketamine might be of benefit in specific situations, such as patients with central sensitisation.</p> <p style="text-align:justify">@@.greentext;''- Routinely use intravenous lidocaine''@@ Lidoaine is option for opioid-refractory cancer pain.</p> @@.greentext;''- Use cannabis-based medicines'' ''- Routinely use weak opioids in moderate-severe advanced cancer pain (e.g. codiene)''@@ <div class="notes">''Practice recommendations - 'Don't know'''</div> ''Further research is needed for the following:'' <p style="text-align:justify">@@.greentext;''- Anti-convulsants, anti-depressants - consider individual benefit to risk ratio''@@ For neuropathic pain once reversible causes have been excluded consider a tricyclic antidepressant (such as amitriptyline) or pregabalin or gabapentin. Titrate the dosage according to response and tolerability.</p> <p style="text-align:justify">@@.greentext;''- Corticosteroids - consider individual benefit to risk ratio''@@ NICE recommends considering a trial of dexamethasone for pain from raised ICP titrated down to the lowest dose that controls symptoms, and discontinued immediately if there is no response. Have a low threshold for prescribing gastroprotection when using steroids.</p> <p style="text-align:justify">@@.greentext;''- Other anaesthetic interventions''@@ Nerve blocks, cordotomy and spinal cord stimulation are considered in specific situations in several guidelines but lack a definitive evidence base. </p> @@.greentext;''- Non-steroidal anti-inflammatory drugs - consider individual benefit to risk ratio'' ''- Acupuncture, massage etc.'' ''- Transcutaneous electrical nerve stimulation (TENS)''@@ !!!<p style="text-align:justify">@@.typing;The bottom line:@@ </p> <center> <img src="images/table.jpg" style="max-width: 100%;"/> ''Table 1: Summary of evidence for paper recommendations^^2^^.'' </center> !!!<p style="text-align:justify">@@.typing;Screen patients with advanced cancer for pain at every assessment. Strong opioids are the drug of choice for patients with moderate or severe pain. Bisphosphonates, radiotherapy or both are effective for bone pain. Use a tailored approach, support self-management and regularly review treatment outcomes. There is no robust evidence for use of oral paracetamol in patients taking a strong opioid. Cannabis-based drugs are not recommended due to evidence of lack of effect. Ongoing research on the efficacy of NSAIDs, anti-depressants, anti-convulsants, corticosteroids and non-pharmacological approaches as well as to support the appropriate selection of patients who might benefit from third-line approaches, such as lidocaine and ketamine. @@ </p> [[Lets meet our patient|patient1]] [[Show me the evidence|ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

<p style="text-align:justify"> @@.typing;''Melanie (Psychologist):'' So Hi Dennis. ''Mr Sanderson (Dennis):'' Hello. ''Melanie:'' Thank you for coming in today to speak with me. So I’m aware you've been through a lot recently, and still are, and this is a chance for you to think more about what you’ve been through and what's going to be helpful going forward? ''Dennis:'' OK, where would you like me to begin? ''Melanie:'' I guess it'd be helpful to hear, so I've got some background information in terms of...erm...your diagnosis and I guess it would be helpful for me to know what you've been told at this point. ''Dennis:'' So recently I went to see the consultant and they told me that I've got cancer of the pancreas, and there's nothing I can do. I can't take that. My daughter's getting married in six months and they say that, I might not be able to go there. But then, you know, I've been looking around, you know, in this day and age and with wonders of medical science, there's got to be something that that will get me there, take my daughter down the aisle, and, it's what I want, so, I’ve been looking, I’ve been looking online, and there's all sorts of things out there that people suggest maybe that’s where I should put my energy in 'cause I really, I can not, I can not, not take my daughter down the aisle...that’s...that would be too much. I can’t...I can’t think of not. So there’s where my energy is. ''Melanie:'' Thank you for sharing that Dennis. So you’ve had some really difficult news and been told that there's no treatments that they can offer you at this time. That's a lot for anybody to hear, and try to make sense of and it sounds like for you that's been quite hard, understandably. ''Dennis:'' The issue is I haven't got the space to think of me. I've got: what can I change? All I can think about is how do I survive, and get her down the aisle. ''Melanie:'' So that sounds like that’s really important to you, your relationship with your daughter, your family, and actually the wedding and being part of that day. So that’s, I can see that that's really, you're kind of homing in on that, as something you want to get to and be a part of. ''Dennis:'' That, that's something that I might be able to control. Trying to get to my daughter's wedding is all I’ve got. ''Melanie:'' So it sounds like that's been one of the ways, you’ve, I guess, coped with this news and... ''Dennis:'' All my attention onto that, I'm not thinking about the other. So that's a lot more comfortable for me than not being here anymore, and what that means. I can’t touch that, that’s, that hurts. ''Melanie:'' ...mmm, of course. But it’s almost, it's important for you to be at the wedding, by thinking about that and planning that in your mind it's, it's, almost distracting from reality of what you've been told. ''Dennis:'' Yeah, to give space to what I can deal with, and, and if I shut everything else out, then I don’t, you know, it takes care of some of those other thoughts, those symptoms. ''Melanie:'' And can I just ask a bit more about that Dennis if that’s OK? So in terms of, you mentioned symptoms and on the referral it mentioned about a lot of abdomen pain you’ve been experiencing. ''Dennis:'' Yeah, it can be, well sometimes I feel really bloated, tight. Sometimes I can't do anything it’s that severe, so that's, that's, really frustrating 'cause it's sort of, trying to help out with family and to not let people know I've got it. It hurts, it really hurts. It's...it's...I’ve never experienced anything like it, just don't know what to do with myself. Sometimes, uh, I have to go away and, you know, shut myself off so that people don't see it. It's it's. It's not who I want my family to see, I’ve always been strong. Person to go to. You know. I’m Dad. And you know, to, to...I don't want them to have this image of a weak person. I want them to remember me as somebody that’s strong, would be dependable, I don’t feel dependable. I feel, that it’s just too much. But I have to have something, I’ve got to control something, I’ve got to be able to do something, that’s just sort of hide away, so, you know, they can't see that. ''Melanie:'' Just noticing you mentioned control a lot in there and it sounds like that element of this is something that's important to you to try and feel you do have those choices or some sense of... ''Dennis:'' I haven’t got a lot of choice left have I? ''Melanie:'' It sounds like the element of... struggling with pain or perhaps also with difficult thoughts or feelings, when they come up, But you don't want people to see that side of you, so you might take yourself away, will try and mask it in some way. Keep up this image of how you want to be seen by others. ''Dennis:'' Yeah, I mean, I think, the difficulty with pain killers when it gets really bad, they don’t really help, and then they just tend to make my head all funny, you know, and I sort of forget things and giddy and, you know, saying things that...personality's changed even, interferes with who I am. How I want people to see me. If I have to go, I’m trying not to, but if I have to go then I want their memory not to be different to who they expect that to be. Heard people say in the past he was a really strong bloke, but in the end did you see him? He withered away, and I don’t want that to be me, I want to be Dad, husband to the end. ''Melanie:'' It sounds like you're investing quite a lot of your time and energy on that, I guess I’m wondering how, how well you think that’s working out for you at the moment? ''Dennis:'' It's not working...it’s...we’re not talking. The good lady, she's always wanted to fix things for me, and you know, more pills, a pill for this and a pill for that, and I don’t want to take any more pills, I can’t think straight as it is, so, you know. Not sure what she can do for me, and she'll try and smother me...I know...I know she wanted to, and you know she's trying, trying, her best. She wants to be there. ''Melanie:'' So it’s something about a little bit too much help. That would be smothering, so that's not something you like... ''Dennis:'' No. ''Melanie:'' And there’s a sense of not wanting to put stress on other people and still be here protecting in some way. ''Dennis:'' That’s who I am, that’s my role. ''Melanie:'' So that makes sense, doesn't it? I guess I'm wondering, so in the short term when you don't share how things are, take yourself away, in a lot of pain. I guess in the short term it sounds like that, that gives you some sense of relief that that you're saving your family from the stress. They don't have to see that. I guess I’m wondering the impact of that in the longer term? ''Dennis:'' I’m not letting them...not letting them help. ''Melanie:'' And it's hard if that's not the kind of person you’ve been used to being, if you’ve been quite fit and healthy, and never needed to rely on others in that way so it's gonna be a hard shift for you to accept that help. I’m wondering how open you’ve been in the family or you mentioned your daughter or your wife, and you said that your tendency is to try and protect others, so not to share, the struggles that you're going through. I guess this is a different scenario, one that you’ve not faced before. ''Dennis:'' This is not something that we can get past is it. ''Melanie:'' I guess when we’re facing something different sometimes, it may be worth looking at how we cope and whether there's an additional way, a more helpful way, maybe a different way of approaching things, what would feel helpful? What do you feel you need at this time? ''Dennis:'' I should really be making plans. That's gonna be…if I'm concentrating on the wedding...then I don’t have to think about those. ''Melanie:'' I’m aware that you said that the wedding was way off? I guess I’m wondering if any discussions have taken place with your daughter or your wife about that. ''Dennis:'' I think I tried...I think I just...I'm strong...I can get there, try to reassure them that it’s all OK. But actually it’s not is it? ''Melanie:'' It’s understandably difficult. And I guess based on just to summarise, I guess what we've talked about today. So you've shared with me, what you've been told by the consultant, how hard that is to hear that news, but in a way you're trying to not accept that’s the reality, that’s really hard and I think. And actually what your focusing on is your daughter's wedding, that you’re desperate to get to it's also been a bit of a distraction, which has meant that maybe other conversations haven't taken place. Also, this sentence of wanting to protect others, so shielding the pain, shielding the emotions that you're going through, but that actually maybe that's not the kind of dad and partner you want to be…potentially? ''Dennis:'' I guess...I guess...if I talk...If I talk through those things...I won’t have the strength. It’s just too much. I might not be here. I can’t face that. I might not get to the wedding. I might not see my wife, my daughter, grandchildren...I don’t know whether...I try and be strong...but I don’t know whether I’ve got the strength to face that with them. And then that means that they will always see me as the weak person that I am. ''Melanie:'' It sounds like those fears are more barriers to you sharing, to talking through some of this stuff. Not easy conversations to have. ''Dennis:'' No. ''Melanie:'' I guess I'm aware as well that you were referred to psychology partly because of the pain you're experiencing, but also has a chance to think about what you’ve been through and what’s important to you. And I guess I’m aware that, I don't know if your consultant has talked to you about this, but in terms of our experience of pain is often influenced by lots of different factors so part of that is from changes in the body, I guess I’m aware that ongoing stress, poor sleep, those kind of things, will have an impact on pain. ''Dennis:'' Certainly not sleeping. ''Melanie:'' So you can relate to that. So I guess by thinking about some of these factors, and some of the...erm...difficulties that are here for you at the moment...in terms of sharing this with other, and actually use the space to think about that stuff, and that’s likely to also have an impact on other aspects of your presentation. ''Dennis:'' If it changes how I cope or what I do, how I feel, that’s got to be a good thing.@@ </p> <center> [[Play audio|therapy]]    [[Next|audiopost1]] </center> <<audio therapy pause>>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actors: Samantha Owen and Ian Price Our scenario 6 advisory support: Abergele Pain Service team Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Sonia Pierce Our creative director and lead programmer: Kate Wainwright !!!Well done for completing VA_Pain training_6 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

<p style="text-align:justify">@@.console; !!!7 months ago: "This isn’t right Dennis, you have to go to the doctors." "Stop badgering me, it’s all I get from you and the girls these days." "It’s because we’re all worried about you Dennis, we love you and we’re all desperately worried about you." "OK, OK, I’ll make an appointment, just to prove you’re fussing for nothing." @@</p> [[Next->patient3]]

"Morning $firstname." Dr Jones sweeps into the office still in his outdoors coat. "Anything of note within the referals?" You gesture with the letter that's still in your hand and quickly summarise the case. "Let's discuss Mr Sanderson at the MDT this afternoon. I'm sure we can offer him something" [[Next|MDT]]

<p style="text-align:justify">@@.console;Thinking he's alone Dennis leans against the worktop and grimaces. He glances at the kitchen clock. It's just gone 2am. A worried voice from the shadows of the hallway. "Can't sleep again Dennis? Is it the pain?" "Just getting a drink, that's all, go back to bed, I'll be up again in a minute." "OK honey, come and get me if you need to." Dennis watches his wife of forty years retreat back up the stairs. He doesn't join her in bed just yet.@@ </p> [[Next|patient5]]

"You're in early $firstname." "Morning Ali, is Dr J in yet?" "Bit early yet, why don't you have a look at latest referrals for triage." Ali drops an armful of letters onto your desk. You pick up the first [[letter|letter]]

# Cancer Research UK. Cancer mortality statistics. Available [[here|https://www.cancerresearchuk.org/health-professional/cancer-statistics/mortality#heading-Four]] # Chapman EJ, Edwards Z, Boland JW, et al. Practice review: Evidence-based and effective management of pain in patients with advanced cancer. //Palliat Med//. 2020 Apr;34(4):444-453. # NICE Clinical Knowledge Summaries: Palliative cancer care - pain. //National Institute for Health and Clinical Excellence//. 2021. available [[here|https://cks.nice.org.uk/topics/palliative-cancer-care-pain/]] [[Back|oncnotes]]

<p style="text-align:justify">@@.console; !!!6 months ago: Dennis stits in a non-descript clinic room on a hard plastic chair. The doctor gives him a simpathetic nod. "I’m very sorry Mr Sanderson but the tests have shown you have pancreatic cancer." Dennis blindly reaches for his wife’s hand, he doesn’t really hear what the doctor says next.@@</p> [[Next->patient4]]

The session is done. Melanie watches Dennis retreat along the corridor out of the department before shutting the door. She sighs deeply and gives you an appraising look. "So $firstname, what do you think is going on? And what can we do to help?" Take a moment to consider: ''What is pain for this patient?'' ''How can we help manage this?'' ''What is the goal of treatment?'' If you have the opportunity you could discuss the case with your Faculty Tutor (Pain) or Clinical Supervisor? Then click ''[[next|audiopost2]]'' <<audio therapy pause>>

@@.typing2; <center> !!HEADS UP ''Scenario 6 includes some content of an upsetting nature. We understand that not everyone is coming to this after a good day We wanted to let you know about some [[sources of support]]'' !!Because you are incredibly important ''Take care'' !!Virtual Anaesthetics ''[[Next|work]]'' </center>

@@.typing; !!!Sources of support Hi $firstname We wanted you to be aware of some of the sources of support available to you: * Think about reaching out to a trusted colleague, friend, or family member * Contact your family doctor or healthcare provider * If you are in education find out about support services they provide ''The Samaritans:'' Provides confidential support for people feeling distress or despair on a free 24-hour helpline, by email, or via a self-help app: https://www.samaritans.org Phone: ''116 123'' Email: ''jo@samaritans.org'' ''#OurNHSPeople'' A package of practical and psychological support resources including a 24/7 wellbeing support line, peer to peer, team and personal resilience support and free mindfulness apps: https://www.people.nhs.uk ''For UK medics:'' * Your educational supervisor or clinical supervisor * Your deanery professional support unit ''Academy of Medical Royal Colleges Support for Doctors:'' https://www.aomrc.org.uk/supportfordoctors/ ''Association of Anaesthetists of Great Britain and Ireland'' Wellbeing and support pages offering a wide range of services: https://anaesthetists.org/Home/Wellbeing-support ''The British Medical Association'' Confidential 24/7 counselling service is available to all doctors and medical students including non-members: ''0330 123 1245'' https://www.bma.org.uk/advice-and-support/your-wellbeing [[Back|heads up]]

@@.typing;''From:'' Sally Fenton ''Sent:'' <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-UK", { day: "numeric", month: "numeric", year: "numeric" } )>> ''To:'' $firstname $surname and 18 others ''Subject:'' next week's journal club Hi Everyone Journal club time again! The paper is //Practice review: Evidence-based and effective management of pain in patients with advanced cancer.// I've attached a summary and included some other refs; you can thank me later. But I need a voluneer to do the session. See you all next week. Cheers Sally @@ <a data-passage="oncnotes" class="link-internal link-image"> <img src="images/bjaonc.jpg" style="max-height: 175px"> </a> Sent from my iPad

The team are all gathered for the MDT. You've just gone over Mr Sanderson's referral letter. "...and the GP has asked us to see him as soon as posible." Melanie, the psychologist is flicking pages over in her diary. "I've got a cancellation next week, two o'clock on Tuesday? We can explore how he's feeling and help work out what he needs?" "Excellent idea Melanie. Perhaps $firstname would like to sit in on the session?" Dr Jones looks at his own diary. "I'm SPA on Tuesday so i'll pencil him in for a medical assessment at the same time so we can make a proper plan between us." [[Melanie and Mr Sanderson's session|therapy]] [[Transcript->transcript1]] <<audio therapy pause>>

# NICE Clinical Knowledge Summaries: Palliative cancer care - pain. //National Institute for Health and Clinical Excellence//. 2021. available [[here|https://cks.nice.org.uk/topics/palliative-cancer-care-pain/]] # Novy D, Aigner C. The biopsychosocial model in cancer pain. //Curr Opin Support Palliat Care//. 2014:8(2); 117-123 [[Back|audiopost2]]

"I've got a really good resource that provides guidance on goal setting in the context of palliative care. Why don't you have a look." Melanie hands you the [[guide|https://www.virtualanaesthetics.com/Module%206/goals.pdf]]. "But it's a complicated question to answer." [[Next|audiopost4]]

It's three weeks later. "That's unfortunate." Dr Jones is talking to himself as he leafs through a pile of notes. He turns to you. "Mr Sanderson was admitted last weekend by his GP for intractable pain. Looks like he was discharged within 24 hours but I think we need to be proactive to try and improve matters. What do you think we should do $firstname?" "I think he needs... [[a higher opioid dose]] [[an opioid switch]] [[a higher dose of pregabalin]] [[corticosteroids]] [[radiotherapy]] [[a thoracic epidural]] [[a coeliac plexus block]] <<if $block is true>> <<else>> <</if>>

"We could increase his opioid dose?" "We could. Increasing the maintenance dose until reaching relief and an uptitration of his breakthrough dose would be one option. The ''[[Scottish Palliative Care Guidlines|https://www.palliativecareguidelines.scot.nhs.uk/guidelines/pain.aspx]]'' have some helpful resources. Can you forsee any issues with that?" You think back to the session you sat in on. "He is already feeling sedated with his current regime to the point complicance may be an issue?" "Absolutely. In some people systemic drugs at the necessary doses cause intolerable sedation. I think we should discuss the option of a coeliac plexus block with Mr Sanderson." [[I want to go back to the other options|audiopost4]] [[Lets get on with the block|block]]

"We could switch his opioid?" "We could. An opioid switch is a recognised method for overcoming tolerance for people on high doses of their current drug or to overcome intolerable side effects. The ''[[Scottish Palliative Care Guidlines|https://www.palliativecareguidelines.scot.nhs.uk/guidelines/pain.aspx]]'' have some helpful resources. Can you forsee any issues with it though?" You think back to the session you sat in on. "Opioid bioavailability and response are highly variable and he is likely to need a dose reduction and then an uptitration which potentially means a period of instability in his pain control which would need close monitoring." "Absolutely. In some people systemic drugs at the necessary doses cause intolerable sedation. I think we should discuss the option of a coeliac plexus block with Mr Sanderson." [[I want to go back to the other options|audiopost4]] [[Lets get on with the block|block]]

"We could increase his dose of pregabalin?" "We could. Let me see...he's on 225 mg twice a day? Well that could be titrated up to 300 mg? But can you envisage any problems with that?" You pause for a moment to consider your answer. "That would primarily be for treating neuropathic pain, so pain described as burning, tingling, pins and needles, shooting and numbness. Mr Sanderson did have some symptoms like that in his feet, but the pain he was mostly troubled by was in his upper abdomen and back and more visceral. He said the tablets weren't helping that pain at all." "Absolutely. In some people systemic drugs at the necessary doses cause intolerable sedation. I think we should discuss the option of a coeliac plexus block with Mr Sanderson." [[I want to go back to the other options|audiopost4]] [[Lets get on with the block|block]]

"We could start dexamethasone?" "That's one option. Corticosteroids can be a useful adjuvant for visceral pain with an inflammatory element and oedema. But can you envisage any problems with that?" You pause for a moment to consider your answer. "Dexamethasone has several well recognised side effects so we'd have to use the lowest possible dose for the shortest time. We'd also have to think about gastro protection." "Absolutely. We have to consider the risk benefit ratio for the individual. I think we should discuss the option of a coeliac plexus block with Mr Sanderson." [[I want to go back to the other options|audiopost4]] [[Lets get on with the block|block]]

"Could he have palliative radiotherapy?" "We should discuss that with his oncologist. Radiotherapy is particularly effective at controlling pain caused by large tumours compressing other structures. But can you envisage any problems with that?" You have a think. "Errr...the oncologists would have already offered it if it was an option?" "Perhaps, but what else?" Dr Jones fixes you for an answer. "...well...the benefit of radiotherapy is usually a late effect. So it could take weeks before it helps." "Absolutely. We need to try and expedite a solution. I think we should discuss the option of a coeliac plexus block with Mr Sanderson." [[I want to go back to the other options|audiopost4]] [[Lets get on with the block|block]]

"Could he have an opioid epidural?" "Epidural or intrathecal drug delivery plays an important role in the treatment of a small group of appropriately selected people with intractable cancer pain. But can you envisage any problems with that?" "It would be potentially a burdensome intervention?" "Yes, percutaneous systems can be an inconvenience to patients and a fully implanted intrathecal drug delivery system are generally more appropriate for people with a life expectancy of more than a few months." Dr Jones pauses reflecting for a moment. "I think we should discuss the option of a coeliac plexus block with Mr Sanderson." [[I want to go back to the other options|audiopost4]] [[Lets get on with the block|block]]

"I think we should offer him a coeliac plexus block?" "OK. Why do you think that's the most appropriate option?" "In some people systemic drugs at the necessary doses cause intolerable sedation, and Mr Sanderson is already having problems with side effects. He's describing a visceral pain that would be amenable to this intervention while he want's to preserve his independence and quality of life as long as possible." Dr Jones smiles wryly, "I would say coeliac plexus neurolysis is one of the most effective methods of invasive pain management in pancreatic cancer. We will make a pain physician out of you at this rate $firstname!" [[Lets get on with the block|block]]

"What time do you need to be in tomorrow dad? I can take you, no problem." "The letter said 8 o'clock, I haven't been up that early since before I retired. They sent me this..." Dennis holds out a ''[[leaflet|https://fpm.ac.uk/sites/fpm/files/documents/2019-11/FPM-PIL-Coeliac-plexus-block-Sep-2019-ed.pdf]]''. It's got faculty of pain medicine across the top. Dennis watches as his daughter reads. ''[[Next|block2]]'' <<set $level to "Not sure?">> <<set $ganglia to "Not sure?">> <<set $where to "Not sure?">> <<set $consent to "Not sure?">>

You're in theatre with Dr Jones doubled up on the interventional list. "Can you tell me where the sympathetic fibers of the splanchnic nerves that make up coeliac plexus originate?" "They originate from the spinal cord at... [[T4-T11|block3][$level = "Not quite."]] [[T5-T12|block3b][$level = "Correct."]] [[T6-L1|block3][$level = "Not quite."]] [[T7-L2|block3][$level = "Not quite."]] [[Just tell me the answer|block3][$level = "Not sure?"]]

"<<print $level>> Sympathetic innervation of the coeliac plexus is from spinal core levels T5 to T12. There's also a preganglionic parasympathetic efferent contribution from the posterior trunk of the vagus and of course the visceral afferent fibers that carry nociceptive stimuli from the upper abdominal viscera that we are interested in. Now what three paired ganglia compose the coeliac plexus?" "They are the... [[coeliac, superior mesenteric, aorticorenal|block4b][$ganglia = "Correct."]] [[superior mesenteric, aorticorenal, inferior mesenteric|block4][$ganglia = "Not quiet."]] [[coeliac, superior mesenteric, prehypogastric|block4][$ganglia = "Not quite."]] [[coeliac, ganglion impar, aorticorenal|block4][$ganglia = "Not quite."]] [[Just tell me the answer|block4][$ganglia = "Not sure?"]]

"<<print $ganglia>> And where are they?" [[posterolateral surface of the aorta, at the level of the coeliac trunk|block5][$where = "Not quite."]] [[posterolateral surface of the aorta, inferior to superior mesenteric artery|block5][$where = "Not quite."]] [[anterolateral surface of the aorta, inferior to superior mesenteric artery|block5][$where = "Not quite."]] [[anterolateral surface of the aorta, at the level of the coeliac trunk|block5b][$where = "Correct."]] [[Just tell me the answer|block5][$where = "Not sure?"]]

"<<print $ganglia>> It's the coeliac, superior mesenteric, aorticorenal ganglia. Now where are they?" [[posterolateral surface of the aorta, at the level of the coeliac trunk|block5][$where = "Not quite."]] [[posterolateral surface of the aorta, inferior to superior mesenteric artery|block5][$where = "Not quite."]] [[anterolateral surface of the aorta, inferior to superior mesenteric artery|block5][$where = "Not quite."]] [[anterolateral surface of the aorta, at the level of the coeliac trunk|block5b][$where = "Correct."]] [[Just tell me the answer|block5][$where = "Not sure?"]]

<<print $where>> Traditionally they are on the anterolateral surface of the aorta, at the level of the coeliac trunk. But that's actually a bit of a trick question. In reality there's a wide range of abdominal anatomical variations which is why we need..." With impeccable timing one of the scrub team pushes the C-arm through the open theatre doors. "Now can you tell me what you are going to go over with Mr Sanderson in terms of the risks of the procedure?" "I'm going to discuss... [[Back pain|blockextra][$consent = "Yes, but..."]] [[Low blood pressure|blockextra][$consent = "Yes, but..."]] [[Sickness and/or loose stools|blockextra][$consent = "Yes, but..."]] [[Numbness and/or weakness|blockextra][$consent = "Yes, but..."]] [[Failure to improve pain|blockextra][$consent = "Yes, but..."]] [[Infection|blockextra][$consent = "Yes, but..."]] [[Intravascular injection|blockextra][$consent = "Yes, but..."]] [[Difficulty with sexual function in males|blockextra][$consent = "Yes, but..."]] [[Rarely paralysis|blockextra][$consent = "Yes, but..."]] [[Internal organ puncture and damage|blockextra][$consent = "Yes, but..."]] [[Bleeding from major blood vessel puncture|blockextra][$consent = "Yes, but..."]] [[All of the above|blockextra1][$consent = "Correct."]] [[Just tell me the answer|blockextra2][$consent = "Not sure?"]]

<<print $where>> But that's actually a bit of a trick question. In reality there's a wide range of abdominal anatomical variations which is why we need..." With impeccable timing one of the scrub team pushes the C-arm through the open theatre doors. "Now can you tell me what you are going to go over with Mr Sanderson in terms of the risks of the procedure?" "I'm going to discuss... [[Back pain|blockextra][$consent = "Yes, but..."]] [[Low blood pressure|blockextra][$consent = "Yes, but..."]] [[Sickness and/or loose stools|blockextra][$consent = "Yes, but..."]] [[Numbness and/or weakness|blockextra][$consent = "Yes, but..."]] [[Failure to improve pain|blockextra][$consent = "Yes, but..."]] [[Infection|blockextra][$consent = "Yes, but..."]] [[Intravascular injection|blockextra][$consent = "Yes, but..."]] [[Difficulty with sexual function in males|blockextra][$consent = "Yes, but..."]] [[Rarely paralysis|blockextra][$consent = "Yes, but..."]] [[Internal organ puncture and damage|blockextra][$consent = "Yes, but..."]] [[Bleeding from major blood vessel puncture|blockextra][$consent = "Yes, but..."]] [[All of the above|blockextra1][$consent = "Correct."]] [[Just tell me the answer|blockextra2][$consent = "Not sure?"]]

Fifteen minutes later you are looking at this: <center> <img src="images/block.jpg" style="max-width: 100%;"/> ''Figure 1: Neurolytic Coeliac Plexus Block via Posterior Approach Lateral View (1,2) and AP view (3)^^1^^.'' ''[[Next|patientpost]]'' ^^1. John RS, Dixon B, Shienbaum R. Celiac Plexus Block. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. [Figure, Neurolytic Celiac Plexus Block via...] Available[[here|https://www.ncbi.nlm.nih.gov/books/NBK531469/figure/article-19100.image.f1/]] This image is distributed under the terms of the [[Creative Commons Attribution 4.0 International License|http://creativecommons.org/licenses/by/4.0/]]^^ </center>

It's eight weeks later and you are in early for one final morning with the pain service. As always Ali is in early opening post. She comes to the door of the office where you are reading through notes. "You looked after Mr Sanderson $firstname?" "Yeah. We did a block for him a couple of months ago. Why?" "Got this today...from his wife." She's holding out a card. Before you even take it you can guess what it says. [[Take it|card]] [[Leave it - END|End]]

<center> <img src="images/letter.jpg" style="max-width: 100%;"/> </center> [[End]]

<<print $consent>> there are other risks to consider and as part of informed consent it's good practice to be able to give the patient accurate information." With a flurry Dr J produces a FPM patient information leaflet that you recognise. <center> <img src="images/consent.jpg" style="max-width: 100%;"/> !!![[Next|block6]] </center>

<<print $consent>> This is certainly something the examiners like to ask so it would be wise to know it well." With a flurry Dr J produces a FPM patient information leaflet that you recognise. <center> <img src="images/consent.jpg" style="max-width: 100%;"/> !!![[Next|block6]] </center>

@@.typing;''From:'' Employment Services ''Sent:'' <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-UK", { day: "numeric", month: "numeric", year: "numeric" } )>> ''To:'' $firstname $surname ''Subject:'' Notification of rotation Dear Dr $firstname $surname This is to inform you that your next placement will be at ''Persistent Pain Management Service''. You will receive a personalised work schedule from your host trust prior to your start date. Your sincerely, Holly Wall ''Employment Services Administrator''@@ [[Next email|email1]]

<<print $consent>> There are a number of risks to consider and as part of informed consent it's good practice to be able to give the patient accurate information." With a flurry Dr J produces a FPM patient information leaflet that you recognise. <center> <img src="images/consent.jpg" style="max-width: 100%;"/> !!![[Next|block6]] </center>

<p style="text-align:justify">@@.console; !!!4 hours later Dennis reaches for his mobile and taps the contact at the top of his recent calls. "Hi Dad are you OK?" "Nothing wrong honey; you can come and get me." "How was it?" "It was fine, all very efficient, I felt like a formula one racing car in the pit stop when they were all wiring me up with the monitoring and such. Lots of beeping. The young doctor was talking to their consultant...something about [[AAGBI minimum monitoring standards|https://anaesthetists.org/Home/Resources-publications/Guidelines/Recommendations-for-standards-of-monitoring-during-anaesthesia-and-recovery-2021?gclid=Cj0KCQjw-JyUBhCuARIsANUqQ_K1qlyOeP_KYABefoVDt9jT3azor3_ska9NtVqT3LzMg7VtLVTfAQoaAmNeEALw_wcB]]? I had to lie on my front while they did the block. It was a bit uncomfortable but not too bad. I felt all warm in my legs after and they've been keeping an eye on my blood pressure becuase they said it can go low. I've got some impressive bruises. They also said I might get loose motions and to watch for that." "Too much info Dad. I'll come and pick you up right now. How do you feel? Has it worked?...Dad?" "It's better..." Dennis's voice breakes and he takes a shuddering breath. "...tell your mum...the pain's almost completely gone." [[Next|block7]] @@</p>

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Scenario_6@@

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

<center> !!!BETA Virtual Anaesthetics_Pain training_6 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/module6.pdf]]'' [[Back|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>