Hello. Hi. I'm Josh Frank. I'm Dr. Frank. Sarah. This is my husband, Tim. Hi, Tim. Hi, doctor. Nice to meet you. So I'm one of the palliative medicine docs and what I usually to start with patients and families is just get general sense of what you're understanding of what palliative care, palliative medicine is. Very little. I've heard of it. Yes. Basically, Dr. Chandran gave me a referral to you and said it would be helpful, and that's all I know. You're not alone in that. I hear that a lot from patients, "I'm here because my doctor said I'm supposed to be, but I'm not quite sure why." So let me talk a little bit about what we do in palliative care. As a palliative medicine physician, I specialize in quality of life. That is my specialty. So what I really want to do is making sure we're addressing all aspects of your health. For some patients, it's about physical complaints. It could be uncontrolled pain, it could be uncontrolled nausea, it could be unwanted side effects from chemotherapy. For other people, it's more about the psychological stuff. It's more about getting more sad, being more depressed, being more angry. So how do we combat that? Other times, patients say, "I'm doing all right. I'm come to terms with this, things are going okay. My partner, my loved ones, they're having a hard time." So we're checking with family members because you're going through this and so we want to make sure that you're doing okay. Then finally, it's what I say, it's your spiritual health in really addressing some of those hard questions that patients have. The why questions, the why is this happening. Where do we go from here? What does this mean for the future? So we can help delve into those questions as well if you're up for it. So that's another thing we could do. So ultimately, it's all about you and however we can help in any quadrant of health is what we want to do. Okay. So for you, I think for today, I want you to leave your appointment feeling good. I addressed what was most concerning to me. I don't know what's most on your mind or most worrisome today? I would say pain. Yes. That's probably it, pain. So pain. So let's start there. Tell me a little bit about your pain. It's my stomach, and the pain's been there for a while, but I would say the past month, it's really gotten worse. Okay. How would you describe the pain? It's hard to describe, but it's there all the time. Then I get these stabbing pains that come and go. Okay. If you had to rate the level of pain, 0-10, 10 being the worst type of pain you've had, where would you rate it? Four maybe. Okay. Not bad I'd say closer to six or seven. Sometimes it gets really bad. That's true. All right. So somewhere between four and six to seven? Yes. Quite a range, and it sounds like it's all the time. Yes. Are you taking anything? Have you tried any medications to help? Well, Dr. Chandran prescribed the Vicodin, and I had been taking that every six hours and I'm still in pain. So it's been really frustrating and worrisome too. Okay. So pretty frequently all the time? Yes. Okay. That's not uncommon thing. Those medications don't seem to last very long. At best, they turn in about 30 minutes, 45 minutes to kick in. They last anywhere from about three to four hours. So it doesn't surprise me you saying, "I need to take it pretty frequently." Okay. Thank you for saying that because that actually makes me feel better. I was starting to feel like it was either a big whimper, a crazy pill popper. No. What's one of the things that people feel relief, and then after a while, it just wears off, that's why you needed to retake another pill to get the relief again. Anytime a day pattern or any activity it seems to make it better or worse? No. I get pretty unfocused when the stabbing pains come along, but I can't say that I've noticed any patterns. No. Okay. Any allergies from medications I need to be aware of? No. All right. Okay. So I'm thinking already of some things we could try and I want to get there. But I also want to get to another problem Dr. Chandran told me about is you're having some issues with constipation. Word travels fast. Yes. That's the thing for me, and I would say, it's definitely been worse since the Vicodin started. Again, that doesn't surprise me. So Vicodin like all pain medications slow the gut. So that's one of the unwanted effects of opioids or pain meds. Whereas other side effects, sometimes people feel they are little altered, they feel mentally a little foggy. Usually, the brain gets better and it counts for that and it goes away over time. Unfortunately, the guts don't get smart and the constipation can actually get worse and build up overtime. Fun factor to predict Yes. So what do we do about that? Yes. So what it is, there's some medications we could try to counteract the effects of the pain meds. So a medication I often use is called Senna. I don't know if you've heard of that. How do you spell that? Senna, S-E-N-N-A, and actually, it's a herb. So it's a vegetable based product. I like it because of a couple things. One, it's very cheap, so you can get any store has it. It comes in different forms, it comes in pill forms, liquid. Then for people that don't like taking pills, or if you're a tea drinker, it comes in a tea form believe it or not Okay. So it's one of those things that I would recommend you prior start with two pills at night, and you just take it every day. If you take a pain pill that you just mentally up, I got to take my Senna tonight too Okay. All right. Got it. Senna, pain pill. I usually say starting 10 at night time is because your body naturally prepares to have a bad moment in the morning anyways, so we want to sync up with the body's normal pattern. So start with night time, but we can always add more to it if we need to. Okay. Sounds good. Sounds good. So then going back to the pain. So I think if before you address the constipation, I think that would help a little bit with the discomfort. But I think also with the pain, there's some things that we can do to better manage the pain. What you're describing before is this up and down pattern where your pain gets bad and you take your pain medication and it gets better. You get relief for a couple hours and then it comes back. It's exhausting, yes. Very much so. So it can be very draining physically and emotionally, uncontrolled pain. So I think what we'd like to do is get something that lasts longer than the four hours. Yes, please. So there's different things on the market. One medication is the one acting form of Morphine. Common brand names are MS Contin or Morphine ER. Those medications last from eight to 12 hours. So we're going to double the time length. They are like your Vicodin in this. Other medications be like Oxycodone, like Oxycontin, which would be like a cousin to Morphine Okay. That freaks me out a little bit because those are the types of things that I hear about people getting addicted to. Yes, you do. Those are things you hear on the news. I think for you, it's going to be less of a worry. For one, your pain is not controlled. If you take pain medications for pain control and you're taking it for the purpose of trying to get back to being normal, addiction is less of a worry. Yes, over time, your body's going to develop what we call tolerance and you're going to need more pain medications to get pain relief, that's normal. But as long as you're taking pain meds for pain relief and not to checkout or I'm really stressed, addiction is going to be less of a concern. Okay. I can see you are not quite on board. It still freaks me out a little bit, but I see what you're saying. Okay. So we'll keep talking about it, and I think that's something that I take responsibility for. We will keep checking in and that's something we'll keep following upon to make sure that you're doing okay. Again, as long as you're taking the pain pills for pain relief, the risk for addiction is very low. Okay. All right. So what I'd probably say is, we'll start your program with a long acting form of Morphine that usually the cheapest and most insurance plans cover it. I'm always trying to find ways to save money for people. You're already paying enough as it is. We are. So I think we'll start there, and what I would do is, you take in the morning when you wake up and you take it at night before you go to bed. Okay. Great. So she doesn't have to take pills all day long? Yes and no. The hope is she doesn't have to. So what we're also going to do is, I'm going to prescribe another medication called short acting Morphine to replace the Vicodin or the Hydrocodone that you're on right now. The reason I want to make the switch there, it's a pure pain med. There's no Tylenol in it. So Tylenol over time, if you take too much in a day, can damage the liver. So this takes that risk away, and you already got enough in your plate. We don't need to worry about one more thing. Okay. But what you would do is, you would take your long acting in the morning, long acting at night, and if the pain creeps up in the afternoon or dinner, I don't want you to have to wait until night time dose. That's when you would take the short acting pill as needed throughout the day. Okay. Then definitely what you could do is keep track of any patterns. So if you come back and see and say, gosh, every lunch, I'm taking a dose and another dose at dinner, that tells me something that we might need to add another long acting dose in the middle of the day. Okay. Great. Makes sense. So if this doesn't work or we need to change plan, do we contact you? So Dr. Chandran is still going to be your point doc. She's still your oncologist. But what I'll do is, I'm going to write this all up, and I'll actually send her a note, and let her know the things we discussed. I would like to see you prior within a week to two weeks at most. Just a checking to make sure things are working and that we're heading the right direction. If we need to make any more adjustments, we can at that time. Okay. Okay. Great. Thank you. Now, that's been really helpful. Thank you. Anything else? I think this is a lot. I think let's get this under control. I think this is most on your mind and I know that Dr. Chandran is concerned about as well. So let's get this addressed first. I think in future visits if it's okay with you, I know that going through this, there's many other things that are happening. I think I'd like to talk a little bit more with you about how you're doing as a person. But we can talk about that next time. Okay. I'm up for that. Great. All right. So nice to meet you both. Thank you very much. Thanks so much. Good bye.
