Samuel Perry

Management of pain during debridement: a survey of U.S. burn units☆

To determine how burn pain is assessed and managed during debridement, questionnaires were sent to 151 U.S. burn facilities. 181 staff members from 93 burn units responded. For a typical adult patient, most respondents preferred a narcotic, but the dosages varied widely without a corresponding variation in assessed pain. The assessment of pain also did not vary with the type of analgesia used or the route of administration (i.v., i.m., p.o or gas). Half the respondents used psychotropic drugs in conjunction with narcotics, but without a reduction in dosage of the narcotic or a reduction in assessed pain. For a typical burned child, although more respondents recommended using no narcotics or no psychotropics or no analgesics at all, the assessed pain for children and adults was the same, i.e. in the moderate range. Pain during debridement was rate as more severe by those with less job experience and by those who gave higher dosages of analgesics before the procedure. The surveys findings indicate a need to reevaluate current analgesic practices for debridement and to document pain and pain relief.

Psychological responses to serological testing for HIV.

To determine the emotional impact of serological testing for HIV, 218 physically asymptomatic adults were evaluated in a confidential clinical setting 2 weeks before HIV test notification, immediately before and after notification, and 2 and 10 weeks later. All received extensive pre- and post-test counseling. The 179 seronegatives reported one or more HIV risk behaviors: homosexual intercourse (n = 111), heterosexual intercourse with possibly infected partners (n = 62), intravenous drug use (n = 20). Immediately after notification, seronegatives had significant decreases in visual analogue scale (VAS) measures of anxiety, depression, fear of getting AIDS, and fear of having infected others. Reductions were sustained at both follow-up assessments and were complemented by significant reductions on standardized self-reported measures of anxiety (Spielberger State Anxiety Inventory, SAI), depression (Beck Depression Inventory, BDI), and psychiatric symptoms (Brief Symptom Inventory, BSI) as well as by clinical ratings of depression (Hamilton Depression Rating Scale, HDRS). Of 39 seropositives, 35 had homosexual risk behaviors, seven had been intravenous drug users (IVDUs; four of whom were homosexual men), and one was a female partner of an IVDU. Immediately after notification, VAS measures of their anxiety were not significantly increased, and at 10 weeks after notification, their VAS measures of distress and mean scores on BDI, SAI and BSI were significantly lower than at entry. Their HDRS ratings were not significantly increased.

Undermedication for pain on a burn unit

As the consultation-liaison psychiatrist for a large burn service, the author investigated the undermedication for pain. This phenomenon could not be adequately explained by the staffs insensitivity, by mistaken ideas about analgesics, or by fears of iatrogenic addiction. For both patients and staff, the pain served to maintain self-object differentiation and to provide reassurance that the patient was alive. Developmental observations and psychoanalytic theory support this unconscious need for pain.

Clinical Research: Analgesia and Morphine Disposition in Burn Patients

Following intravenous administration of morphine (MS) to eight burn patients, the plasma concentration of MS, along with the analgesic effect, was determined over time. The pharmacokinetic measurements revealed rapid and extensive distribution of the morphine as well as rapid elimination. The values did not differ significantly from those found in normal controls. A plot of the mean log MS vs. mean pain relief demonstrated a relationship between the plasma concentration and the analgesic effect. The findings show that burn patients can eliminate morphine normally and can receive effective pain relief when plasma concentration is sufficient.

Orogenital Transmission of Human Immunodeficiency Virus (HIV)

Excerpt To the Editor:Three previous case reports (1-3) have suggested possible female-to-female sexual transmission of human immunodeficiency virus (HIV). Sabatini and colleagues (1) described a 3...

Moderators of bereavement distress in a gay male sample

Abstract Several variables believed to affect bereavement, including social support and hardiness, were examined in a gay male sample. Diverse bereavement symptoms were assessed including depression, anxiety, and general distress. Most S s had experienced multiple close losses in the prior year. Social support, hardiness, and number of losses all had a significant relationship to symptomatology.

Distress reduction during the Structured Clinical Interview for DSM-III-R

In an attempt to assess the influence of standardized diagnostic interviews on psychological distress in research volunteers, the Visual Analogue Scale (VAS) was used to measure anxiety and depression during the Structured Clinical Interview for DSM-III-R, Non-patient version (SCID). Subjects were 50 adults with concerns related to the human immunodeficiency virus who were seeking testing and treatment in research trials. Repeated measures analysis of variance showed significant decreases in distress by the end of the interview: 72% of subjects reported diminished anxiety, and 54% reported diminished depression. Thus, the SCID appeared to provide a positive interview experience, a finding that may serve to reassure subjects, their families, and review boards regarding participation in studies that employ structured interviews.

Does physical improvement reduce depressive symptoms in HIV-infected medical inpatients?

The Beck Depression Inventory, Karnofsky Scale of Physical Performance, and a visual-analogue scale to assess subjective distress were administered to 32 HIV-infected medical inpatients shortly after admission and prior to discharge. Twenty-eight percent of subjects had severe depressive symptoms on admission. Most of these subjects remained in the severe range of depressive symptoms at discharge, despite physical improvement comparable to subjects with lower levels of depressive symptoms. In contrast, subjects with moderate depressive symptoms on admission showed a significant decrease in depressive symptoms at discharge. The results suggest that the etiology and management of depressive symptoms in HIV-infected medical inpatients may differ depending on the initial severity of depressive symptoms.

Determining resuscitation status: A survey of medical professionals

Regarding the determination of resuscitation status (RS) and the writing of do-not-resuscitate orders, we compared the recent Presidential Guidelines with the attitudes and perceptions of 143 medical professionals in a major medical center. Seventy-four percent of respondents believed that RS was primarily determined by the physician. Only 1% believed the patient decides and a minority (40%) believed the patient should decide; 61% would want to decide for themselves if they were ill. Most respondents agreed that neither patients nor staff were well-informed about the individual patients RS. When presented case vignettes requiring a decision about RS, the respondents frequently chose a RS contrary to the wishes of a competent patient. The findings of this survey point to the significant differences between the Presidential Commissions guidelines and the actual attitudes and perceived practices of clinicians.

Coping with the possibility of testing HIV-positive

Abstract This study examined the relationship between the coping styles of monitoring and blunting, and emotional distress in individuals confronted with the possibility of being HIV infected. A sample of 200 men and 49 women undergoing an HIV antibody test were administered measures of emotional distress and asked to predict whether the result of their test would be positive or negative. All of these subjects subsequently tested seronegative. In subjects who predicted the result of their HIV test to be positive, those high or low on both monitoring and blunting experienced substantial emotional distress. However, subjects who used primarily either a monitoring or a blunting coping style and predicted their HIV test result to be positive experienced a moderate level of distress. The results suggest that individuals who do not use a specific coping style, or attempt to use two conflicting coping styles at once may cope ineffectively and feel more emotional distress when confronted with a health threat.