Page 211 Guide to Pain Management in Low-Resource Settings

Management of Pain in HIV/AIDS 199

drainage procedure is not undertaken, a poorly healing and brings up her breakfast all over the clinic fl oor, making
sinus or fi stula may develop. Also not addressed, is that the procedure exceedingly challenging for the staff .
the abscesses are extremely painful, particularly in an
What are some possible things that could
area such as the axilla, which will be manipulated during
have been done to have prevented this state
dressing, transportation, and so on. Relief of the pressure
of aff airs?
is in itself an eff ective pain management procedure.
2) Aspiration. Small abscesses can be aspirated with While it is often traumatic for parents to watch blood
ease with minimal pain to the child. Th is process allows being drawn from their child, it is more often more
the pus to be drained to the surface and prevents sinus traumatic for the child to face the procedure alone feel-
formation as well as relieving the pain of the abscess it- ing abandoned by their mother, whom they trust to pro-
self. Unfortunately, inadequately aspirated abscesses of- tect them from pain. It is therefore advisable to encour-
ten recur with resultant recurrence of pain. It is diffi cult age parents to remain in the room and speak words of
to adequately aspirate large abscesses, particularly those comfort to their child during the procedure (they do not
which have been present long enough to begin develop necessarily need to watch the procedure). Also, parents
into separate locations. or caregivers should be encouraged to explain why the
3) Incision and drainage (I&D) under general an- blood has to be taken as far as the child can understand.
esthesia. In some cases this method is preferable to the Th ey should also be encouraged not to mislead their
outpatient procedures for children as the pain of the children and promise that no blood will be taken. Par-
procedure is completely dealt with by the anesthetic. It ents should be discouraged from “villainizing” the staff
allows the abscess to be completely drained and to en- performing the procedure. It is often the natural instinct
sure that all septae are broken for good drainage. On the of mothers in particular to vindicate their child’s pain by
other hand, general anesthesia requires that the child be promising them that they will hit the doctor or, as one
separated from her mother, admitted to hospital, and patient’s mother promised, report them to the police!
exposed to an unfamiliar and scary operating room. Th is behavior serves to increase the child’s fear of the
And, of course, the postoperative pain still has to be staff and makes the child begin to doubt their mother’s
managed, just as for the outpatient procedure. word or ability to off er the protection promised.

What can be done in future to alleviate
Case report 2 (“psychological pain the situation?
due to recurrent procedures”) Th e multicomponent approach described in Table 2

Edith is a 2½-year-old girl who has been attending the should be introduced. EMLA should be used in an at-
tempt to reduce pain. As soon as the child is old enough
antiretroviral clinic since she was 6 weeks of age. She
was started on HAART at 12 weeks of age and was seen to make brachial vein blood sampling as easy as exter-
nal jugular vein sampling, this option should be ad-
monthly for the fi rst year of her life. Blood samples were
taken every 3 months. Since she was 6 months old, the opted. Th e child will be able to remain on her mother’s
lap with her mother’s loving arms as her unforced re-
necessary blood samples have been taken from her exter-
nal jugular vein, which involved her being held supine on straints. Off ering some form of comforting compensa-
tion like a chewy sweet or lollipop will often stop the
an examination bed with her neck slightly extended over
the edge of the bed while her hands were held by a nurse to tears or at least attenuate the trauma of the procedure
with some positive association.
prevent her from trying to pull the needle out. Her mother
has a fear of needles and couldn’t bear the sight of the doc-
tors inserting a needle into her baby’s neck, so she would al- Case report 3 (“pain due to
ways place the baby on the examination bed in the care of opportunistic infection with
the nurse ready for the blood drawing and then leave the exacerbating psychosocial factors”)
room until the procedure was complete, when she would be
called back in. Two years later, it now takes two nurses to Abigail is a 12-year-old girl who is brought to the clinic
hold her down fi rmly enough to make phlebotomy safe for having just been diagnosed with HIV. Her parents died
her, with the doctor performing the procedure. As soon as 2 years ago from AIDS-related illnesses, and her mater-
she is supine, she begins to gag until she induces vomiting nal aunts have been caring for her since then. When they