How Real is Your Pain?

"And now would you please choose a number from one to 10 describing your pain - one being almost no pain and 10 the worst pain imaginable." The ER nurse's voice seemed to trail off as she got to the end of the mandated recitation.
She had the patient look at a graphic on her clipboard as he answered. The graphic was a 10cm line with numbers like a ruler, as well as upside down smiley faces depicting progressively greater discomfort - the VAS (visual analog pain scale). Patients are supposed to tell our nurses how much pain they feel by pointing to a spot along the line.
I knew why the gusto had gone out of the nurse's voice. One of the patient's arms was horribly broken and bent at an ungodly angle. She had just started a large-bore IV in the other. And while her big fat needle pierced him three or four times before it found blood, this stolid 60-year-old Eastern European block of a man had made not a sound. His face hadn't registered a flicker of pain, his arm stayed still, even his hand remained limp. No reaction to this needle torture promised an unsatisfying go at the VAS. But dutifully she administered. Protocol.
"One," said Jacob.
That meant she was not even supposed to offer him a pain med; the purpose of the VAS is, among other things, to decide "scientifically" when to give pain drugs.
"Get me 10 of morphine please" was my response to this. The nurse's relieved face looked up from the meaningless fill-ins on her clipboard. She got the drug and gave me the syringe.
"This will make it easier for me to get the arm straight, OK?" I said to Jacob.
"Yes, doctor, OK."
This Jacob was no baby. I pushed the first few milligrams and went to work. Not a peep as the bones crunched back into place, although a sudden sweat and slowing of his heart told clearly he had felt it.
"Thank you doctor" came out as the cast hardened. I gave him his instructions. He did everything perfectly - including taking the pain prescription the way I told him to - every six hours for the first 24. And his arm healed and he went back to work.
You see a few like Jacob. I remember him best because of the patient in the next room that night. My very next patient, right next door. This patient had been in an automobile accident 48 hours earlier. After the accident she had gone home. She then came in to the ER the evening I was on call because she said her pain had become "excruciating - like I'm being stabbed with a thousand knives." Charlene complained of pain in her head and neck, both shoulders, upper back, lower back and one knee. There was not a mark on her. Between her physical exam, scans and X-rays, I was unable to find any abnormality other than nonreproduceable joint stiffness (they moved well except while I examined them) and generalized pain wherever I touched her.
Now we can't just write off patients like Charlene as quacks; there have been more than a few with this presentation who were dead a day later from bleeding around the brain, heart or abdominal organs. There are also some real cases of what's commonly called whiplash that look like this too. Fine after the accident and bed-bound a week later. But Charlene's exam seemed too much an act, her vocabulary was laced with too much plaintiffese and she showed far too much interest in the notes that the nurses, the secretaries and I were making about her. She leaned over to peer at my chart, gave me time to write and volunteered many more symptoms and disabilities, adding frequently that she had never had these problems until the accident (although she had taken plenty of narcotics "for other things"). As I dutifully recorded, in walked Vicki, the nurse who had just helped with Jacob. She had her clipboard, to administer the VAS.
"Oh at least a 10. Can I put 11? Or 12? It's way off the scale." Vicki wrote 10 in the box. This meant she was supposed to give strong pain medicine, quickly. Another quick look from Vicki; she had only been in the room for two minutes with this patient yet she already had the same feeling, one that I was quite sure about: that there wasn't really that much pain here and that the VAS protocol (a hospital policy at that point) was wrong for this patient too.
"Let's start with Toradol," I said to Vicki. Toradol is a non-narcotic pain med.
"I don't want her passing out in X-ray and she might have elevated ICP," I added, referring to high pressure from injury around the brain that can be worsened with narcotics. Vicki knew exactly what was going on.
Charlene's face fell. "Toradol doesn't work on me. I'm immune to it. Another doctor once gave me something that worked really well though, it was light, just a pill, I can't even remember what he called it, perca or perco something."
Charlene's ruse is so common, so old, it's like listening to Beatles music. And I can't help but sing along.
"Percogesic? " I asked, with mock innocence. This is the non-narcotic pain reliever whose primary selling point is a name quite similar to the highly addictive Percocet that Charlene was trying to get me to give her.
"No...oh..., its... Percocet! That's right, Percocet. They worked really well, no side effects or anything. That's what I need."
No Percocet from me. The patient is still out of work. Pain worsening.
Initiating a possible lawsuit.
There are, unfortunately, a lot more Charlenes than Jacobs in our area. People like them teach something important: pain is a special case of the mind/body problem. Ask many "experts" in pain management. Was Charlene in pain? Yes. Was Jacob? No. Why? Because these practitioners hold that pain is only what the patient reports. In a simple way it's impossible to disagree with them. But I do.
Medical technology has yet to invent a machine that can look into another's mind to see what he's feeling, or thinking. No doubt the body, with its physical brain, responds physically to noxious stimuli. But the non-physical mind is yet the only realm in which the bad experience of suffering exists. Mind and brain are mysteriously related. Lobotomized or drug-loaded patients can still answer questions. Stick one with a big needle and ask: does it hurt? Yes, it does, doctor. You can get him to report a VAS number. They might even withdraw from the needle. But there is no grimace, no groan. They certainly feel pain - but they don't care. And they don't need pain medicine.
There is, however, a mind-reading machine that certain doctors and nurses can use in cases like Charlene's and Jacob's. Its use is frowned upon by many in administrative positions and specific measures to render these machines useless, most notably long forms, committee meetings and menu-driven care algorithms, are being implemented with increasing ferocity. It is only this machine that can make rational and humane treatment decisions for the suffering though. It is, in fact, only this machine which suffers. See past the ones that beep and blink; the mind remains our most important machine in medicine.
[Time]