Thursday, April 17, 2008

Perceptions of Pain, pt. I

Pain, a subjective quality to which we are constantly trying to attribute objective value, is often a difficult symptom to fully understand. This is the first in a series of entries in which I will explore the way I have found my patients recognize their own pain, come to grips with it, and how they decide to outwardly project the experience towards the world.

Dispatched for the "possible heart attack," I arrive to find a tall, strong man in his 40's chatting with a police officer. He is walking around the small doctor's office, refusing to sit down and ignoring the nurse's increasingly frustrated attempts to apply a nasal cannula. "I'm fine," he insists, "I'm fine."

The doctor pulls me aside, rolling her eyes a bit as she shuts the door between us and the patient. "I don't care what he says," she tells me, "he's got something going on." The man came to the clinic because he has been waking up in the middle of the night drenched in sweat, short of breath with an "aching" feeling in the crook of his left elbow. At some point he admitted to some nausea as well, and the ECG taken today showed some mild ST elevations in the anterior leads. "After he realized that this might not be a simple sweating problem, he clammed right up," the doctor told me.

She was right about the clamming up. In fact the man was positively evasive when I tried to do my assessment. He would respond to specific questions with general answers, refusing to make eye contact at any point. When I asked him if he had any chest pain he replied "Well, yeah, I get pain all the time. Like when I work out, or if I fall down." He was probably one of the toughest patients that I've had to interview in a long while, and I was surprised to find that someone would so effectively try to sabotage his own care. I've heard of denial before, but there is usually a point where people - out of fear or whatever else - finally open up. This man simply would not, and we spent the ride to the hospital in tense discussion as I asked - and re-asked - each question.

The man was visibly shaken as we rolled him through the hissing doors at the emergency room entrance. His voice trembled as I asked him for his registration information, and despite my efforts to help him relax, his hands remained gripped tightly to the stretcher rails. We transferred his care to the hospital staff, and he released his grip from the stretcher only once: to shake my hand.

"I'm fine, but thank you," he says.


Brett said...

Are you going to do a special about the "aye dios mio"

Anonymous said...

Did you go to the JEMS conference (and therefore the JEMS Games)?

If you did, then you know that pain is good... it's a diagnostic tool!

Lethal said...