Nature of Pain

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Today I took the bus to Seattle for my Orthopedics rotation. "Ortho" is a favorite "EM2" (Second year Emergency Medicine Resident) rotation because you can basically be a huge slacker, um...I mean, it is a great opportunity for independent learning. I set my own hours and pretty much show up whenever I want to; it's pretty much an anomally, almost unprecidented in my medical education with the possible exception of something called the "fourth year of medical school," but I digress.

Ironically, the rotation is set at Harborview, which many of you will remember from my previous posts as being the source of so much pain and suffering (for me if not for patients). Believe me, this irony is profound--I'm still grappling with the cognitive dissonance that comes from being so blissfully at peace while being within the confines of that place. Even so, I enjoy riding the bus to work there. The gritty feel of public transportation is a fitting prelude to the cacophony of the Harborview ER.

One of the first patients to catch my eye was a twenty-seven year old man wearing a tank top, plaid flannel pajamas over black thong underwear, suspenders, a large S&M type dog collar and a black straw cowboy hat with a prominent white skull-and-crossbones device on the front. He was quite loud and it was not difficult to learn that he was a heroin addict and thought quite deeply about metaphysical issues. At least, I assumed as much because he used the word "metaphysical" quite frequently. I smiled to myself when I overheard a frustrated intern tell him "Look, I don't have time to talk about metaphysics, I've got lots of other patients I need to take care of."

I knew a fellow resident from my program was rotating as "Medic One," (essentially the chief resident for the "medical," as opposed to "surgical" aspects of the ER) so I went to say hello. I found him standing over a patient on a ventilator. The very strong odor of feces was in the air. "Hey John, would you mind helping us role her?" Happy to help, I put on a pair of gloves and helped turn the patient on her side, revealing the source of the smell. My greeting completed, and the mess somewhat abated, I finally attached myself to the Orthopedic resident on call.

The resident on call was very pleasant (and tall) guy I'd met months ago on my last Harborview rotation. It was nice to have an instant rapport on a new rotation, and from there the rest of the evening went relatively smoothly. I got to reduce a both-bone forearm fracture in an elderly lady who had fallen on an outstretched arm (it was an open or what used to be called "compound" fracture), help reduce two shoulder dislocations, and inject a knee joint in a lady who had been in a car accident (to insure that the ugly gash on her knee had not torn into her joint space--it had not).

The shoulder dislocations were particularly interesting, for a variety of reasons. Both patients were repeat offenders (having dislocated many times before) and arrived at about the same time. One had dislocated his shoulder during a seizure and the other was a manual laborer who thrown it out. Both of the dislocations were very difficult, requiring multiple attempts at reduction. What was remarkable was to so poignantly observe such different illness behaviors from two different people with the same problem. [Note: Anyone who has seen enough different women give birth will know what I mean here. With some, there is complete emotional decompensation, with others remarkable aplomb]. The post-seizure patient never seemed to have enough pain medicine--we ultimately gave him many times what would normally have been considered adequate (the most I'd ever seen of the drugs we were using). He was so drugged that when we were not actively manipulating his arm he would fall immediately asleep and snore loudly. When we attempted reduction, he would wake and SCREAM all sorts of things not suitable to repeat on a family blog. The other gentleman needed much much less and when we attempted the reduction he watched quietly, obviously uncomfortable but with the understanding that it had to be done, making no comments about our mother's whatsoever. These patients were not twelve feet from each other, observing one-another's reactions as we alternated between the two, trying a new technique on one while giving the other an opportunity to rest. As of this writing, both shoulders are in place--the whole affair (i.e. both reductions together) took almost two hours. Seriously, I could write a book about how interesting (and disturbing) an experience the whole thing was--the questions it made me revisit, about ethics and about the nature of pain--it's biochemical nature and it's emotional meaning to a patient.

Shortly afterwards the laborer was discharged. The screamer had to be admitted as he went pretty much into a coma post-reduction. [Note: No, not a literal coma].


Some guys have all the fun!

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This page contains a single entry by John published on August 2, 2003 12:41 AM.

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