Lessons of Pain

As I neared the end of my first Day, post-op (that's "after surgery" for those of you who have never watched ER, Gray's Anatomy or any other hospital show.....), my experience of pain began to change. Now that my drain was no longer evacuating the fluid from leg and the anesthesia was worn off, I started to feel like someone had hit me in the butt with a baseball bat. Either that, or my surgical team loaded me up with a squat bar and made me squat for 2 hours. I was sore. It was discomfort related to tissue trauma and it was hard to really quantify. Pain is perceptual so there is no way to really convey to another human being what your experience is. The hospital has all kinds of pain tools like verbal and non-verbal indicators. Crying, screaming, vomiting, and threatening to dismember your nurse or nearest healthcare professional are generally pretty telltale signs that one is not comfortable. However, other than this, pain is much harder to determine. Enter the dreaded "pain scale," the bane of everyone's existence. Nurses don't like it because it is too simple and most patients have no idea how to use it despite numerous teaching attempts. Patient's don't like it because trying to quantifying pain is like quantifying love. "Well, I love you more than my favorite TV show but less than chocolate." Yeah, that's effective. I mean, are we talking really good chocolate or the cheap kind you might find at a truck stop? And which episode of your favorite TV show? The one where McDreamy and Meredith finally seal the deal or the one where Izzy can't remember the secret ingredient to her Mom's famous cupcakes? Seriously? It's like that.

The Wong-Baker faces scale is a tool created by Donna Wong, a pediatric nurse and Connie Baker, a child-life specialist back in 1981 to try and evaluate pain in children at a Burn Center in Tulsa, Oklahoma. The primary goal for creating this tool was to assist children in communicating the extent of their pain to parents and clinicians so that they could provide adequate pain relief. The Wong-Baker faces scale is a rendition of 6 faces with corresponding numbers. While this scale is generally used for children, it helps adults to clarify a number in terms of how much pain they are in. All of us experience pain differently and the presence of physical pain might not be as big as, or magnified by, the issue of emotional pain.

It is without fail in my job as an ER nurse that I struggle with this pain scale primarily because it is not measured, but rather, reported by the patient. Take for example the 6'2", 200-pound male that presents after breaking his collarbone while riding his motorcycle. He's manly and proud and spends most of his emergency room visit telling me about how he cut his hand "near off" with a buzzsaw or suffered multiple concussions while playing football in high school. He's tough. He can "take" it. He will tell me his pain is a "3" on a 1-10 scale. "Great!' I'm thinking we'll just get this guy a sling, a referral to an orthopedist, and send him on his way. However, the minute I stand this very large, very proud man on his feet, the color invariably leaves his face, his pupils dilate and he gets all sweaty right before he tries to pass out. Try stopping a Sequoia from toppling over in the forest. The best you can do is change the direction of fall and hope he lands on something soft. However, this makes me, the nurse, question whether or not patients can really give me an adequate representation of their pain.

Now let's look at the other end of the spectrum: A 52 year-old female of average height and weight comes in with severe back pain. She takes all kinds of pain medications including morphine, oxycontin and the muscle relaxant du jour. We load her up with enough pain meds to drop an elephant. 30 minutes later, asleep and drooling all over herself, I wake her up to see if her pain is relieved and if the medication was effective.

"Mrs. Jones your pain was a "10" (worst pain ever) on the 1-10 scale before the pain medicine. What is your pain level now on that scale?"

Mrs. Jones struggles to open her eyes, does a little head bob and manages to slur out the number, "ten," before she drops her head back on her pillow and drifts off into a pleasant, slumber.

Hmmmm. Really? Let me run right back and get you some more pain medication.......

So nurses get to be skeptics and have to rely on other tools other than patient statement regarding pain. The problem with this is pain varies from person to person.

Take a 5 year-old patient who comes in with a broken leg after falling off a trampoline. A "10" on the pain scale is considered the worst pain you have ever had in your whole life. Well, a 5 year old has had little life experience, so this is presumably the worst ever and warrants a "10". Simple enough.

However, take a 9 year-old who has previously fallen off of a trampoline, crashed Dad's ATV, got 22 stitches when he broke Mom's favorite vase and a bloody nose when he ran over the goalie at his soccer game and now presents in your emergency room with a broken arm after falling off of his skateboard. He tells you his pain is "no big deal, maybe a "4" on that same scale( Dad is also watching which may or may not have an effect on the actual number). His answer is slightly incongruent with his age and experience until they tell you the laundry list of emergency department visits they've had. And now you are thinking this kid needs a helmet just to eat his cereal in the morning.

This incongruence can be present in adults as well. I've met plenty of 30- or 40-somethings who spent their entire life in a bubble with their worst injury being a paper cut until they come in screaming and moaning and carrying on because they were in a car accident and they broke a fingernail. This is almost always the case when the 9 year-old is right next door which prompts him to say, out loud, "What is WRONG with that lady Mommy?" Okay, it should also be said that the emotional response to a traumatic event tends to magnify pain and a patient's report of pain, so now I'm giving high doses of Morphine to a 33 year-old female with a broken fingernail while my 9 year old next door is laughing on Motrin with an arm broken in 3 places.

Finally, there are the 70 year olds who come in with a decreased pain sensation anyway, but have lived life to the fullest and now have two new knees, a hip replacement, a pacemaker, a lifetime of smoking, and come in for a "a little chest pain" because their granddaughter said she saw something on TV about how important it is to get something like Chest Pain checked out....... Little do they know they are having the "big one" and I'm running around getting cardiac drugs and defibrillators while this guy tells me about his sciatica and how that hurt much worse than this little old heart attack!

Pain is based on experience. Pain is different for everyone and different with each system and each precipitating event. In my life, I have had 6 knee surgeries. 4 of them were arthroscopic, snipping out unwanted and non-crucial cartilage that broke loose or having synovial fluid evacuated. 1 was due to a subluxed (simultaneously dislocation then relocation of) patella that required a little resurfacing and the other was to fix a total blowout to the lateral side of my left knee after a ski accident where I also broke my Tibial plateau, the top part of my lower leg. In this same accident, I broke my femur in 8 places which warranted a separate surgery called an "open, reduction, internal fixation" of my right femur after I not only broke it, but it shot out the back of my leg and ripped a pretty sizeable hole. I broke my pelvis in 4 places and my lower back which was accompanied by debilitating back spasm for a year. I've had stitches, concussions and pulled muscles and ligaments in just about every major joint in my body. I have been around the proverbial orthopedic block so to speak. And if that's not enough pain experience, let's talk about two pregnancies and two 'almost' natural deliveries.

I am on comeback number 11 by my count. Hip replacement surgery is just another walk in the park and I really thought that maybe I could skate through it with ease.

However, at the end of my first day, I was beginning to revisit the joys of post-surgical tissue trauma which included pain and swelling and it was time to cry uncle.

My nurse Mirtha came in the room.

"What can I get you darling?" she offered.

"I think I need something for pain, Mirtha."

"What is your pain on the 1-10 scale?" she asked.

The shoe was now on the other foot. After having to analyze pain in hundreds of thousands of patients and determine if their non-verbal cues matched their verbal ones, I was now being asked to provide my own number. It was karma and a hard lesson into the actual difficulty of trying to identify a number that matched my pain. I felt like I was taking the SAT. I gave my answer with clarification.

"Well, I'll give it a 7. It hurts enough to do something about it, but it could still get worse and I would like it to get a whole lot better. Compared to a broken femur, it's probably more like a 5 but that was a long time ago."

Mirtha, unimpressed, went to get me some Vicodin. I felt defeated.

"You just had hip replacement surgery," my husband reminded me.

"Yeah, but I still feel like a sissy. I should have said 6."

The fact is, there is no wrong answer. It is dependent solely on how the patient perceives their pain, which as I have mentioned, can also be affected by a precipitating event inducing a hypersensitive emotional state, a lifetime of experience, or lack thereof to compare their level of pain with. Patients get it wrong sometimes. Not because they are bad people, but because it is hard to quantify pain, especially if you happen to take massive amounts of pain medication and are unable to tell if you really hurt or if your brain is telling you that you hurt so it can get its narcotic fix. The new trend in healthcare to reduce the judgment and skepticism is to consider pain the "fifth vital sign". Phooey. Vital signs are directly measurable. You can't fake or control a blood pressure, a heart rate, oxygen saturation or a temperature. They are what they are. Pain is based on subjective data and too many factors. However, until someone comes up with the pain-o-meter that directly measures impulses and their impact on one's central nervous system, we are all stuck with the patient's perception and report of pain in number form. Nurses and patients will continue to make mistakes, but hopefully, we can treat and be treated with dignity and respect regardless of the pain tool du jour.

Mirtha gave me my first Vicodin at 3pm. However, by 6pm, I still felt like I had been the center of attention at a butt-kicking convention. She gave me another Vicodin. I could see that Mirtha did not care if I could quantify my pain or not. After 30 years of nursing, she just wanted a number to write down because with pain being the "fifth vital sign," it meant she had to record it. I gave her a 6.

After two Vicodin, my pain was under control by shift change. I was much more comfortable at "2" on the pain scale and appropriately "fluffed up" for the new night shift nurse who was a young, Filipino gal named Violet. Violet was not the calm, smooth, nurse of many years of experience. She played by the rules, and was obviously irritated by the use of my call button.

I was always sad to see my husband go when he left the hospital. He provided perspective into my skewed thought processes and when he left, I felt unsure of myself. Should I really get up and go pee without calling my nurse? Seems perfectly logical to me but I always like to bounce the biggies off of my spouse, like what is that big orange glob in the middle of my dinner plate? Now he was gone and I was left to my own devices, again. Perhaps sleeping would bring him back sooner, with lattes in hand. Once again, I could not get to sleep. As I watched the minutes creep by with my iPod and 3 failed TV program attempts, I realized I was uncomfortable. I hit the call button.

Violet appeared shortly. I told her my pain was returning and I might need something a little stronger this time as the Vicodin was not lasting as long as I had hoped. She explained that I could have 2 tablets every six hours. However, because my last one was at 6pm, I would have to wait until 12am to get the second tablet. I asked if that was all there was, and she, very frankly, retorted that those were my "orders."

Hmmm. Dr. Stefan said I had Dilaudid for breakthrough pain. One tablet of Vicodin for a post-surgical hip replacement patient with 2 more hours until her second tablet and my nurse was not budging on either the breakthrough pain med nor the 120 minutes left on the clock. I wanted to get self-righteous, I wanted to start screaming obscenities at miss "holier-than-thou," but the truth is, I have walked a mile in her shoes. I have stood before a patient and told them something similar and the weight of this news was now weighing on me personally. I was learning a lesson and the gift of this lesson was worth retaining my dignity and gutting out the remaining time. However, I did not wish to lay awake for the two hours I had left nor deny my traumatized tissues the rest they so desperately needed. I played my last card.

"I'm pretty sure Dr. Stefan wrote me something for sleep. Can you bring me something to help me sleep through the discomfort of the next couple of hours please?"

Violet returned with Ambien and a defeated look on her face. I would see her once more at around 4am when they came to take my blood pressure. Since I was awake, I took the two Vicodin tablets I could now have according to my "orders", and drifted back into pleasant, chemically-induced slumber. It was the last I saw of Violet......and the formerly, skeptical, self-righteous damaged diva.