Thursday, May 24, 2007

painful for everyone

I don't think I'll be stepping on too many toes (except perhaps my own) by telling you that I don't really like being on the Pain Service. I just don't. It's probably a temperament thing--doctors choose to go into the field of anesthesia for certain structural constructs of the specialty (hands-on, real-time medicine, no overhead, limited need for bedside manner after the first 20 minutes), and many of these constructs are not present when it comes the the subspecialty of pain management.

There's all the ambiguity of it, first of all, not really being sure of the cause and effect of things or if and why certain treatments will work. Secondly, there's all the talking. THE TALKING. Now, hey, you know I used to be in Pediatrics, I can summon up the touchy-feely when need be, and I'm reasonably good at active listening, taking a good history, conveying warmth, that kind of thing. But pain patients, oh lord, the pain patients! They are a challenge. In the OR, when patients get too chatty and disruptive, I just smile and pat them on the arm while turning up the propofol drip, returning them to their happy dream of Brad Pitt in a pile of bunnies. When a pain patient starts off on a tirade about how he's going to sue this guy and sue that guy and hey, WHAT ARE YOU LOOKING AT, MAYBE I'M GOING TO SUE YOU TOO, AND WHERE THE HELL IS MY MORPHINE? there's nothing I can really do except pretend that I got paged and back away towards the door.

(I don't really do that, by the way. I did that once to leave Grand Rounds early, though. Don't tell.)

I know this means I'm being insensitive and all that, and I know that chronic pain is a real problem, and that these patients are used to being told that the pain isn't real, that they're faking it, that they're drug addicts, that they're nuts. I try very hard not to think these things. And hey, I believe that they have pain. Pain is all perception, so I have to take what they say at face value. But the intrinsic subjectivity of it all is what drives me nuts. Having a patient telling me they have 10 out of 10 pain ("zero is no pain, ten is the worse pain you can imagine") while they're sitting in bed smiling, eating a bag of chips watching "American Idol" does not compute in my mind. I think to myself, if my pain were a ten, I'd be rolling around on the ground screaming and praying for the sweet release of death. And also, I would be ON FIRE. It drives me nuts, the variability of it all and the inability to translate person to person.

The Pain rotation is a nice break, and it's fun to be out of the ORs for once, and wear nice clothes and cute shoes and make rounds just like all the other fancy doctors. But sometimes I just want to go back to the OR, where there are numbers that mean things and that I can compute and convert and understand and treat. Give six units of platelets. Give 20mg of Lasix. Transduce the CVP. Figure out what to do and watch it work and know why. Trying to sort out all the other stuff is just too hard for me. I'm glad there are people who can do it better than I.

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