Thursday, November 11, 2010

Faking it...

Honestly, if you're going to insult my intelligence by lying so blatantly to me, the worst you can do with your sob story is gin up some real tears. A two-year old can come up with better crocodile tears than you.

Last night proved a classic example of pain. I read a book once, You're Never the Same Once the Air Hits Your Brain, written by a neurosurgeon (sorry, can't remember the author's name) where the good doctor, as a young medical student/intern, learned the difference between real pain and 'fake' pain. Note: when I say 'fake' pain, I don't necessarily mean that the patient is faking being in pain. They may very well be in pain, and usually are in some discomfort, and therefore, must be treated as such (never tell anyone they aren't in pain. No one feels pain the same, and what may be a 10/10 to one patient could be a 4/10 to another). But 'real' pain vs 'fake' pain patients will differentiate themselves.

Patient one called for abdominal pain, due to gallstones. A previous attack had shown what the pain was, and, though surgery was scheduled, another attack came on. The patient complained of pain at a 10/10, and could not find a comfortable position. The entire 25 ride to the hospital was spent with the patient moving around constantly on the captain's chair (no stretcher by patient's request, as it would restrict movement too much), stretching, breathing, sighing, and doing everything to not cry. The patient couldn't describe the pain very well, only that it 'hurt badly' and was so distracted by the pain that she couldn't even remember her age, could barely walk, and just could not find a comfortable position. When asking the patient questions, we had to frequently remind her of the question we asked, or ask several times, as she was so distracted by the pain that she would forget within seconds of what we asked.

Patient two actually called for chest pain, but arrival on scene showed it was a frequent flyer patient with a history of back problems and general muscle pain and spasms. Frequent flyer-ism is not unusual with chronic pain patients, as they call when something happens to disrupt their homeostasis; they run out of meds, have a particularly bad day (weather can do this), or overstretch themselves, and need more relief than they can get from their home meds. This patient had a history of spinal issues after a recent (within the last year) car accident. This car accident was reported to be the patient's fault but the patient was currently suing everyone involved, from the other driver to the police and EMS departments for poor handling of the case. A laundry list of medical history accompanied her. The entire call consisted of much screaming and yelling, and then crying as she related her story, complete with embellishments I'm not sure are ever possible. Her story was related with a lot of detail, including dates and names of those involved. By asking our own questions, we were easily able to distract the patient from her pain complaints, and when we asked about pain in general, we got an answer of 'It's the same.' However, if we immediately asked about a specific body part ('What about your big toe?), the answer was a scream or wail of how it hurt so badly.

Do I doubt either patient was in pain? No. Again, pain is extremely subjective, and who are we to say that a patient has pain or not? Chronic pain patients often have high pain tolerances, and acute exacerbations of their pain are often accepted with resignation and familiarity, and they tend to not trend towards the dramatic side of the scale. Patient in 'real' pain are often unable to describe the pain unless prompted with suggestions, because all they know is that 'it hurts.' Patients in 'fake' pain often use colorful imagery, such as ' it's sharp, like miniature elves are running up and down my legs, stabbing me with red hot pokers.'

Again, this is all very subjective, and I tend towards the treatment rather than not. Patients in pain are in pain, and whether they are trying to sucker you for drugs or for insurance-itis or they are totally and completely really in pain, they all should be treated the same. Keep a high index of suspicion, but don't discriminate.

Another note: I have minor chronic pain. Severe carpal tunnel in both hands, constant shoulder pain that has only been partially relieved by rotator cuff surgery, and lower back pain are my friends. I am no where near some of these patients level of pain, but I also have a high pain tolerance (my rotator cuff was torn for over a year before it was repaired, and that was a year of push-ups and weight lifting and firefighting). So, I'm just saying I have a very slight view of what some patients go through.

1 comment:

Anonymous said...

I wish some of the other medics I work with would remember this.