Understanding pain in my patients

I've been through some painful things in my life (not some of the ones I've been told in medical school are the most painful -- childbirth, kidney stones, peritonitis, or bone cancer), but none-the-less painful.

Most recently, I herniated my L5 disc.  At least, the docs are fairly certain I did -- no MRI was done, but symptoms all pointed that way.  And between visits to the chiropractor, visits for OMM, and doses of Advil and Prednisone, I'm doing better.

But better doesn't mean pain-free, and anyone who's had a back injury knows that pretty much everything you do (from yawning and coughing to walking and sleeping) involves core muscles.  Which means everything you do involves pain.

I wear a pedometer, and lead a fairly active lifestyle.  Even with medical school studying, I manage to average well over 10,000 steps a day, and that's not including runs.  The first couple days of my injury (until I begged some family to come help me out), I basically laid in bed in excruciating pain, preferring dehydration and hunger over the possible need to get up and use the bathroom.  I averaged only 300 over those early days . . . and when you think about my bed being 50 steps from the bathroom, that's saying a lot.

I finally spent a half hour on the treadmill yesterday, just walking and testing out the waters.  Of course, by the time I was done, I was sore and tired, and not just from the back injury, but also from the disuse and stiffness my muscles had accumulated after a week flat on my back.

Even now, walking is 85% back to normal, and sitting is at least 50% there.

And I'm laying flat on my back as I type this.  Even though the pain isn't extreme, it's there.  It nags with every movement I make.  Every action requires a little extra preparation, a little extra thought and planning.  Instead of hopping out of bed in one smooth movement, I carefully execute three.  Standing for an hour has me exhausted.  Sitting for two hours had me wracked with pain.  Everything I do adds just a little pain, and takes just a little effort.  And it all adds up -- to pain, and to exhaustion, both mentally and physically.

I know that getting up and going for a walk will feel good, and that it's better for my body.  Half of me is antsy to be up and jogging again.  But the part that's winning as I type this is the part that knows that as long as I just lay here, I won't hurt for now.

There's immediate cessation of pain if I just lay here.  IMMEDIATE.  If I move, even though it'll pay off in the future, it'll mean I hurt today, add to the growing overwhelming exhaustion, and have to dive back in.

I think I might finally understand how patients with chronic pain syndromes feel.  

Studies have shown that exercise greatly improves health of those suffering from most chronic pain syndromes.  And in my mind, I always thought, "Well, if they KNOW it'll help them, and it's THAT bad usually, why not do it?  Wouldn't you give ANYTHING to feel better?"

Dear patients . . . I'm sorry.  I get it now.

In no way am I trying to say that what I'm going through is as debilitating as month after month or year after year of symptoms, but sometimes someone just has to make their own "ah ha" connections.  This is mine.

This is not a well-researched article on chronic pain, or a well thought-out position piece on treatment.  This is the largely unedited stream of consciousness from someone who's been subsisting on Advil, Flexeril, and Prednisone for a week, and got a quick and fleeting glimpse into the life of someone with chronic pain.

Apparently we're not going about "treating childhood obesity" the right way.

http://pediatrics.aappublications.org/content/early/2013/09/04/peds.2012-3940.full.pdf+html

Sad, sad.

Drunk Mom, Sick Girl -- Case Study

One night I worked a shift in our normal coverage area.  It was a Sunday night, so I didn't expect it to be too busy, and it wasn't.

Our only call for the night did leave me wanting to punch multiple people though.  We were dispatched to a home for a 14 yo girl who was dizzy.  And ambulance had been previously dispatched, but then canceled by police while still en route.  Our dispatch came about 1/2 hour later.

We were met at the door by a police officer who stepped outside to give us forewarning that "Mom is wasted."  Sure enough, inside the house I see another police officer trying to talk to the mother, who we'll call June (Leave it to Beaver irony, obviously) for our purposes here.  June is walking around the living room, obviously drunk.  Well, we can't say that.  We can say she was belligerent, combative, had an unsteady gait, was non-sensical, and smelled very strongly of EtOH.  Anyhow, the 14 year-old girl, who I'll call Cindy, was slouched on the sofa, while an 8-10 year old boy (henceforth known as Bobby) was standing in the living room, observing everything.

I let my male partner deal with PD and with June, and I bee-lined to the girl.  She's coherent, alert, and doesn't appear to be in immediate distress, but is complaining of dizziness, shakiness, her "head is spinning", and dry mouth.  She says it started a while ago, so she called 911, but then her mom made her cancel the ambulance.  But it came back so she called 911 again.  PD is telling my partner they don't want to do a breathalyzer on June because then they'll be forced to send her in to the ER with us for detox admission. 

So, I have a sick 14 year-old girl, whose only parent is wasted beyond belief, and a younger half-brother who can't take care of himself.  Can't leave the boy with mom.  Really shouldn't take the girl without a parent.  What's the solution?  Guess they're all coming with me.

I put the Cindy on the cot and buckle Bobby into the bench seat.  Normally I'd put him up front where there's a better seat belt, but he looks a little small  for the airbag, and anyhow, I want June up there so we can restrain her as much as necessary and keep her yelling drunken self away from Cindy.  Bobby isn't even phased by any of this.  He's not concerned about the slurred, drunken profanities being yelled by him mom in the front seat, nor being in an ambulance, nor the sight of his sick sister.

That, alone, terrifies me.

I start checking out Cindy.  She has no meds/history/allergies, and her chief complaint hasn't changed.  Her gait was steady on the way to the ambulance.  LMP was 2 weeks ago.  She ate dinner tonight, no caffeine or energy drinks today.  She's sinus tach at 140 or so on the monitor, 98% pulse ox, and her blood glucose is 136 mg/dl.  Respirations are 24-28, skin p/w/d, PERRL, motor intact.  But her blood pressure I get as about 165/90 in her left arm.  Uh, she's a normal-looking, average weight 14 year-old girl.  That blood pressure is through the roof, even if she's agitated/stressed/scared.  I had my partner double-check in the right arm, and he got 170/90.  Well, so something's not right.  Cindy gets an IV.

On our way into the hospital, June is alternating between sobbing about how she looks, being paranoid that she didn't lock the doors, freaking out about not knowing where her phone is, or screaming back to her daughter about how she knows she's not really sick and "don't need no ambulance."  At one point, she even grabbed my partner's arm and tried to turn the steering wheel to get him to pull a U-ee and go get her phone. 

You can imagine that went over well.

I also spent a few minutes on the phone with the boy's father, telling him which hospital we were all going to.  He was trying to get out of coming to pick the boy up, since he "doesn't get along well with [his] ex" when she's like this . . . well duh, no one does, and I imagine she's like this daily.  I informed him that his son needed his father to come and remove him from this situation, and that in my opinion, it would be in no one's best interest to do otherwise.

We had security meet us at the ER doors for mom.  And here's the kicker.  They did nothing.  Once they determined we didn't suspect direct child abuse in this case, they just put her drunken ass in a chair next to her daughter, and let the three of them sit in the hospital room together.  All the while she's still alternating between sobbing and telling her daughter she doesn't really need a hospital.

The girl is sick.  There's no normal reason for her BP to be that high.  She needs a loving caring mom, and if she can't have that, the LAST thing she needs is to be exposed to more of her mom's BS while she's in the ER. 

Here's what worries me:
1)  The son had no reaction to the trauma at all.  That means that not only is he exposed to it often, but that his coping mechanisms are in full-swing and he's in trouble one day.
2)  I hope the girl gets the treatment she needs.  I would put money on her having a serious illness, (before you say she's was stressed and anxious, that still shouldn't get her BP to 170/90), and I worry that she doesn't have family to help her get the treatment she needs.
3)  I doubt anyone called child protective services on the mom.  We reported it in our charts and incident reports, but the hospital seemed so non-concerned.  I hope they do more.

Here's hoping I helped a little.

But what's a drop of help in an ocean of insanity?

Some surprises I've been spared . . .

There are some surprises I've been spared in medical school.  And I'm grateful for that.

For example, one of my classmates spent this last Saturday morning at a clinic for the underserved population of our local downtown area.  Thing big city, little money.  Anyhow, her comment was how surprised she was about how many little kids were there, who obviously had no money, poor nutrition, and poor care in general.  I wasn't surprised at all.  I wasn't horrified.  This didn't phase me a bit.  And that's a bad thing.  When did I become so used to the scores of children transported from hell holes into a busy ER that I stopped understanding what it really meant?

But I know why I'm like this.  What if you walked into a trailer home on a freezing cold winter night and saw pizza boxes stacked 3 feet high by the front door?  The (very well fed) mother is taking care of twins, who are both about 2.  One has a seizure disorder.  Neither twin is clean, and the trailer is filthy.  The huge (I mean HUGE) television is hooked up to a Nintendo Wii (the mother states the state bought it for her as part of the seizure therapy for her daughter) and both kids seem sick.  Fever, flu, you name it -- and definitely nothing good for the one with the seizure disorder.  We recommended taking both kids to the ER -- mom was fine with that.  As a matter of fact, she was hoping we would, because she didn't have a car to take them herself, and didn't feel like calling a friend, so she just dialed 911 even though she knew it wasn't immediately life-threatening. Today, I'm okay with that.  As we try to load the kids into car seats (thank God she at least had those), we realize she has no socks for the kids.  It's about ten degrees outside and snowing, and no socks.  Then, we realize she has no blankets we can tuck around them either.  Then we start getting angry.  We run to the ambulance, grab a couple of our own blankets, and I make my partner ride in the back with them.  He's a good guy who watches his nephew as a son.  I know he'll be good with them.  And frankly, I can't look this lady in the face anymore.  You can buy pizza and televisions and gaming systems but no socks for your toddlers.

I guess that's when I stopped letting myself get really angry about the way kids are taken care of around here.  Hopefully one day I'll find a happy medium where I can feel the anger and not let it affect my professionalism.  It's just hard with kids.

Stumbled across this . . . .

http://www.ncbi.nlm.nih.gov/pubmed/16032608

Well-trained urban paramedics diagnose STEMI as accurately as physicians.


Which, of course, is refreshing to read after being exposed to the "memorize the what and forget the why" attitude exhibited by many paramedics  (http://slevit1.blogspot.com/2008/03/from-paramedic-to-doctor.html)

"Never forget the 343" (9/11)

As 9/11 rears its head tomorrow as the 11th anniversary, there will be a lot of talk about never forgetting the 343. 

Well, please allow me to alter that number:

343 members of the NYFD (341 FFs, 2 paramedics, and a chaplain)

23 members of the NYPD

37 law enforcement officers of the Port Authority

8 private service EMTs and Paramedics

55 military personnel serving at the Pentagon

And a poor bomb-sniffing dog named Sirius.

My point is, there were almost 3000 victims of the attacks, not to mention families and loved ones, and far more than 343 of them were serving in one form or another. Lots of people "ran in while others ran out", including civilians.  When we think about the men and women whose lives have been lost in the war (ostensibly) begun by the attack, the number jumps even higher.  

So honor the 343, but when you say "never forget", please never forget the others, either.

And to all of you who serve in any way, or who hold someone who serves dear, thank you.

Edit:  Emergency medical service personnel who are non-fire-based often feel like the red-headed stepchildren of emergency services.  We/they are often ignored, ridiculed, criticized, or forgotten all together.  Yet their ranks include some of the brightest and best out there.  I'm sure this applies to law enforcement officers of non-city departments, as well (such as the port authority).  Regardless, I wouldn't want someone forgetting my colleague who died trying to save a life simply because he wasn't on NYFD, let alone if that person were family.  

Spin and media coverage does not a hero make.

Misconceptions and Surprises

There are some drawbacks to being a "nontraditional" medical student.  It's a different perspective, and it's still surprising how different it is from expectations.

I knew medical school would be hard.  Really, I believed them when they told me. 

(Okay, if we're being completely honest, I did think all of my years as a medic would make it alittle easier.  A smidgen.  At least.)

I knew I'd have to sacrifice stuff and I figured it was good I was single.

What I didn't realize is how much I'd be sacrificing.  As I sit in a quiet study room and fall peeks its gorgeous head into the world, I'm yearning to be outside in nature, hiking, biking . . . doing anything, really.  But I have a test tomorrow.  So I won't be making money and bringing home a paycheck (I miss those).  Or hiking or biking today (Sigh).  Or doing anything else I got used to doing.  Manymost of my classmates have been in school non-stop since they were 5.  They don't really know anything else other than a life that revolves around school and studying.  They don't know what they're missing.  Or maybe they're not missing it because their lives haven't grown yet to be non-academically focused.  

But I know.  And I miss it.

The other misconception I had was how much drive I would have to learn the non-clinical material.  The first two terms of class work are strictly basic sciences.  My particular college has opted for an integrative approach, where classes feed off each other and clinical correlates are presented as often as possible, but at the end of the day, biochemistry is still biochemistry, and microbiology is still microbiology.  And I still have to engage in rote memorization of concepts I'll not be asked to recall past the next exam.  The futility of that leaches me of my drive to study.  Put anything clinical into the picture, and my interest is piqued. 

I suppose that's another drawback to the been-there-done-that life of a critical care paramedic.  The hands-on skills and the basic clinical knowledge is old hat to me.  And outside of surgery and some smaller procedures (arterial line placement, chest tube placement, etc.), there aren't that many physical skills I haven't done yet.

One last thing that I wasn't expecting:  how much of a workout my brain is getting.  I literally feel physically exhausted at the end of a long day studying.  We're all smart people -- we couldn't have made it this far otherwise -- but for many of us, this is the first time in our lives serious studying has been required.

Serious studying.

I still love medical school.  And I still hate rote memorization