Katz J: Perioperative predictors of long-term pain following surgery. In Jensen T, Turner J, Wiesenfeld-Hallin, Z, editors: Proceedings of the 8th World Congress on Pain, vol 8, Seattle, 1997, IASP Press.
From AAFP, an excellent educated layman’s summary includes this:
Other studies have tended to show that adequate anesthesia during acute pain prevents the remodeling of pain neurons into fibers which are primed to carry chronic pain messages.
Don’t you think that’s a decision the patient should be allowed to make while in possession of all the facts, rather than being deceived by his or her doctor?
I absolutely would have. I had four cracked teeth, one so completely broken that it’s filling had fallen out and become infected, to be beaten back by antibiotics before the procedure could be done. Leaving it untreated exposed me to eventual severe pain, loss of all molars on the left side, and/or a jaw abcess. Not pretty. I had every reason to want it done ASAP.
Besides, I abhor lying to people for their own good. If people are don’t get needed medical procedures done because they fear the potential pain, that’s their decision, as it should be. I’m far more afraid of the unknown. If they’d said I’d need a week off, I’d have been prepared, gotten my desk clear, laid in supplies, arranged friends to check in on me. If I was better earlier, great-- I like my job and know I’m needed, so I’d have gone back as soon as I felt able. I shouldn’t be punished because some other people exagerate, malinger, or use their doctor as an excuse to shirk their responisibility. I don’t.
I visited the ER last month for a broken rib. The pain was an order of magnitude greater than anything I’d ever experienced. It felt like somobody had driven five or six railroad spikes into my chest. I couldn’t move – I couldn’t even breath – without getting light-headed from the pain.
The doctor asked me to report my pain level on a scale of 1 to 10, and after some consideration, I picked 7. My reasoning being that, while my pain was intense, it probably wasn’t as bad as being gut-shot with a 12-gauge or having my limbs chewed off by a conveyor belt. The doc wrote me a prescription and I thought, “Wonderful! An end to my suffering at last!”
It turned out to be Ibuprofen.
Apparently, there really isn’t much you can do for a broken rib in most cases except get some rest and wait for it to heal. After a few days of being bedridden and suffering the agony of the damned (which kept me from moving, eating, or taking deep breaths) my dad was able to dig up some leftover vicodin from dental work he’d had the previous year (yeah, it’s illegal to take somebody else’s medication. Sue me).
It was a Godsend – the pain was diminished to an acceptable level, and I was able to sleep soundly for the first time in days. Of course the vicodin ran out after a day or two and I was back to square one, but I got a good idea of the kind of pain relief that should have been offered to me by the ER doctor.
The moral: the next time I’m severely injured, I might as well stay home.
Exactly. And even worse, what evidence do doctors like Doctor J have for their assumption that everyone is exaggerating and therefore treating people like you as if you are? None. That’s my point above. Because some small number of people don’t act responsibly, some doctors treat us all as if we are irresponsible.
I advocate for my husband and he advocates for me - he feels every last little thing and I often end up bleeding without noticing.
A common refrain in my house is, “Where’d ya get that big purple bruise on your leg?”
“I don’t know, it wasn’t there yesterday”
He has the added disadvantage that novacaine doesn’t last more than 5 minutes before wearing off. Good thing he’s tough AND the dentist has marks all over his chart.
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He was right there when I had a kidney stone - 'She’s usually really stoic, I can tell this is really hurting her bad. I’ve never seen her like this."
And I was right there when he had a twisted ankle - “He’s in a lot of pain and having trouble sleeping. We’ve exhausted the options I can think of, is there anything else to do before resorting to other pain medications?”
It does drive me nuts that it’s subjective. After a bad car accident, we saw different docs. I got opiates and an anti-inflamatory and a muscle relaxant. He got a muscle relaxant and advised to take advil. To make a long story short - he had fractured two vertebra and had a concussion while I merely had a concussion. He really was much more seriously injured, but didn’t get the same care I did.
I deal with women in labor frequently. They are all planning a natural childbirth. I’m very interested in this topic, because I see a lot of suffering.
I thought the whole 1 - 10 pain scale thing was for determining if a patients pain has increased or decreased.
I went to the ER in pain, I called it a 6. They got me in a room and found a huge gallstone blocking a duct at the exit of my gallbladder. Within 10 minutes they got an IV started and medicated me to La La Land. They then asked me my pain level on a scale of 1-10 and I said 0 and giggled. I wasn’t a druggie, they saw a real medical problem. I assumed at this point, the hospital staff knew that when I said, “6” it meant lots of pain.
It makes me angry to know someone had broken ribs and a doctor sent them home with lame medication, knowing full well that broken ribs are painful.
And I want to add about the LASIK procedure. I had it done Tuesday and it was horrific and painful for 15 minutes. Kinda like a little slice of hell. The next 2 hours were bad, eyes burned and I couldn’t open them or see. I took my 4 hour nap as instructed and then I was fine. I’ve been pain free since the nap. Being able to see is worth the quick trip through hell.
Depends on the procedure, of course - and the person’s tolerance for pain. I had excisional surgery (local anesthetic only) on a couple moles (i.e., removing the mole and a decent margin around it by cutting out that area of skin, then sewing you up) that left me with two 2" stitched-up incisions, then got up off the table, put my clothes on, and went to work for 8 hours. The doc joked with me on the way out - I had it done at the medical center I work at - saying, “Dr. [hospital head] wants you to get back to work!”
Anyone giving the 1-10 pain scale should also be handing over a piece of paper with descriptions of how bad those pain levels are. I get frequent migraines so my pain scale has been revised downwards from before I got them - it’s amazing how much pain you can be in and still function. I’d have to be screaming in agony and unable to respond to the question to rate anything a “10.”
Ok - I just think many people wouldn’t, or would decide to wait until the condition was much worse.
Obviously “some discomfort” was a huge understatement. Perhaps he meant “Some discomfort compared to having your arms ripped off by a pack of wild dogs.” I also, think he should have said something closer to “You may have little discomfort, but you may need to take extra time off work depending on how you react to the procedure - if you have an important meeting the next day, you should reschedule it.”
Now, if you couldn’t reschedule your work committment, and from the sounds of it, you couldn’t reschedule your tooth appointment, maybe he was hoping if he said it would be ok, you’d be convinced it would be ok, and it would be ok.
It sounds like you may have put the guy in a bind - “I have to get this procedure done today, but I can’t miss work tomorrow - that’s going to be OK, right?” He probably should have said no, but maybe he felt backed into a corner. Dentists and doctors are, after all, just people too.
That reminds me of something I overheard when I dragged my husband into the ER for pancreatitis a couple years ago. The man in the next bed over had, apparently, sliced the hell out of his hand (as in, after he left someone had to come in and mop the blood off the floor, bed, walls, etc.) Apparently, from what I overhead, he had sliced skin, muscle, tendon, nerve… Mr. Sliced Hand was going “But I GOTTA go to work tomorrow, doc - if you do the surgery tonight I can go to work tomorrow, right?”
The doc said, just once, very serious: “Look, we have just one chance to repair this - IF we can. If we can’t, you will have to learn to beat off and wipe your ass with your other hand. Do you understand? You are not going to work tomorrow. You are not going to work for the rest of week. If you do so, you risk permanent disability and losing all use of your hand. Is that clear?”
Sometimes, you have to be up front with people, even if they DON’T want to hear it. Part of being a doctor (nurse, dentist, etc.) involves delivering bad news people don’t want to hear.
But yeah, there are problems with communications regarding pain, patients, and medical professionals. Sometimes you have to communicate both ways.
Like, for instance, I’ve been know to break bones (specifically, ribs) and sprain a knee and get up the next day and go to school. I never needed more than asprin/Tylenol for those injuries. That’s me. It’s also those particular injuries - if I broke a different bone I might have felt differently. On the other hand, I have very sensitive teeth/gums (or did for awhile) and at one point required codeine for routine dental procedures until the problem I was having was fixed. Again, that’s me. For some reason I can tolerate pain in my legs better than pain in my teeth, and I communicate this and plan accordingly.
Having someone else advocate for you is important, too - doctors who dismiss me as a whining, hysterical female might listen to my husband when he describes my normal stoicism in the face of injury.
I also think there is a VAST difference between doctors who have experienced severe pain themselves and those who have never experieced more than “mild discomfort”. Or, as my sister, a mother of two who is currently in medical school, once told a couple of her classmates: “That woman is NOT “drug-seeking” - squeezing a kid out of your croth HURTS!”
I wasn’t trying to be harsh when I suiggested I wouldn’t have a medical procedure done before an important day. Obviously, the dentist mislead in the OP. But our resident surgeon did mention a recent story about an elecdtive procedure causing bruising just before a wedding.
Don’t be too harsh on DoctorJ. The sad truth is most of the patient’s who report 10-12/10 pain are sitting on their bed in no apparent distress – and are clearly exaggerating their pain. I can’t tell how much pain someone is in, but if they can fall asleep comfortably, I would not personally consider this 10/10 pain. That said, I think pain scales are crap, and use them only to gauge improvement in pain that I have treated with narcotics and (seemingly) appropriate meds. In this regard, I only consider improvements of 50% or more (8/10 to 4/10) valid. I make no difference between 6/10 pain or 8/10 pain and consider the pain score to be fairly useless as a clinical tool.
I recommend the definitive work on Pain by Melzack. I have a copy. This book contains everything you’d want to know by the guy who did much of the research.
I wouldn’t claim it was 10/10 pain, but I didn’t go to sleep about ten minutes after my cat Tuffy stuck his claw into my eyeball. Slept through the night, too. The ER doctors the next morning were a little startled.
If a patient is going to be in pain after a procedure, he/she should know it in advance. If you’re told there “might be some slight discomfort”, and you wake up screaming and clawing the walls/your head/your incision/whatever, not only are you in pain, but you are scared - OMG, he said slight discomfort and I’m dying - something must have gone wrong. Tell people honestly what to expect and you remove to “fear” angle from it.
Exactly. When you are experiencing unexpected pain, you panic. You’re sure something is seriously wrong, but when you call the doctor you get, “Oh, that’s normal.”
The thing is, I COULD have rescheduled my work commitment-- if I was told ahead of time. I’m addled and doped up so I don’t seem to be phrasing it properly. The time to know I couldn’t work was Monday morning (or earlier, when I scheduled the appointment), not Tuesday morning when the reality of my pain set in. Maybe I didn’t say it right to the dentist, I don’t know. I think it was all a big misunderstanding in the end. I presented myself to the office today, because my pain was actually gertting worse, saw the dentist and lo and behold. . . I’ve developed dry socket. They cleaned the impacted food & other crap out, packed it with medicine, and I feel like a new woman.
Still would have liked warning about how bad Tuesday & Wednesday were going to be.
Obsidian - It seems like your pain was probably worse than normal for this procedure, though. You yourself said, “it’s just a bad reaction to the procedure and anethesia”, although it turned out to be dry socket as well. So for a normal procedure, most people probably wouldn’t experience the level of pain/the absence from work which you have. The dentist, basing his level of expected pain on normal recoveries, was probably correct. Unfortunately, you had a worse than normal recovery.
It seems to me that if the medical profession is going to use a 1-10 pain scale, they ought to tell people what the different numbers mean. Just as the children’s chart has illustrations, the adult chart should say “1 - mild discomfort; 3 - constant awareness of pain; 7 - acute pain which interferes with normal daily functioning; 10 - severe, constant pain which causes sweating, nausea or fainting.” That way people know when they give a number that everyone is on the same page. And quite frankly - someone in a 9-10 pain range should seem to be obviously in pain. Not sitting chatting with their spouse, doing crosswords or playing solitaire. It’s important that as little subjectivity be in the equations, I think.
It’s not terribly useful on other side of the desk either, Dr. P. As a 35 year migraineur I got tired of trying to calibrate my pain, so I streamlined the goddamned pain scale to this:
0 - no pain
1 - migraine, can function
2 - migraine, can’t function
That is as specific as I’m ever going to be. I think the 1-10 scale is far too imprecise, subjective and sometimes even contentious. In fact, worrying about whether a headache is a 4 or a 4.5 generally turns it into a 6.
I have to chime with those who have complained of the difficulties that people in chronic pain have with getting appropriate meds, because of people who exaggerate how much pain they’re in or lie to get more medicine. I have a relatively painful chronic condition – not ripping-down-the-wallpaper-whilst-spazzing-out bad, but pretty damn uncomfortable at times, to the point of making it hard to concentrate at work or on necessary household tasks. I also suffer from fairly frequent pain in my knees and my lower back, and I get really annoying, painful period cramps that, again, make it hard to concentrate on daily tasks. However, despite their annoying qualities, all these pain conditions could probably be alleviated, or at least significantly helped, by some ibuprofen.
The only problem is that the underlying chronic medical condition I have prevents me from taking ibuprofen, or aspirin, or Aleve. The only over the counter pain med I can take is Tylenol and, at least for me, Tylenol sucks at giving any pain relief. So, I’m stuck in this really crap situation of being afraid to ask my doctor what to do about this problem, because it really looks like a bad, drug-seeking type thing – “She’s asking for prescription pain meds for a little arthritis in her knee? What a faker! She must be intending to sell the pills down at the corner! Let’s arrest her in advance!” – when I’m the farthest thing in this world from a drug seeker. I hate taking medicine, and I have to take at least 26 pills a day of various shapes and sizes, and get occasional IV infusions of medicine, on top of that. I would infinitely rather that I would just feel good again, and never have to take another pill in my whole life. sigh It sucks.
But, more topical to the OP, I feel for doctors who are trying to determine how much pain someone is really in, because it is so subjective, and so variable even in the same person, even for similar injuries/procedures.
When I got my wisdom teeth out, they did them two at a time, a week apart. The removal of the first two put me into a miserable, painful, swollen funk for three days, where I had to make full use of my tylenol with codeine prescription and sit around with an icepack (consisting of a bag of frozen peas) on my face for most of the day, while eating pudding and mashed potatoes and sucking down milkshakes. The day they did the second procedure, I went shopping at the mall and ate pizza within five hours after I got out of the dentist’s chair.
Still, I always appreciate when a doctor or nurse is honest with me and, even more importantly, that they acknowledge that pain that isn’t excruciating is still significant, especially in children who have little experience of pain. I used to hate, hate, HATE it when I went to the doctor when I was little and they would sneer and jeer at me because I didn’t like getting my finger poked for the little blood tests they wanted to do. Because they treated me like I was a big weepy baby even when I tried my best to be stoic in the face of what, to a 6 year old, was pretty darn painful stuff, I got a real complex about it and started to really dread and fear it, to the point that I would scream and yell and fight back against them when they tried to do the finger stick. I think that if they had said, “It’s going to hurt, we’re sorry, but it’ll be over in just a second if you just hold still,” to begin with, instead of acting like I was the world’s biggest weenie because I didn’t like it, I would never have gotten to the point where it was a huge ordeal that made me freak out every time.
When my sister was little, she had a cavity in one of her baby teeth. The dentist took this disregarding of a child’s pain to an extreme and drilled without any anesthetic use, saying, “It’s only a baby tooth” as if that means there’s no pain. We didn’t find that out until afterwards, and didn’t go back to him again.
