An Insider’s Perspective on Pain

 

 
 
 

A.J. Heightman, MPA, EMT-P | From the March 2014 Issue | Thursday, March 13, 2014


All pain is not created equal. It’s important providers have the capability to not just triage pain like they triage severity of conditions at a mass casualty incident, but also understand the causes, location and effect of pain on the patient.

It’s most important that we sympathize with the patient experiencing pain and do all we can to make them comfortable. Sometime, this pain can be invisible to your eyes and mind.

There’s what I call “visible and audible pain,” such as when a person receives second-degree burns, or a motorcyclist rolls down the highway and sustains a fractured pelvis and significant road rash. These patients are usually howling in pain and don’t stop until you relieve them with cold water, ice packs, splinting or medications. Their pain is usually seen and heard throughout your time with them.

Then there’s “visible pain,” such as when a person has a myocardial infarction (MI), a severely angulated knee dislocation or a fractured tibia/fibula. When you see an MI or ectopy on the monitor, you can usually correlate it to the patient’s description of “crushing chest pain” and the twisted look of pain on their face.

But, the most complex pain is what I term “invisible pain,” and these patients need just as much attention (and understanding) from you. This is pain the patient describes or complains about that you can’t find a cause for, or when you don’t appreciate or understand their malady or causative condition.

I’ve lived through a few of these instances.

First, I’ve been the unlucky host for kidney stones several times in my life. These tiny (sesame seed-sized) calcium obstructions resemble Kryptonite from the Superman series. These glass-like shards, fused together into a tiny, circular mass, get lodged in your ureter, the narrow tube that drains your kidneys into your bladder.

When a kidney stone gets lodged, you feel pain in your back like someone is sticking a knife in you. Some describe kidney stone pain as being similar to what a mother feels during child delivery. All I can tell you is, when I experienced it, the pain and pressure were so intense I could’ve put my head through a wall.

As a paramedic, I was always taught to titrate and administer 10 mg of morphine slowly. But when I had kidney stones, the ED staff hit me with much more than 10 mg (un-titrated) before I felt pain relief. That’s important to remember because, just as all pain isn’t equal, pain medication dosages and delivery aren’t always equal. Often, the more pain the person has, the more pain medication (or dosage) is necessary to abate it.

The second pain experience I had that made me more sympathetic came from a seemingly minor back injury that occurred after my car was rear-ended.

Several days after the incident, although sore, I was on a cross-country flight to a conference when swelling near the affected vertebra caused pressure on the nerve endings and every movement of my torso put me in agony. I flew for two hours with my curled fist and thumb pressing on the site of the pain to get relief.

In Orlando, Fla., an EMS medical director was able to examine me and prescribe muscle relaxers and Vicodin (an oral narcotic pain medication) so I could survive the five-day event.

However, I didn’t just suffer the physical pain, cold sweats and incapacitating effects of that seemingly minor compressed and swollen nerve. I also suffered the psychological pain of friends, co-workers and family members who couldn’t understand why I was complaining, unable to walk through special events at Disney World, or even unable to walk a short distance to
a restaurant.

Believe me (and your patients): When you have a back injury, it’s as painful as if you were mauled by a hungry, enraged bear.

My most recent pain encounter came suddenly and with little warning. It started as a small annoying patch of skin on my abdomen that was sensitive to the touch. But, by the time I called my doctor to get an appointment, a rash had appeared and the area felt like a crazed acupuncturist had left 1,000 burning needles in me.

It was shingles, a viral infection of the nerves and skin that impacts one-third of the population. I had never had it, nor had I ever treated a patient who had it.

Although shingles can occur anywhere on your body, it most often appears as a band of blisters that wraps around either the left or the right side of your torso. Some people get shingles on their arms, legs, and even their face and eyes.

Shingles is caused by the varicella-zoster virus—the same virus that causes chickenpox. After you’ve had chickenpox, the virus remains inactive in nerve tissue near your spinal cord and brain. Years later, it can reactivate as shingles.1 While it isn’t a life-threatening condition, shingles will normally last from 2–4 weeks and the pain in the affected areas tends to be continuous.2 When I had it, simply brushing against my bed sheet felt like course sandpaper was being scraped over me.

There’s not much you can do for the shingles patient other than understand their condition and pain.

Understanding Pain
As an EMS provider, it’s important to realize the human body has 45 miles of nerves and millions of single-cell neurons. Pain messages are forwarded along the nerves as electrical impulses, traveling at a speed of 248 miles per hour.

There are more than 200 named nerves accepted by the medical community. However, biologists point out there are still many unnamed nerves, such as those that run to small sensors in the skin or the periosteum, and many that are heavily repeated (the intercostal nerve for example).

It’s estimated there are as many as 100 billion neurons in the human brain alone. And there are more neurons in the human body than any other cell type.

Outside the central nervous system there are large collections of individual cells that all follow the same or similar anatomic route through the body (within a single outer connective tissue pipe or sheath), like the sciatic and radial nerve.

There may be just one nerve going to a given muscle, but this will contain perhaps a thousand neurons, each branching at its end to supply thousands of muscle cells with their individual signals.

There’s also a high level of personal differences in the actual neuronal anatomy of the content of named nerves, so one person’s sciatic nerve won’t have exactly the same number of neurons as the next. Neurons that commonly exist at one particular level in the spine may also exist at another level in some people.

It’s said there are enough neurons in the human body that if all other cells were removed, you could still easily recognize someone.

To show this to you, I included an illustration from one of my favorite books, Human Anatomy: A Visual History from the Renaissance to the Digital Age.3 This illustration and countless others were created from 1782 to 1871 (long before the digital age), from an infrastructure of anatomists, artists, lithographers, printers and publishers in France, who dissected cadavers for accuracy of education.

Conclusion
Accept the fact that your patients do have “a lot of nerve(s)” and be understanding (and treat) any complaint of pain presented to you. More specifically, be sympathetic to the complaints of your patients, particularly those who are older and have experienced the full variety of pain in their life. Remember that, as a young EMS provider, you may not have experienced the pain that results from a severe burn, heart attack, kidney stone or shingles, but odds are that you or a family member will in your lifetime. jems

References
1. What is shingles? (Feb 21, 2013.) In Medical News Today. Retrieved Jan. 25, 2014, from www.medicalnewstoday.com/articles/154912.php.

2. Mayo Clinic Staff. (Sept. 1, 2011.) Singles. Retrieved Jan 25, 2014, from www.mayoclinic.org/diseases-conditions/shingles/basics/definition/con-20....

3. Rifkin B, Ackerman M, Folkenberg J. Human anatomy: A visual history from the Renaissance to the Digital Age. Abrams Books: New York, p. 274, 2006.

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Related Topics: Administration and Leadership, Leadership and Professionalism, swelling, shingles, pain management, pain, neurons, nerves, kidney stones, invisible, back problems, Jems From the Editor

 
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A.J. Heightman, MPA, EMT-P

JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.

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