Don't Ask, Don't Tell
Don't Ask, Don't Tell?
How do you handle pain?.. Your own?... Someone else's?...
How do you respond when you are lying on an examining table, and your doctor says, "This is going to hurt"? When you are a treating a patient who tells you, "I was in a lot of pain after our last session"?
When I entered occupational therapy school I was oblivious to the fact that I was preparing for a career that might call upon me to cause people physical pain for the sake of their eventual healing. This pain factor within our profession was never part of a lecture or class discussion but was occasionally present "between the lines."
I remember my pediatrics professor telling us about a child with serious burns who wanted a hug at the end of her OT sessions; my professor was pleased when she came up with a way she could do this without causing the child more pain. And I'll never forget the patient with rheumatoid arthritis whom I treated as a fieldwork student; while using some kind of metal instrument to get a joint measurement, I managed to squeeze his inflamed joint instead. Apologizing to him did not alleviate my guilt!
Working in mental health--and beginning next month, school-based practice--I have avoided "pain-filled" settings such as acute rehab and hand therapy, but I have frequently wondered how my colleagues in those positions cope. How do they strike that balance between compassion and detachment? How do they differentiate, and help their clients differentiate, between "normal," to be expected pain, and pain that indicates some aspect of treatment has gone wrong? And how do they approach the subject of pain with their clients?
In my own experience, many health care professionals avoid the topic, with the attitude, "Don't ask, don't tell."
Several years ago I experienced a non-routine gynecological procedure. As the doctor began, I was lying on the examining table, listening to music on my CD player, and feeling very relaxed. Suddenly I experienced painful contractions. They caught me by surprise--the doctor hadn't prepared me--and I started yelling. The unexpected pain frightened me; I began to panic, thinking it was a sign something was wrong. I started to sit up, and the nurse sternly told me to lie back down. I tried focusing on my breathing but started to hyperventilate, and the nurse chastised me for getting so worked up. As the contractions continued, I yelled some more. Fortunately, the test didn't last long.
I felt shaky as I got dressed. I told the nurse I had cramps; she didn't respond. I asked her for some water, and she directed me to the water fountain down the hall; I had to ask for a cup and get the water myself. When the doctor came in I asked her if the procedure was typically painful; she said no, and that no other patient had reacted the way I had. I would have felt better if someone had at least acknowledged, "That was rough for you." Instead I felt like I had lost my dignity.
I was puzzled by my doctor's apparent lack of understanding that a procedure that caused contractions and cramping might be "uncomfortable" at the least. It was clear to me that just because other patients hadn't yelled or complained didn't mean no one else had found the same procedure painful. It was even more obvious that neither the doctors nor the nurses wanted to deal with my pain.
"Don't ask, don't tell," says the health care practitioner to the patient. "Don't ask me if this is going to hurt, and don't tell me if it does."
And when the patient doesn't ask, and doesn't tell, s/he lets the professional off the hook.
I began imagining how things could be different.
What if, at the beginning of their relationship with new patients, health care practitioners could comfortably and confidently raise the topic of pain? Get the patient's self- assessment of their pain tolerance and their level of anxiety about being there? Find out from the patient how much s/he would like to be told in the event an exam or procedure would (or might) be painful? Assure the patient that s/he need not be stoical? Encourage the use of specific strategies to help the patient cope with the pain?
Patients would always have the option of saying, "Don't tell me if it's going to hurt; just do what you need to do."
But what if those of us who wanted to be pro-active could be given sufficient information so that we would understand what the practitioner was going to do and why, feel reassured that s/he was sensitive to our pain, and be prepared to do what we could to make things easier on ourselves?
Don't ask, don't tell?
As allied medical professionals, how do we handle pain?
Please Comment!
MS pain differs from the kind of pain you might get with a headache, a joint injury, or muscle strain. It's more diffuse, affecting several areas of the body at a time. It often changes over time, getting worse or better for no apparent reason and it tends to fluctuate a lot. People often find it hard to describe: It's sometimes described as like a toothache, other times like a burning pain, and sometimes as a very intense sensation of pressure. It's very distressing for patients because they have a hard time explaining what their pain experience is.
You can confront these people with the facts – that their pain is just an illusion created by the nervous system, that the nervous system sends pain signals as a warning phenomenon when something harmful happens to the body. In MS, the nerves are too active and they send pain signals with no good reason – they're firing a pain message when they shouldn't be. I can't disregard their pain though and all the facts in the world won't diminish what they're feeling.
I medicate and I sympathize, and more often than not, I think the sympathy does more good. Knowing that others with their condition felt excruciating pain or chronic pain forces an odd sort of acceptance on the patient: they're not alone. They're not the only one with this painful burden. And somehow there is comfort in that.
Let me know your thoughts too,
nursekara81@hushmail.com
The "don't ask" mentality is fostered when we don't think there is anything we can do when someone is suffering; so we want to be able to plead ignorance. But the truth is we can always throw out a lifeline and say, "Tell me what that is like for you." And so often, patients will open up to us much more than they would to relatives and friends, because they want
to spare those closest to them.
And, yes, the psychic pain of feeling alone-- of feeling like we are the "only
one," and that no one else understands-- can be even worse than physical pain.lse
I have to agree with you that many patients have just so much pent up pain; pent up because they don't want to share that burden with family members, who will only become distressed and upset, and in the long run can do nothing at all. I've used music for those with severe arthritis and found that it provides an opportunity for pain relief, anxiety and stress reduction as well as positive changes in both mood and emotional state. Sometimes, to watch it happening is like uncorking a champagne bottle, you watch the pressure build and build, watch their faces tense and contort until they just just let go and all the emotion comes gushing out: anger, happiness, relief. It's actually quite beautiful to be able to give that to these patients.