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78 Reflections on ED analgesia
of us has never experienced this when under the stimulation of competition,
fear, or simple distraction? This is hardly a useful trait for longevity, especially
when we observe it in elderly patients who may never perceive any discomfort
with the acute onset of very serious disease (e.g. cholecystitis, acute
myocardial infarction). Why is it that so many life-threatening diseases
produce little discomfort, while trivial problems often seem to incapacitate
the patient?
Pain is a cultural phenomenon as well as a physical one. Certain kinds of
patient obtain more attention from their relatives or immediate companions
and friends, and seem always to overreact to pain. Other patients seem to
think it wrong to express discomfort and often hide the symptoms that would
help in their evaluation. They often fail to request pain relief even when it is
obvious they have a condition that can produce pain. Unfortunately, we in
the health profession seem to expect stoicism, and respond much more
positively to someone who appears to be doing his or her best to bear up
under the pain than we do to the patients who complain vociferously.
Moreover, there is a language barrier to the effective communication of
pain. Many patients cannot describe radiation, or gradations of pain. They
only know they hurt. This is also true for patients whose first language is not
English. They may simply not know how to talk about their pain.
Why is it that in certain situations when we do perceive pain it is the wrong
degree and the wrong location? For example, in multiple trauma victims, it is
often observed that the patient complains about a trivial injury, when there
are major severe injuries that the patient is totally unaware of having sustained.
For example, we saw a patient, a 45-year-old man, who complained of
a wrist injury (it was sprained) after a motorcycle crash. He also happened to
have 12 rib fractures, a humerus fracture on the side opposite the wrist
sprain, a shattered liver, and a femur fracture. Yet his only concern was the
wrist, and the pain was quite mild. Through the lens of analgesia research,
this patient (on the basis of his injuries) would appear to have been undertreated
because he was given no opioids.
Imagine trying to collect evidence for the utility of any single agent when
the population studied is filled with patients like the one just described.
There is no shortage of other potential confounders to conducting (and