- Email: [email protected]
Pain and Empathy
CHANGE OF SHIFT
Pain and Empathy Joshua C. Lerner, MD* *Corresponding Author. E-mail: [email protected]. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.01.022
[Ann Emerg Med. 2017;70:98.] The first time I met her, she was not a patient. She was the screaming mother of an infant coding in what was my first pediatric code as an attending. I vividly remember the code—asystole the entire time—and I remember ending the code with her in the room and then walking over to her to crouch down and offer my condolences as she kneeled on the floor, crying. I also remember sitting in the family room a short while later to talk with her when everything had settled down. As if midday in a single-coverage ER after a pediatric code could ever settle down. I was not a parent at the time and I am thankful for that. I remember a calm detachment that carried me through the remainder of the shift. Perhaps it was that detachment, but I did not remember her. Or at least I did not remember her well enough to realize who she was when I saw her the second time in the same ER a year or so later. A nurse who was with me for the code let me know, although I could not decide if it had been meant as a warning. For the first time my patient, she was now in the ER for some innocuous psychiatric reason. As if there would be an innocuous psychiatric condition after such tragedy. Good, I thought before I had learned her identity, her anxiety won’t need inpatient treatment and she won’t take up a bed in my crowded ER for long. At discharge, her identity now known, I prescribed a few Ativan, something I don’t normally do. Knowledge of her past legitimized her anxiety. The next time she registered as a patient on my shift, I did not need notification or warning. I knew who she was and I began to see what she had become. She was in the ER for a different, albeit benign, complaint of knee pain. Chronic, by her own admission, replete with a story of MRIs, failed injections, and other interventions. I offered Motrin for the pain, but when she told me that didn’t work and asked for something else, I acquiesced far too easily. She left with a prescription for a few Percocet. Pain was the common complaint from then on. I only saw her a handful of times over the next few years, but her
98 Annals of Emergency Medicine
visit history during that time indicated far more frequent ER contact. Each time it was the same story of MRIs, injections, lost medications, and various pending orthopedic visits. Interspersed were occasional visits for trivial falls with trivial back pain and other similar complaints. And each time we danced the same dance of NSAIDs and opiates. And each time, she left with a few of the latter and a gentler narcotic scolding than usual. Never once did she mention her past. She never played the bereaved parent card, nor did she ever pander for pity. I am not sure if fear or reverence stopped me, but I too never mentioned who I was in relation to that unspoken past. I am not sure if she remembered me from that first day, and I do not know if that would have changed things. Neither of us ever discussed anything other than her current complaint of pain; she always needed something for the pain. Neither of us ever made note of the shared horror that had occurred in the trauma room just down the hall. But that shared horror gave me greater empathy for her current complaint each time. Although I could not feel her knee pain, back pain, or anxiety, a part of me at least understood it. By the latter of her visits, for many in the ER sympathy turned to frustration. Others grew tired of her frequent presentations and displeased with my scattered prescriptions. They viewed her as another drug seeker amidst a busy department with limited resources. Perhaps they viewed me as an enabler. I often wonder why she felt the need to repeatedly return to the site of such tragedy and whether I was helping her, a patient in pain, or merely facilitating an addict. Was her pain more than just a physical complaint? Was pain medicine the only thing I could offer? To this day, I still don’t know. But I do know that others could not feel her pain. Others had not lived that first day she and I shared. Author affiliations: From the Department of Emergency Medicine, Harrington Hospital, Southbridge, MA.
Volume 70, no. 1 : July 2017
Pain and Empathy Joshua C. Lerner, MD* *Corresponding Author. E-mail: [email protected]. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.01.022
[Ann Emerg Med. 2017;70:98.] The first time I met her, she was not a patient. She was the screaming mother of an infant coding in what was my first pediatric code as an attending. I vividly remember the code—asystole the entire time—and I remember ending the code with her in the room and then walking over to her to crouch down and offer my condolences as she kneeled on the floor, crying. I also remember sitting in the family room a short while later to talk with her when everything had settled down. As if midday in a single-coverage ER after a pediatric code could ever settle down. I was not a parent at the time and I am thankful for that. I remember a calm detachment that carried me through the remainder of the shift. Perhaps it was that detachment, but I did not remember her. Or at least I did not remember her well enough to realize who she was when I saw her the second time in the same ER a year or so later. A nurse who was with me for the code let me know, although I could not decide if it had been meant as a warning. For the first time my patient, she was now in the ER for some innocuous psychiatric reason. As if there would be an innocuous psychiatric condition after such tragedy. Good, I thought before I had learned her identity, her anxiety won’t need inpatient treatment and she won’t take up a bed in my crowded ER for long. At discharge, her identity now known, I prescribed a few Ativan, something I don’t normally do. Knowledge of her past legitimized her anxiety. The next time she registered as a patient on my shift, I did not need notification or warning. I knew who she was and I began to see what she had become. She was in the ER for a different, albeit benign, complaint of knee pain. Chronic, by her own admission, replete with a story of MRIs, failed injections, and other interventions. I offered Motrin for the pain, but when she told me that didn’t work and asked for something else, I acquiesced far too easily. She left with a prescription for a few Percocet. Pain was the common complaint from then on. I only saw her a handful of times over the next few years, but her
98 Annals of Emergency Medicine
visit history during that time indicated far more frequent ER contact. Each time it was the same story of MRIs, injections, lost medications, and various pending orthopedic visits. Interspersed were occasional visits for trivial falls with trivial back pain and other similar complaints. And each time we danced the same dance of NSAIDs and opiates. And each time, she left with a few of the latter and a gentler narcotic scolding than usual. Never once did she mention her past. She never played the bereaved parent card, nor did she ever pander for pity. I am not sure if fear or reverence stopped me, but I too never mentioned who I was in relation to that unspoken past. I am not sure if she remembered me from that first day, and I do not know if that would have changed things. Neither of us ever discussed anything other than her current complaint of pain; she always needed something for the pain. Neither of us ever made note of the shared horror that had occurred in the trauma room just down the hall. But that shared horror gave me greater empathy for her current complaint each time. Although I could not feel her knee pain, back pain, or anxiety, a part of me at least understood it. By the latter of her visits, for many in the ER sympathy turned to frustration. Others grew tired of her frequent presentations and displeased with my scattered prescriptions. They viewed her as another drug seeker amidst a busy department with limited resources. Perhaps they viewed me as an enabler. I often wonder why she felt the need to repeatedly return to the site of such tragedy and whether I was helping her, a patient in pain, or merely facilitating an addict. Was her pain more than just a physical complaint? Was pain medicine the only thing I could offer? To this day, I still don’t know. But I do know that others could not feel her pain. Others had not lived that first day she and I shared. Author affiliations: From the Department of Emergency Medicine, Harrington Hospital, Southbridge, MA.
Volume 70, no. 1 : July 2017