What is the most pain you have ever felt

[phillysailor]

Primum non nocere…first do no harm… is a mantra that has been around for a very long time (?Hippocrate).
My colleague was mentioning repair of an aortic aneurysm or ruptured AAA. This is a condition more common in men that have smoked and above the age of 65. But anyone with atherosclerotic disease can get it.
It starts as a dilation of the aortic artery. If found and small it may just be monitored. If large then discussion with patient on management (Stent vs open surgery).
The concern is spontaneous rupture. If rapid, this causes a very rapid death. If slow it may present as abdominal or back or testicular pains. It can be a little tricky to diagnose initially, so high index of suspicion is required. The feeder vessel to the spinal cord can vary quite significantly from person to person. It may already be tenuous because of the atherosclerotic disease the patient will invariably have, it might be right in the way of where you need to clamp it to stop the patient bleeding out in front of you, it may be difficult to see or get access to because the belly is full of blood and dying gut. Or the dynamics of flow may mean that although patent the flow of blood to the cord may be impaired During the cross clamp of the aorta.
How we approach the management of these patients depends on many factors. The end result is to have a patient alive and obviously in reasonable condition.
But if the patient is already in crap condition before you start, then it may be more appropriate to allow the patient to be comfortable with a morphine infusion, and die that way. This is big surgery in the emergency situation with higher mortality rates. In those in poor condition. The use of endovascular approaches to stent the inside of the vessel with bespoke stents has revolutionised treatment of this condition. With patientS previously cons inoperable able to be treated. But they may still have aberrant feeder vessels. They may still have poor renal function from diabetes or whatever that complicates the process. Their lungs may be crap their heart may be crap they may have poor cerebral vascularity. Each patient will have their own issues.
Ruptured thoracic aneurysm are an extra level of crap as it may dissect up to the heart, you may need a valve replacement at the same time. It’s long laborious surgery requiring heart lung machine.

we are all too well aware of Primum Non Nocere.

Well written, sir.

A case that has lived with me, in a manner not unlike PTSD, was a ruptured abdominal aortic aneurysm in an ex-marine with loving family who had been twice denied an elective repair due to anticipated problems, surgical and non-surgical, by different vascular surgeons.

As Capt K points out, he had many co-morbidities, and was best described by C Dickens in The Pickwick Papers. He was morbidly obese, smoked, had sleep apnea, diabetes and grew so short of breath when lying down flat that he always used three pillows for sleeping. He'd been in heart failure just days before his emergency admission with intense abdominal pain.

I met him after the ER treated his dropping BP with five bags of fluid and an hour in the CT scanner during which he was unable to lie still, and so they sedated him with the result that they got the pictures, but he needed intubation soon after.

Suffice to say, nine hours and five graft attempts later (the aorta just kept shredding with suture tension), the belly was full of blood & the labs I was getting told the story. This guy wasn't going to make it and the preop evals rejecting him as a surgical candidate were spot on.

I hand ventilated him in PACU with family at bedside in the dark hours of the day until they told me I could stop. Went to his funeral and didn't feel ok for weeks. Still recall that day with aversion.

Many of my finest interventions with patients has been to encourage families to consider alternative endings for their loved ones' life. Malnourished patients with yards of dead bowel, octogenarian patients with fatal cancers and septic shock, patients with devastating neurological outcomes all deserve a rational decision be made, and not a reflexive "do everything."

 

[Code 2]

Yeah - kidney stones were bad - but in a scary what the F is happening way. I was in my mid-20's pissing blood for 2 days before the pain started. I was more afraid of the blood coming out in a spot its not supposed to be...

 

[veni vidi vici]

Yeah - kidney stones were bad - but in a scary what the F is happening way. I was in my mid-20's pissing blood for 2 days before the pain started. I was more afraid of the blood coming out in a spot its not supposed to be...

I am far from being a hypochondriac or a worrier, but smart enough to understand that if something is not normal one should get it medically checked out.

 

[Charlie Foxtrot]

Recently moved to Florida, Charlotte’s still in St Loo, two days in the new house, working 16 hr days over the 4th of July holiday to get some, any, order in the house. Then a 1:40 am wake-the-hell-up with a searing pain in my side.

Kidney stones. Doc said the pain from stones is typically about 8/10. Don’t want to ever experience a 10/10 or even a 9, or for that matter, a 7 again.

 

[veni vidi vici]

Recently moved to Florida, Charlotte’s still in St Loo, two days in the new house, working 16 hr days over the 4th of July holiday to get some, any, order in the house. Then a 1:40 am wake-the-hell-up with a searing pain in my side.

Kidney stones. Doc said the pain from stones is about 8/10. Don’t want to ever experience a 10/10 or even a 9.

When in pain and asked that silly question is infuriating, sure it makes some sense to those asking because they deal with patients and pain day in and day out. The poor suffering patients perhaps have never experienced severe pain before.
Of course being a man and not wanting to appear weak even further confuses the moment.
Of course the chronic ER pill chasers have it down to a science.
Back on topic, I have had hydro and oxy prescriptions over the years for post surgery and never liked the side affects for me, constipation , itchy skin and difficulty urinating, so I was always glad to stop taking them and not able to understand the high people like from taking them.

 

[phillysailor]

Whenever I use the 10 scale for pain, I am suspicious of its utility. Most persons in pain want/need it to stop, and so will say, "11" or "13."

So I tell patients that someone slamming their toe with a hammer is an "8", the end of Braveheart where his arms are torn from his body and he is cut open and his entrails removed is a "9" and a "10" means inability to breathe coupled with loss of consciousness.

IMO, 10/10 pain threatens life via arrythmia,MI, aspirating stomach contents or a stroke.

On this scale, ability to form a complete sentence stops at about a 7, and speaking clearly about 6.

On this scale, a score of 3 or 4 means opioids in usual acute pain doses.

One or two is Tylenol and NSAIDs.


But NO ONE uses this scale.

 

[Ed Lada]

Recently moved to Florida, Charlotte’s still in St Loo, two days in the new house, working 16 hr days over the 4th of July holiday to get some, any, order in the house. Then a 1:40 am wake-the-hell-up with a searing pain in my side.

Kidney stones. Doc said the pain from stones is about 8/10. Don’t want to ever experience a 10/10 or even a 9.

The problem with any pain scale is it is subjective. It is nice to get some idea of the pain the patient is suffering for a number of reasons. The problem is it doesn't end at 10. Or 11. I truly believe how much pain a person is in, for whatever reason, it can always get worse. In my opinion, no doctor has a right to tell you what level your pain is. If you say it is 10, then it's 10. If the doctor gives you shit for that then tell them to fuck off and demand to talk to a doctor that will listen to you. It is only one of many diagnostic tools and it isn't even necessary, it's just helpful. I've worked many trauma cases both when the patient was conscious and when they weren't. I don't ever recall even once when the ER resident leaned over a patient who might be screaming, bleeding and possibly dying, or perfectly calm yet severely injured, and saying : "Can you tell me on a scale from 1 to 10 how much pain are you experiencing right now?"

I would suggest a comparison. Did you ever deliver a child? How was that pain compared to this pain. Did you ever break a large bone, did you ever have a gall bladder attack, did you ever have a kidney stone, etc. etc.? How did this feel compared to that? That might provide some useful information rather than from 1 to 10.

The only real function the pain scale has is for threads like this. You can tell people about your suffering. You will get empathy probably. Others will feel compelled to describe their pain and also benefit from sharing. That's a good thing and it's useful. In many cases in a medical setting, it's often useless.

The world is full of stupid shit that people do because they've always done it. That is no guarantee of the validity of the stupid habit. I despise many things in this world but stupidity is high up on the list, especially repetitive stupidity. I am only one person but I fight stupidity every chance I get. It is a Sisyphean task, I should change my name to Don Quixote. I get mocked and scorned for it. I get laughed at. I get criticized for it. But every now and then I succeed in achieving some insight in some individual and something changes. A journey of a thousand miles begins with a single step. I'm not a goddamn quitter.

 

[MR.CLEAN]

Age 19: Ed Eckelhoff flips my whaler 15 in an 8 foot breaker off long beach, NY while trolling for blues and sharks.

While searching for one of the crew, I get picked up by a wave and my knee drops on the still-spinning prop and then deflects on to the sharp foil edge of the lower unit. Never thought I'd get an exploded view of the inside of my knee. Once the adrenaline went away, sitting on a lifeguard's backboard while they tried to wash out some of the sand, the pain was the worst I'd experienced. I cried until the morphine kicked in.

Still hurts when I ski bumps or play full court basketball.

 

[veni vidi vici]

Ohhh…. I like that
Sisyphean task !
I did have gallbladder issues/ pain and 10 days later removal, it was for me a ??? 6 ???
Right up there for me was a broken bone in my hand, I didn’t realize it was broken at first because the first thing I did was submerge it in a bowl of ice water, mostly ice. Since a teenager and discovering what good therapy ice is for sports type injuries. The pain would have been probably 10xs less if I had done nothing. I had to lay on the floor because the “good pain “ was making me faint and breaking out in a cold sweat. When after 20 minutes of my had in the bowl and taking my first look I realized that big lump was something more than a sprain. Off to the walk in xray and cast
DIY sports medicine 😏

 

[veni vidi vici]

Another component of pain for me is that if I understand the why or what it is much easier to handle than pain from unknown causes.

 

[phillysailor]

The problem is it doesn't end at 10. Or 11. I truly believe how much pain a person is in, for whatever reason, it can always get worse. In my opinion, no doctor has a right to tell you what level your pain is. If you say it is 10, then it's 10.

Yeah, I disagree.

Once you've passed out and vomited into your lungs with pain, in jeopardy of a stroke or heart attack its not gonna get worse, just better by dying.

I don't disagree with patients, just take what they say as a point of information as you suggested. But your interpretation of a 10 scale is useless. It's also the most common interpretation by those who are asked the question.

 

[Black Sox]

My friend is a T5 paraplegic, mostly complete; no power and about 25% sensation below the nipple line. He got gall stones and just felt vaguely unwell. The cause of his discomfort was only discovered after various scans. He ended up having his gall bladder removed but not before his pancreas was damaged and he now a Type-2 diabetic. He subsequently had kidney stones and wasn't aware of an issue until he started hallucinating and it turned out that he had septicemia (sp?) probably caused by or related the kidney stones. stones were removed surgically and he's a much happier bunny now. Not feeling pain has its down side.

 

[phillysailor]

My friend is a T5 paraplegic, mostly complete; no power and about 25% sensation below the nipple line. He got gall stones and just felt vaguely unwell. The cause of his discomfort was only discovered after various scans. He ended up having his gall bladder removed but not before his pancreas was damaged and he now a Type-2 diabetic. He subsequently had kidney stones and wasn't aware of an issue until he started hallucinating and it turned out that he had septicemia (sp?) probably caused by or related the kidney stones. stones were removed surgically and he's a much happier bunny now. Not feeling pain has its down side.

Interesting implications with these patients, since they have unpredictable sensory/physiologic responses to pain.

Their body’s stress response to pain below the level of the sensory deficit can create effects far beyond their outward appearance or perception of pain.

These people need anesthesia just as much as those without neuro deficit in order to keep vital signs under control, maintain safe hormone levels, etc.

Before this was well understood, patient’s bodies have suffered irreparable harm from pain they never “felt.”

 

[veni vidi vici]

My friend is a T5 paraplegic, mostly complete; no power and about 25% sensation below the nipple line. He got gall stones and just felt vaguely unwell. The cause of his discomfort was only discovered after various scans. He ended up having his gall bladder removed but not before his pancreas was damaged and he now a Type-2 diabetic. He subsequently had kidney stones and wasn't aware of an issue until he started hallucinating and it turned out that he had septicemia (sp?) probably caused by or related the kidney stones. stones were removed surgically and he's a much happier bunny now. Not feeling pain has its down side.

Damn ! That sucks

 

[veni vidi vici]

Interesting implications with these patients, since they have unpredictable sensory/physiologic responses to pain.

Their body’s stress response to pain below the level of the sensory deficit can create effects far beyond their outward appearance or perception of pain.

These people need anesthesia just as much as those without neuro deficit in order to keep vital signs under control, maintain safe hormone levels, etc.

Before this was well understood, patient’s bodies have suffered irreparable harm from pain they never “felt.”

Interesting conversation

 

[Black Sox]

Damn ! That sucks

Yeah, and he still can't fuckin' walk either!

 

[Ed Lada]

I don't disagree with patients, just take what they say as a point of information as you suggested. But your interpretation of a 10 scale is useless.

Can you clarify what you said about my interpretation of a 10 point pain scale is? And in the next sentence you say It's also the most common interpretation by those who are asked the question.

I'm confused doc, help me out here.

If I think what I'm reading in your second sentence, then I think that proves the futility of the scale as many people won't give a useful response.

But please try to explain what you are saying so I can understand your point. Right now I didn't know.

Perhaps the AMA can come up with a meaningful mostly objective pain scae that can actually give a dcotor a reasonable assessment of the pain level. Something involving comparisons as I suggested earlier along with vital sign data; increased blood pressure, tachycardia, you know measurable things you often see in severe pain. If only the doctor understands the scale, that doesn't do the patient much good. Even more pain than this or less pain than this is more helpful than a number in my opinion. At least then you get some reliable information. Or ask them "Well what do you think would hurt worse than this. When a person is in pain which could produce serious side effects it's no time to be doing patient education on the 1-10 pain scale is it? And I think it is absolutely true that some people are more stoic than others and for many reasons, people want to minimize the pain they are experiencing and others want to exaggerate it.

I'm not arguing with you, I just don't know what you are saying.

When I had my first heart attack, I had been working in ERs and trauma centers for some years. The doc asked me the 1 to 10 question and I said an 8. He said "C'mon really? An 8? So I said "Fine it's an 11. WfF? He ended up giving me 2 mg of morphine which didn't help at all and gave me 3 more when I told him the pain ws no better after the 1st dose. And I'm sure that's not an uncommon experience. He was a nice doc, he listened to me for the most part but I was a bit pissed off about the pain thing. Perhaps I was 38 years old, in very good shape and no history of hear disease. The EMTS came to get me and asked me to walk to the ambulance because I was 6'5" and weighed 230 lbs. and I wasn't turning blue, lying on the floor and moaning. So I did. The EKG showed some clear abnormalities but they still weren't sure it was a heart attack. At the time they couldn't run the cardiac enzymes as fast as they do now and they sent me to a telemetry unit. It wasn't until a cardiologist came in looked at the EKG and had the enzymes that he said yes, you had a heart attack.
The 2nd heart attack I had was in a hospital where I was recovering from a severe leg infection. I was only having mild to moderate pain but after on MI I wasn't taking any chances. I told the doctor when she came in that I was having a little chest pain. She go an EKG machine and ran the EKG. Before she even said anything I could tell something was wrong by the look on her face. The y took me up to the ICU, gave me morphine and a few other drugs and called around to see where I could have a heart cath done ASAP. It turns out the 2nd MI was caused by viral myocarditis brought on y the leg infection, and since the heart cath the first tome also didn't show any blockages, that was probably the cause as well. The first MI was much more painful but left little damage,. The 2nd on was uncomfortable but no more than that and I ended up with 30% LVD. I'm sorry if I don't take much stock in the 1-10 pain scale based on my own health experience and what I saw working in the ER.

My experience tells me that doctors aren't infallible, and that's understandable. Some of them have little regard for whatever a patient tells them, and patients are often unreliable in reporting symptoms and pain levels. These are variable human factors that are hard to overcome in most cases. One possibility that could help is give doctors more training in psychology and human behavior, especially focusing on listening skills, empathy, and believing a patient who has far more experience with their body than the doctor has. I've worked with a lot of good doctors and also have been treated by a lot of good ones. But I have also had arguments with some, occasionally walked out and I've dealt with a few terrible ones either assisting them or being treated by them. My worst experience was telling 2 different doctors at age 55 that I had a pneumothorax (I'd had had 2 prior ones) and they both blew me off. And the 2nd one was a pulmonologist! When the pulmonologist heard from the radiologist who read the CD from the CT, he called and told me to get to the hospital. No shit sherlock. Even a small pneumo is usually quite clear on a CT.

What we need are Star Trek Tri-Corders and we need them now.

 

[Point Break]

Pain management. What a roller coaster that has been over the years. Over my career as a medic the philosophy regarding pain management - at least in the prehospital setting which correctly tracked general medical views - porpoised from very limited to aggressively manage pain back to very limited several times over the years. Each time there seemed sound medical reasons but I always found it odd that it vacillated so much. Make no mistake, some of it political both internal and external to the medical "establishment". When I started you would get a MS order for 2mg IVP. Really? Never mind. Then later the ordering algorithm changed to give 10mg IVP in 2mg increments and titrate to effect. Better.....then back again.

Our education merely skimmed the surface of what there is to know about the administration of narcotics and now much later other agents, but I'll bet I have given gallons of MS over my active years for any number of medical conditions, not just for pain relief but other pharm effects like vasodilation in certain medical conditions. One thing I learned.........everybody perceives and tolerates pain differently...and there are many different reactions to narcotic pain meds. One persons overdose doesn't touch anothers pain. The 10 scale is meaningless because it relies on 1) your personal perception/experiance of pain and 2) a comparison to the "worst pain you've ever felt" being the proverbial 10. Pretty subjective stuff. Frankly I found a persons general anxiety, respiratory rate and pulse rate the best indicator of true "relief"....at least in the acute setting. Additionally, different people get relief from one agent more than another. Pain from say......an isolated extremity trauma might not (often did not) get much if any relief while we were very successful with say cardiac pain in relieving the pain and reducing anxiety and therefore the load on the heart.

My hat is off to those Doc's trying to navigate that minefield of pain relief. Its far more complex than the average person understands.

 

[MR.CLEAN]

Pretty amazing what the body can get used to. While it pales in comparison to my knee trauma, I have 15 years now of wrecked C5/C6 and the radiopathy that results. I have gradually weaned myself off all drugs, when it spasms up I might pop two advil, but that's all. Pain is mostly as it was, but my body has learned not to really give a shit.

 

[Titilingus]

Nasty weapon. What year?

I'd rather not reply in public to specifics seeing as I was attacked for being scum of the earth by anti military crowd for being patriotic in this thread: https://forums.sailinganarchy.com/threads/240363/
PS, my post was the thread starter but I asked for it to be deleted, I am "deleted nember". I didn't realise how much hate there is out there towards us. However, talking here has really helped me more than you know.