Pain

I find pain one of the more difficult things to manage, something I hope to learn more about when I am in anesthesia. Pain is subjective. It's experiential. What objective markers and tests we have for pain are crude and rudimentary. I've written about this before, and the philosophy of it is fascinating. We live in internal worlds and we know only our harbored experiences. The shared world - the external world - acts as a bridge for us to interpret the worlds others live in. This objectivity is limited. If someone is in pain, then they are in pain, unless we have reason to doubt them. Few objective markers allow us to confirm or deny that statement.

But rather than wax philosphical, I wanted to write about two sickle cell patients. Sickle cell crises are intensely painful, and I recently admitted two sicklers in the midst of excruciating pain. They kept on demanding more and more narcotics, to the point that I felt uncomfortable; one who was allergic to half a dozen conventional agents wanted meperidine (demerol). It is an opioid with dangerous drug reactions - it may have lead to the death of Libby Zion, a college student whose death gave rise to the work hour restrictions we have today. Furthermore, exceeding the FDA-approved dose increases the risk of seizure dramatically. This patient demanded more and more demerol, past the maximum dose of the drug.

So what is pain? Of course these patients are in pain; sickle cell is a painful disease. But on the other hand, continued escalation of pain medications has its risks. I worried about exceeding maximum doses, causing tolerance, even feeding drug-seeking behavior. Yet all I had objectively was the word of the patient, his vital signs, and how he looked in bed. I wanted to treat this patient's pain; it's unethical not to. But the patient demanded more and more until he was so somnolent we could hardly wake him. What do we do in these cases? How do we approach them?