Monday, January 24, 2011

Pain Tolerance

My favorite scripture is Luke 9 24-25 "For whosoever will save his life shall lose it: but whosoever will lose his life for my sake, the same shall save it. For what is a man advantaged, if he gain the whole world, and lose himself, or be cast away?" My favorite line from a movie is, “Life is pain, highness, anyone who tells you differently is trying to sell something.”

Lately, I have been thinking about pain tolerance. Recently I had a patient who was generally not tolerant of any inconvenience in his life. He was impatient and angry when I first met him. He contacted me upset that he couldn’t get his CT scan the same day. We found a stone which was not obstructing his kidney and therefore should not have been causing significant pain. His pain, however, had been present for years in a location separate from his kidney. I explained that treating his stone might not resolve his pain. He could not accept this. I scheduled surgery and eventually successfully pulverized the stone with a laser and told him that he would now pass the small pieces. Two days later I got a call from a hysterical patient that had become unhinged (10 times worse than becoming unglued) As I listened to the wailing over the phone I felt bad and arranged for him to come in to be treated for his pain. But I was left to wonder why he had reacted so violently to something that generally is not that painful for most people.

Often, people will exclaim to me that they have a high pain tolerance as they are asking for more narcotics. The degree of their reported pain does not correlate with their clinical presentation. My first reaction is to wonder why some people tolerate pain so differently from others. Over the years I have found a non scientific correlation between certain personality traits and pain tolerance. Those who are impatient, demanding and overly critical often are upset when a solution to their problem cannot be resolved instantaneously. These individuals also don’t tolerate pain well. They cannot abide loss of control in their life. Medical care has its flaws. It is not always immediate. There are many things we cannot fix. Some pain cannot be relieved, even with strong narcotics. Many will suffer despite are best efforts.

What is pain tolerance? I view it as two different responses to a given noxious stimulus. First, it is the way in which we perceive the pain. This is measured in a subjective quantization by our brain relative to the physical injury or insult to our body. Second is how we respond to the perceived pain. To what degree can we suppress the impact of the pain on our consciousness and continue to focus on the task before us. The difficulty is that we can only judge one person with and any true credibility; ourselves. When someone tells me that they are in pain, I always believe them. Who am I to say, “That does not hurt.” However, it is clear that a specific fixed source of pain stimulus will evoke a wide variety of responses from different individuals. One might continue to work while another will be in the hospital on intravenous narcotics.

Yet, how someone will respond to pain is not completely unpredictable based on how they handle others aspects of their life. People who are intolerant, feel entitled or tend to blame others for any problem in their life also tend to blame others for their pain. Our society raises us with the notion that all pain is avoidable and that if we experience pain, someone is culpable and, ergo, owes us recompense. Yet, there are many others that see beyond their pain. They accept it, manage it and work to overcome it. Their positive outlook is more potent than Percocet. They combine faith and science with hope that they might emerge, maybe not pain free, but whole. They accept their new normal and move on.

Some pain is acute and may last for a few seconds or a few weeks. Some suffer pain every day of their life. It never goes away. This is the worst. My heart aches for these.

Some pain is not physical. Emotional pain associated with loss of companionship or isolation, even within a relationship. Spiritual pain associated with guilt and thoughts of worthlessness. Depression deprives so many from enjoying even a little beauty in their day. We feel pain in so many ways. I want so much to alleviate pain from peoples’ lives. As a doctor I can treat the source of their physical ailment. But so much more is needed. Beyond healing the body, I can help heal the soul. First, I must listen, without judgment. Second, I must offer hope.

Last year I had a patient who was very sick. He wanted to die for the last five years since he lost his wife. He argued, “Why should you treat me? Just let me get sicker and die.” He had nothing to live for. As we spoke I knew that the only remedy was for him to lose himself in the service of others if he were to save himself. We spoke of what he could to help other people. Finally he commented. “For all this time I have been preparing to die when I should have been preparing to live.” He smiled and I saw the flicker of hope rekindled.

Life is pain. We can’t always remove it. But we can lose ourselves in the service of others to save ourselves. From Him that suffered all things comes our hope and our tolerance of pain.


Monday, January 17, 2011

Looking back at 2010

Mostly what I noticed in 2010 is how a certain normality returned to our lives. Predictable patterns emerged; both in my health and in our daily activities. I cycled my chemotherapy, one month on and one month off in an attempt to prevent rejection. It worked. I did not have any episodes of heart rejection in 2010. Albeit, the cyclophosphamide is progressively the source of more complications with each new cycle. But the alternative month feels so good.
We lost too many people in 2010. Both from the amyloidosis support group and the heart transplant group. The year ended with the passing of Bill. His wife Dina runs the amyloidosis support group. I remember the first time I met Bill. His body had already been ravaged by amyloidosis, yet I gained so much hope as a reflection of his courage. Bill and Dina were strong for all of us. He will be greatly missed.
Last week I went to Santa Clara to get my 4 month heart biopsy. This time felt different; it hurt. I realized that my body's nervous system is now innervating my foreign visitor. The Scarecrow is finally talking to the Tin Man. As I mentioned this, the fellow doing the biopsy, (assuming that I was complaining about the pain) walked around the table to explain. He said, "What you are feeling is the ..." My laugh cut him off as I retorted, "We doctors are all the same." As I looked up I saw a strange look and finished, "You just told me what I am feeling. How can you know that?" How many times have I done the same thing.
A few hours later, sitting in the transplant support group, I heard the same complaint over and over; 'my doctor didn't listen to me'. We all try so hard to fit everyone into a box that we understand and forget how differently we experience things.
2010 was a wonderful year. We went to the Grand Canyon, Paris, Spain, Utah and New York. Barbie finished her prerequisites and was accepted to Dental Hygiene school. Jeremy, Alexandria and Rebecca graduated from college. I never called in sick (although there were days I wanted to.) I love going to work and I love coming home. I am humbled by the extra days that have been gifted to me. As my friends pass from mortality to their eternal home, the words, "There but for the grace of God go I," occasionally pass through my mind. I used to think of this cliched phrase as selfish and unfeeling. Yet now I understand. I may not have passed this year, but it is certain that some day I will. We all will. So much is not in our control. I accept that as I accept God's grace in my continued daily breath. I do not understand why some die and others live. It clearly is not based on merit. My only peace is through the faith in my Saviour.
As I look forward to 2011, I am excited to continue in my relationships with friends and families. I feel really good, physically, mentally emotionally and spiritually. I begin this year with no regrets.