My psychology of pain

Three and a half weeks ago I crashed my mountain bike riding downhill over a jump in Epping Forest, trying to keep up with my 9 year old who is perfectly comfortable being airbourne. I somersaulted in mid air landing on my back, then bounced onto my head and back onto my back (or something that felt like that). The small backpack I was carrying with tools, snacks and spare tubes, dug into my back on the right side of my chest and I was winded, speechless and in a lot of pain. My ride home was exquisitely painful. I diagnosed myself with 2 fractured ribs at the back of my chest and one at the front on the right side and one at the front on the left – I could feel a small step and some movement where they hurt, and still, sleep is almost impossible, sneezing agony and I cannot find any painkillers that do much (apart from 100mg diclofenac suppositories which give me about 5 hours relative relief)

I went back to work the day after the crash – GP partners have a ‘shadow contract’ which stipulates that we shall continue working up until the point of death and for a minimum of another month after that.

It’s still painful, but I can ride to work (10km) so long as I don’t stand up or change speed too quickly.

I’ve begun to notice small signs of improvement and changes to the nature of the pain. More and more it seems to hurt deep inside – where my liver is. I’ve been telling my (non-medical) wife that my liver feels bruised.

Yesterday a partner came back to work after maternity leave, noticed my discomfort and asked what happened. “How do you know you haven’t got a liver haemorrhage?!” she asked, aghast. I let this sink in while my attention drifted into and around my ache.

Ever since then it’s been impossible to shift the focus of my concern. Now it’s my liver that hurts more than my ribs and the nature has become more of a tense, dull, livery kind of pain and less of a sharp, crunchy ribby kind of pain. I’ve given up alcohol for a month and paracetamol and have started being more cautious with how I move.

Simply being more focused on ‘a bleeding liver’ has changed my pain perception and my pain behaviour. It definitely ‘feels like’ my liver is swollen and engorged with a big blood clot. If I have a scan and can see how much or how little damage there is (as represented by the scan) how will I feel then? If it’s ok, will the pain resolve, will I celebrate with a drink? If not, will I worry more and if it looks bad, will the pain get worse and more ‘livery’?

I don’t know.

The iatrogenic harm (harm done by the things doctors say and do) that comes from a suggestion is significant, but largely overlooked – by doctors at least, except perhaps by GPs who are constantly picking up the pieces after their patients have attended A&E with unexplained symptoms onto which an enthusiastic junior doctor has attached a list of possible diagnoses that their daft old GP couldn’t possible have thought of. Our patients come back to see us saying – “the hospital told me you have to refer me / arrange a scan …” Furthermore the more tests we do, scans/blood tests etc. the more abnormalities will show up that are unrelated to any disease or adverse prognosis, but are a reminder that our bodies are flawed and imperfect. A reminder that may make us actually feel unwell.

By not presenting myself to hospital, but avoiding a scan, I’m avoiding a diagnosis, a label and a cascade of interventions. I’m also evading the potential indignity of poor care and invalidation. I’ve had a lot of A&E and follow up hospital visits in the last year of cycling related trauma and the petty humiliations: being ignored, nobody introducing themselves, being patronised and condescended to, upset me. But also it’s upsetting because I / we are all representatives of the NHS and these petty humiliations are symbolic of a service that is failing. And this is another kind of pain I’m keen to avoid.

 

5 responses to “My psychology of pain

  1. I am so sorry you had this accident and rather worried by this post. I can’t concentrate on your (very interesting) comments about pain because I am concerned that you need to get your liver checked out asap. I am not a doctor, and a liver haemorrhage sounds very serious to me and not something you should neglect. I know that doctors often make the worst patients and I do think that you need to get this seen. Please do! I think this must make a difference to how you treat your patients too – how can you be compassionate to your patients and take their pain seriously, if you are neglectful of yourself? How can you concentrate if you are in such pain? Please take the time off and get seen – the golden rule, ‘treat others as you would like to be treated’ only works if you are kind to yourself!

    • Thanks. It sounds serious, but it just resolves like any other bruise. I wouldn’t recommend my own course of action to my patients though

  2. This is a wonderful insightful post. Accept my sympathy that you had an accident and are in pain. I am hoping your son isn’t worried about you or feeling guilty as people do by association. But also, accept my delight at seeing the understanding that pain can be iatrogenic, by suggestion, just as moods can be. I am not saying it is all in the mind, and neither are you, only that mind and body are intertwined. Although not a doctor, I am a scientist who loves the skills and helps that medical knowledge has brought, and at the same time a contradiction believing in unconscious factors that underlie the way we use our knowledge/s. There is “hurt” and “injury” that I distinguish by saying the first will repair itself if we do not get in the way and if we nurture the body-mind the hurt happened within. Injury needs intervention, help from the person/others with the skill, when the nature of the injury is known. How do we/you/ I tell the difference? Well there’s a question. Possibly self awareness [counter-transference /mindfulness ] helps. You have decided you are hurt and for the moment do no further harm. Do share with your patients, though, not “recommend”, wonder how each would answer the question re hurt or injury. Sometimes if I visit my doctor [seldom] that question is what I want to be helped with. Great thoughtful and thought provoking post. thank you and get well soon.

    • Thank you. My son’s reaction was moving/ interesting. He was afraid to show me what he thought, but when we got home I realised he’d been crying all the way back with worry. My wife was furious with me. And still has barely forgiven me. My children are far more affectionate and forgiving of my injuries, but caution me to be careful whenever I go out on my bike. Fortunately they’re very skilled and confident (how I envy them). They’re also great to discuss the social world of pain with – they know that context and meaning have everything to do with why and how much pain hurts – so that the same injury or type of pain ‘feels’ completely different if they’re alone or with others, having fun or frightened, with adults or without. What I’m also aware of is that my set of values around pain and meaning shouldn’t be projected onto others.

  3. Your colleague’s comments causing such a stir for you reminded me of a woman I briefly cared for as a midwife (she was about 30 weeks pregnant at the time). Her regular community midwife had palpated her bump and said that she could feel where her placenta was and how it hadn’t moved. The midwife must have also mentioned something about placenta accreta.
    I’m sure the midwife didn’t mean her to think that she had a placenta accreta (a placenta that is adherred to the uterine wall and can cause dangerous bleeds because it gets stuck) but that was totally what the woman had taken away from the encounter. And she was incredibly anxious about it.
    Initially I thought, stupid bloody midwife, but then remembered all the times when, sometimes just at a loss for something to say, or maybe to vaguely show off my knowledge (you know us midwives – always got a tiny bit of a chip on our shoulders that we are not doctors!), I’ve started talking about some medical condition, assuming that the woman had taken in the start of my sentence when I said “your blood results are normal although it’s interesting that…..” or something like that.
    Yeah, we never quite know how what we say will be interpreted.

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