PRIVATE PAIN AND PUBLIC DISPLAY: HOSPITAL CASUALTY DEPARTMENTS
My friend Ron Melzack, a Canadian psychologist, and I decided to examine and compare patients who were admitted to the emergency room (the casualty department) of the largest general hospital in Montreal. In a gentler setting, we could probe with questions that had not been possible in more urgent and dramatic scenes. We examined the first 138 patients to enter, who were alert, rational and coherent, 37 per cent of whom said they did not feel pain at the time of the injury. Of those patients with injuries limited to their skin, such as abrasions, cuts and burns, 53 per cent had a pain-free period. However, of those patients with deep tissue injuries, such as fractures, sprains and stabs, only 28 per cent had a pain-free period. The majority of these people reported the onset of pain within an hour although some did not feel pain for many hours. The predominant emotions of the patients were embarrassment at appearing careless or worry about loss of wages. None expressed any pleasure or indicated any prospect of gain as a result of the injury.
A 52-year-old senior machine-shop foreman lay on a trolley in the emergency room after a collapse of heavy machinery had amputed the front of his right foot. He stated that there was no pain. This was not his first experience of painless sudden injury because an unexploded aircraft canon shell had lodged in the upper part of his leg during the Second World War, and we observed the old scar. He was coherent, sad and thoughtful, and said 'What a fool they will think I am to let this happen', and 'There goes my holiday'. He lay still on the trolley with an intravenous drip running while waiting to go to the operating theatre. After a while he complained of a painful cramp in his left leg although the injured leg remained pain free. The pain went away with massage. Evidently, his analgesia was present only in the region of the original injury. This phenomenon had already been reported by Beecher, who observed that pain-free casualties complained of pain when intravenous needles were inserted.
We can now summarize key points of sudden injury. For a start, sudden injury may or may not be painful. The victims can be coherent and rational throughout. There may be no pain from the moment of injury. The pain-free state is localized precisely to the site of the injury. And all victims are eventually in pain.
Let us now turn to the majority (63 per cent) who were in pain from the moment of injury. How much pain? They were asked to rate their pain on a scale of o to 10, with 10 as the worst imaginable pain. The answers were widely scattered. Anyone, expert or not, observing someone who is injured almost inevitably assigns an 'appropriate' amount of pain which they expect. On what do they base this assignment of the appropriate: personal experience, professional experience, empathy, sympathy, knowledge of the victim or what? The staff of the emergency room thought that 40 per cent were making 'a terrible fuss', nearly 40 per cent were 'denying' pain, and 20 per cent gave the 'appropriate' answer. Clearly there is something fundamentally wrong here. People generally are convinced that a certain degree of injury inevitably produces and justifies an appropriate amount of pain. Clearly this is not the case but we have great difficulty in accepting the fact. (It is strange that even professionals may ignore their experience and persist in expecting patients to display only an appropriate amount of pain.)
A major theme of this book will be the exploration of the factors that, in addition to frank damage, produce pain and modulate its intensity. One crucial aspect is that patients are not only assessing their private misery but also making a public display. Their private misery is not necessarily about the pain. For example a 22-year-old Israeli Army woman lieutenant with one leg blown off above the knee by a shell explosion was in deep distress with tears flooding over her face. When asked about her pain, she replied: 'The pain is nothing, but who is going to marry me now?'
What did the patients say about their pain? Melzack has made an extensive study of the words people use. He divides the words into 'sensory', such as 'sharp', 'burning' and 'stinging', which describe the sensation itself, and into 'affective', such as 'tiring', 'sickening' and 'annoying', which describe what the feeling is doing to the person. It is interesting that on their first encounter in the emergency room with doctors and nurses, patients used almost entirely the sensory words. Much later they would add the affective words. In this emergency situation, the first priority of communication was to inform those who brought aid exactly those details they would need to diagnose the injury. They delayed, to less urgent times, the information about what the injury was doing to their mood.