Wednesday, February 4

...for the chemical burn following a bizarre horseback riding accident...

MedicBlog999 had a great post bringing up the topic of pre-hospital pain control. I had made a comment that I used to be conservative in administering pain meds since a Doctor in the ER told me he was unable to assess a patient's knee injury.
We all know it's not about him, but the patient. But still, that kind of thing has a way of skewing your perspectives on pain.

Pain is indeed relative. We use that stupid 1-10 scale to get a number. We just love to qualify and quantify. I understand it is to trend the treatments, but isn't it more about comfort? I recall a gentleman with a broken hip telling me it still hurt like a 12 out of 10, but he didn't care as much about it after morphine. And that's what it boils down to is making the patient more comfortable for that bumpy ride to the ER.

Also impacting our judgment to administer medications is our own experiences. I often ask women who tell me their pain is a 10 if they have children. Then I ask them to reevaluate the pain using childbirth as a 10 and wouldn't you know that number comes down as the smile on their face goes up.

I think practitioners who have experienced real agonizing pain are quicker to get meds on board, if for no other reason than to not see someone suffer what they went through. It was just such an experience that changed my views on pre-hospital pain control.

OK 999, here is your explanation of what I called "chemical burns following a bizarre horseback riding accident."

Personally, I never experienced true pain until soon after I got married. Sounds like a joke, but true story.
We were on a cruise, it was a Wednesday. Just your average everyday Wednesday, September 12th, 2001.
We were in Mexico going on a horseback riding excursion and it was hot, so we're in shorts and t-shirts. Lathered in sunblock and bug repellent we went on a fantastic group ride through the forest and along the beach. The mosquitoes down there were the size of school children and some of them held down regular jobs at local markets. When one landed on your leg, you felt your whole body shift under the added weight. I noticed the local guides picking wild limes, biting into them and rubbing them on their skin. I asked one of the guides why they did that and she replied, "It keep the mosquitoes away, they hate the lime."
Well, I was being eaten alive so I did what they were doing and, sure enough, no more mosquitoes around me.
It was the next day, while snorkeling, that I began to feel the beginnings of the worst pain I've ever felt.

Describing the sensation is difficult, but it was similar to when you have really badly chapped lips and smile accidentally, that tearing sensation and the sudden, sharp pain. I had begun feeling that, but there was no outward sign of any injury. No discoloration, no increased pain on palpation, nothing. The sensation reached from my knees up to the tan line of my shorts on the entire anterior aspect of both legs. Pretty much everything that was exposed to the sun on the horseback trip.
It was the next day, friday, when the first blisters appeared.

We were on a cruise ship in open water off the coast of Mexico steaming back towards Long Beach Harbor when the blisters began to throb and ache. Simply wearing shorts and walking into the wind was difficult and hurt more than anything in my life up to that point. Had you assessed me then, that would be my 10.
We had concluded that it was a combination of the sun block, bug spray and lime juice that had combined to burn my legs from the inside out and decided to call the on board Doctor.
Down into the bowels of the ship we went, where the floors are linoleum and the lights a clinical fluorescent white. The Doctor was off duty, but on-call, and we could call him in...for $300. We decided to stick with just the nurse at that point, realizing that whatever he said, she would act on, so we just went with her recommendations.
About an hour later my legs were caked in silver nitrate and covered with sterile bandages. It was watching her bandage the legs that made me realize that when those blisters grew tighter I would be in real trouble.

Our ship mates made jokes about the newlywed having sea legs when I nearly cried each time I had to gently move the pant legs off my legs just to sit down and eat.
But I couldn't just sit in the room and cry. The news of September 11th was everywhere and on every channel of the shipboard TV. We wanted to sit on the deck, take dancing lessons, do what we could to make the trip a positive memory on account of all the negatives already happening.
We finally made it into port and I was having trouble keeping myself together. Add the extra hours needed to search the ship for terrorists and I was nearly ready to jump off the boat just to get into an ambulance.
My father in law met us on the dock and we relayed our situation. The decision was made to go straight to the ER, after everyone got a bite to eat.
In the ER the staff chose to medicate me before removing the bandages. Thank goodness they did. After quite a bit of Demerol the first nurse to touch my legs almost got punched square in the face I jumped in pain so fast. "We'll give him some more I think," he said and the rest of the visit is fuzzy.

What is in my memory is the weeks of physical therapy, sitting in the Whirlpool tanks and having my bandages changed every day. I remember having to stretch my legs constantly so that the healing skin didn't grow back too small, stunting my mobility right there and then.

Whenever I see someone in pain, I remember my horseback riding trip and wish I had someone on the boat that could dose me up, and fast. And each time I hear someone say their pain is a 10 out of 10, I ask them what the worst pain they ever experienced really is. I don't pass judgment, I just want to make an honest comparison.

So there you go, my experience that changed the way I interpret pain pre-hospital and why any and every burn patient I encounter gets an immediate call to open the reserve doses, just in case.

The scars are mostly gone and I'm still smiling,
Happy Medic


Anonymous said...

Interesting story HM, and one that will change the way I think. Not being a medic, I have to call ALS when I see the need, which I have done several times for "Pain Control" before moving a pt. in certain types of distress. I have always found it interesting to watch the individual medics go through their assessment and deduce judgment on whether or not pain meds fit the situation. Your story explains the differences I see in medics. Some are real stingy, some don't have 'issues'. I had a pt. with a 'suspected' upper femur fracture (later confirmed) and the medic didn't think any pain control was required and that the pt. was just being "hysterical and uncooperative". Finally she dosed morphine, but we had a rough time boarding the pt. and another dose was issued enroute.
Saw that medic a few days later and told her the Dx, she said "I'll be damned, she seemed like a whiner to me". Sometimes I spend almost as much time handling the medic as I do handling the pt. But I'm just an EMT.

Capt. Tom

Anonymous said...

All I can say to that is....."Ouch!!!!!"
Although the story is crying out for some witty comment on marriage etc, I will let that one pass for now! Sounds like it was a bit of a nightmare, and something that Is easy to see how it can help make an empathetic paramedic.
Personally, I don't think I have ever experienced significant pain( thankfully ), but unfortunately my wife has, ranging from renal colic (kidney stones), acute abdo, IBS, a brow presentation delivery resulting in a emergency section after trying to push the latest little 999 out for 8 hours. All in the last 3 years. Her experiences have taught me a lot, and gives me great satisfaction when I see the difference I can make to someones experience of pre-hospital health care.
Great post mate, thanks for sharing your horror!!!

Dantarious said...

Didn't we once intend on creating a shirt that said "better living through sedation"? I also remember one that said "will intubate for food" (I did wear that in a cardboard sign), and there was another one about EPI, but I don't remember it exactly. We were just talking about your lime experience the other night i think, and hope the bugs in Mexico are a little calmer in the future. This post hit home for me, I have had sedation on the mind a bit lately. I had a recent event that brought the issue of Chemical restraint up on a difficulty breathing call. We had a patient that recieved 5mg of Versed, after becoming dangerously combative, and the Versed only lasted a few moments. We were barely able to get him to the gurney, and then had to wrestle to get the soft restraints in place. in hindsight, would have liked to have administered it earlier in the call, and would have liked to have had more available.