pain

Pseudoseizures

Seizures are a fairly common 911 call. Fever and epilepsy are the most common causes, but I've also seen patients seize due to head injury, overdose, or withdrawal from drugs or alcohol. 

Recently, I've encountered more patients with a previous diagnosis of "pseudoseizures" or
"behavioral seizures." That was new to me, and based on how these patients were often treated in the ER, I assumed these terms were non-confrontational euphemisms for "faking it." Consider one patient, whom I delivered to the hospital twice in one shift. The patient had been prescribed a number of medications, none of which had been effective in stopping their frequent seizures.  They were going to the ER by ambulance several times a week, where they usually spent a few idle hours before being sent home again. Their seizures weren't associated with any of the signs we usually associate with epileptic events, and the ER staff mostly rolled their eyes and wrote it off as a waste of precious resources. It seemed like a pointless exercise. 

Pseudoseizures, I learned, are not so easily dismissed as fakery. The current term for them is Psychogenic Non-Epileptic Seizures (PNES). They are not associated with the electroencephalographic patterns of epileptic seizures, nor the typical physiological signs we often see in epileptic seizure patients. They are caused, researchers believe, by the mind itself. 

Yet we now differentiate them from malingering, or consciously displaying symptoms for personal gain. That difference is critical: from the patient's perspective, they may be experiencing a distressing event not unlike a seizure. We'll never know for certain, because like the experience of pain, their truth will forever remain their own property, a place we may speculate about but will never visit for ourselves. The entire diagnosis of PNES rests upon a fundamental trust that patients are telling us the truth. 

What is perhaps most interesting (and sad) about the syndrome is that the prognosis for PNES patients is relatively poor. If the seizure events were merely the response to transitory stresses in their lives (or if the people were merely faking), you would assume the symptoms would resolve after a while on their own. Changes in their situation and stressors would eliminate the need for such a disruptive event. But it appears that's not the case. Something about the seizure-like event becomes written into the person's story, and grows difficult to erase. 

When someone's heart stutters and stops, I can reach within them and apply electricity; I can open an access point their vascular system and deliver medications to their core. How do we fix a system we cannot see, or know, and for which the tools we possess may never fit their faltering machinery?

Everything is in your head

I recently responded to an incident in which a large number of people were exposed to a substance that's essentially harmless, but not something you typically get on your skin. A significant number were reporting a burning sensation and other symptoms. Ultimately, their symptoms resolved and none required emergency care. 

I think their condition likely had two causes. First, fear and anxiety at having been exposed to a foreign substance caused them to pay close attention to the normal sensations coming from their bodies. Their perceptions were filtered through biased cognitive processes, with pain as the result. Second, the reactions of the people around them actually influenced their perceptions of their own bodies.

It's easy to dismiss mass psychogenic illness as "hysteria" but I think it's an indicator of the powerful role our innate social impulses play in our health. We gather data and form our experiences not only through our nervous system, but also through other people.

Someone asked me recently if I'd ever seen a connection between my demeanor on an emergency incident and the patient's outcome. "Almost every single call," I replied. Fear and anxiety are hidden amplifiers of patients' symptoms. While I never hesitate to perform whatever medical interventions are necessary, sometimes calm and compassion are the most powerful tools at my disposal.

It's as if we have a second, invisible nervous system that extends out from our bodies and connects with others. 

I'm not going all woo-woo hand-wavey here. I can't cure a developing heart attack with niceness. But take this example: in a heart attack, cardiac muscle tissue doesn't receive enough oxygen-rich blood, and becomes hypoxic. Eventually, deprived of oxygen, it will die. A fast-beating heart uses up more oxygen, rapidly exhausting the limited supply. If my demeanor helps ameliorate a measure of that anxiety, and slows the heart down a little, might it help preserve a little precious cardiac tissue? 

Maybe, maybe not. I can't find research that addresses the patient's anxiety level during the event and compares it to long-term survival. But that's just one of the ways I see a little human compassion having far-reaching effects in EMS. We spend a lot of time training people how to perform other critical skills. But no one ever trained me in basic techniques for demonstrating compassion and reducing anxiety in patients. It's time for that to change. 

On a scale of 1 to a number you select, part 2

"On a scale of 1 to 10..."

The problem of determining pain treatment is complicated by how subjective people's self-reports are. 

People respond differently to the pain-scale question. Young people, even ones with extensive injuries, almost never say "10." They're much more likely to say the pain is a 7 or 8. I think they take the pain scale very literally, and they figure something always could be a little more painful than what they're experiencing that moment. 

Adults are different. They're aware of the subjectivity of pain. Many approach the pain scale as a means of communicating their experience, rather than assigning a literal value to what they're feeling. That's why a surprising number of adults answer my question with the number 12. 

I'm going to admit something unflattering here. At first, when people said their pain was a 12 out of 10, it annoyed me. I hid my reaction, but I couldn't understand why people, when given a specific measurement scale, were trying to circumvent it. Why not just say 10?

[Aside: I don't think anyone has ever said their pain was an 11. I don't know if that's because they don't want to sound like Nigel in Spinal Tap, whose amps go to 11, or if there's some other reason.]

Then I really started thinking about why people were saying their pain was a 12 out of 10. 

I began taking note of who was most likely to say 12. I don't claim this to be anything other than a series of anecdotal observations, but I noticed some patterns. Often it was someone with other medical problems (and experience with the medical system), whose pain was not associated with visible injuries. In other words, there was often little means of independently verifying that the patient was experiencing what they reported. 

The explanation for 12 out of 10 pain is a little depressing. I think it's the patient's way of saying "I'm really in pain here," because their pain reports haven't been taken seriously in the past. The medical system has effectively taught them, through operant conditioning, that they have to push hard to get care. They were ignored or treated inadequately when they said their pain was a 5, or a 10. Maybe 12 will work. I suspect it does not; it may actually have the opposite effect. 

Why were they ignored? My sense is we haven't yet mastered when and how to treat pain, especially in the absence of verifiable clinical signs. Emergency Rooms don't just administer the maximum dose of narcotics to everyone who says they're hurting; that would be unsafe, not to mention economically unsustainable. So we ask people to tell us how much they hurt, but don't always take them at their word. If we're going to ignore their response, why ask them at all? 

I keep asking the question, of course. And when people say their pain is a 12 out of 10, I see it as an unfortunate response to our own uncertainty about how to fix a problem that's entirely subjective, all in our head... and totally real. 

On a scale of 1 to a number you select, part 1

"On a scale of 1 to 10, with 1 being no pain and 10 being the worst pain you can imagine, how would you rate your pain right now?" 

I've asked patients this question, with minor variations in wording, hundreds (thousands?) of times in nearly two decades in EMS. It's strange, and at times frustrating, that this is the only way I can monitor pain. I can view numbers for pulse, respiratory rate, exhaled CO2 levels, pulse oximetry, and blood pressure in real time, but I can't really know what someone else is experiencing. 

It's not an idle question; my ambulance carries narcotic meds that are generally very effective in pain relief. The protocols governing their use leave a great deal of room for discretion: "Administer [medication name] as needed for pain."

Pain, like pretty much everything, is all in your head. In other words, real. I liken it to the sound of fingernails scraping on a chalkboard. People react in all kinds of ways, from relative indifference to great anxiety, and all those responses are "real" to the people having them. I have a high tolerance; the sound doesn't bother me very much. If I tell you to stop minding it just because I don't, that doesn't actually help you at all. 

For every patient who reports pain, I have to make a judgment call on whether it's in their best interests to administer a powerful narcotic prior to reaching the Emergency Room, or whether their pain can be better managed by a physician, and informed by a complete medical workup. I don't necessarily give narcotics to everyone who reports that they hurt. They have potential side effects, and they may be overkill for the pain at hand, which may be better managed through longer-acting meds available in the ER.

But as Paramedics go, I'm pretty aggressive about pain relief. My job is an opportunity to help people and alleviate suffering, so I don't consider it my role to deny medications to someone just because they might be seeking drugs or they don't look like they're really in much pain. I can't necessarily articulate a rationale that guides the decision for any given patient. It's a black box mechanism that I can't open. I do what I think is right. 

Imagine trying to write a strict set of guidelines that would specify when to administer narcotic pain meds in a pre-hospital setting. Should anything above a 7 on the pain scale qualify as "needed," or should you base the decision on physiological measures? Should you factor in the patient's apparent distress, or is this too easily confounded by the vast differences in people's tolerance for pain?

The decision about whether to give pain meds is a bit like scrying within someone else's psyche. It's not uncommon for someone to tell me they're experiencing 10 out of 10 pain, while they sit in apparent comfort, in no visible distress, and with vital signs that look like a person at rest. Do I take them at their word? Is their self-reported number the best indication of whether pain medication is justified, or do I allow my own experience (and possible bias) to factor into the decision? 

Who am I to make the decision, anyway? Well, someone has to, but it's a valid question, and one I still ask myself. 

[Continued Monday]