The most memorable patient of my pediatrics rotation had, to
my knowledge, nothing particularly wrong with her.
She bounced back to the emergency department three times
with gastric pain. She was overweight
and deceptively tall for an
eleven-year-old, making it hard to remember that she was a child, not a teenager
or young woman. She kept having stomach
pain that worsened with food, albeit without any blood in the stool. We all wondered if something was very wrong with
her home or school that she should want to keep coming back.
The team dispatched me to try to find out if something was
wrong with her: Was there bullying at school?
Abuse at home? Was she intentionally
malingering?
Or had we missed something very major?
She had all of imaging and laboratory tests we could think
of. Even the emergency room’s psychiatric
consult came back negative. My
conversation with her, unsurprisingly, was not much more fruitful: she had
multiple episodes of abdominal pain so intense at school that she could not
walk, and yet she did not wake up, grimace, or startle with even deep abdominal
palpation. The medical team’s consensus
was that this was acid reflux, gastroenteritis, and/or increased pain
perception for secondary gain.
* * *
Three ER visits and hospitalizations later, her tests did
come back positive for H. pylori. We also found out that she had gained 40
pounds in the past year and ate constantly; she told us she appreciated that
her large size made her intimidating.
Unfortunately, because of her size, she also felt obligated to stand up
and speak for her classmates.
Consequently, she was often in conflict with teachers. Conversations with her father confirmed the
constant eating; conversation with the mother revealed that the father provided
much of the “junk food” available in the home. Everyone, after extensive assurance about the
lack of obvious life-threatening abdominal problems and education on the slow
effect of proton-pump inhibitors, agreed that she should have a psychiatric
consultation for stress and overeating.
Her pain also magically reduced from 8/10 to 4/10 in time to
go home to meet a sister visiting for the weekend.
* * *
It was easy to assume her varying assessments of pain were
made-up, but my supervising physician reminded us that subjective pain scales
were notoriously inconsistent. For my
writeup, I decided to research subjective and objective pain scales. What I found suggested that, especially for
pediatrics, there is a role for both measuring the subjective experience of pain (which can be
influenced or manipulated) and examining objective measures of unconscious
automatic responses to pain, such as grimacing (which cannot be easily
manipulated). It was illuminating to
learn that manner in which subjective pain was assessed affected the final
score, but most surprising was the frequency by which healthcare providers
underestimated patients’ pain.
Our patient may have been malingering, or maybe there really
was something wrong at home. But after
reading about pain assessment, I am no longer surprised by how much this
patient’s subjective pain assessment fluctuated compared to the objective pain
assessment of her almost complete lack of grimaces and facial expressions of
pain.
Instead of feeling frustrated at our inability to help, I
must acknowledge she may simply have been an eleven-year-old girl who was
hurting and experiencing the worst pain she
had ever felt – even though it was not the worst pain we, as healthcare
providers, had ever seen. For her, it
was a 9/10, because she had never experienced true 10/10 pain of being hit by a
car or dying of metastatic cancer.
I am rather happy about that.
* * *
As she gets older, she will experience more pain and
consequently become better at rating and coping with pain. She will learn to stifle her expression of
pain to fit with social norms and become adept at finding the appropriate
painkiller, distraction, or if intolerable, doctor’s visit to deal with the
pain. After giving birth, or a bad
accident, or another unfortunate event, she may finally be able to give a
subjective pain rating that matches the objective pain rating of her
physicians.
But I certainly hope that she never will experience the kind
of 10/10 pain that would persuade a healthcare worker that she is, in fact,
hurting. Rather, I hope that she will
have such good self-care, healthy habits, fortuitous genetic composition, and
the necessary generous dose of luck needed to someday—when old and gray, full
of satisfying years of life, and ready to leave—slip gently away in her
sleep.
In the meantime, I hope that that we as a team can
acknowledge that even though her pain was not the worst pain we had ever
observed, objectively speaking, it really could have been the worst pain she
had ever felt.
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