A Painful Yarn part two

Continued from Eric’s A Painful Yarn part one

……So, what did I notice? First, the adrenaline that accompanied the accident was wearing off. I could feel moment-by-moment discomfort and tension increasing in my right ankle and left knee as they swelled. I also got the sense that my body wanted movement. I found myself doing the proverbial writhing. I shifted to and fro, at one point I was upside down on the bed with my feet elevated as high as they could get up the wall. I really could not stay in any position for long.

After a while of this I picked up the phone and called one of my “counselors”—so normally you trade time but in cases of pain and death it is allowed to have one-way time. I talked with her, walked through the accident step-by-step, talked through my worries and concerns, moaned, and kept telling her I just wanted to be a little ball—which  is ironic, I guess because I am far from a little man. It was weird, but after I started to do this, and curl up into a ball these bouts of discomfort started to abate and I felt a bit calmer. The sense to move was ceasing and I could feel myself easing into relaxation.

During this time I did notice my psoas, and left hamstring all seemed to be stuck in the “on position”. I could feel them “bubble”—reflexively contract—as I would try to breathe or perform some gentle side-lying type movements, but they were in lock down protection mode. Also, I had super nerve tension in my back: to look down would send electrical signals through my spine. In fact, afterwards I had extreme difficulty getting into the car because I could not flex my head to fit in the door.

I went through a phase of nausea, about the time I think my adrenaline was coming down, this was brief but not that intense. After I had relaxed for a bit and had gone through about 30-40 min of counseling I started to feel very hungry. So I ate the lunch I packed for work—not the accident. What followed was a very cold feeling in my feet, so much so that I could not tell if my feet were cold or painful.

Eventually, I hobbled out of the ED. I could not stand up straight and the left knee felt loose—I was apprehensive about putting weight on it and bending it. It also felt like there was corset around my waist that was cinched down super tight.

I made it back home with the aide of my counselor friends. Eventually, I curled up into a ball and gradually eased into sleep. Throughout the day, I altered between supine, side-lying, standing and hobbling. I found myself hobbling with a straight left leg because of perceived apprehension of ligamentous stability of my left knee.

At approximately 12 hours post-accident I decided to take 800 mg of ibuprofen, mostly because I wanted to see the effects; they were dramatic, maybe 50% more ease with movement. Still, I walked with a very guarded gait but after I felt much more comfortable experimenting with different types of walking.

My experience has led to these reflections.  My discomfort was worse when I was alone; having someone there—albeit on the phone—greatly aided my discomfort. Expression of pain through moaning and writhing did help.  In my case, instinctive movement following the ideomotion principle worked after I believed I could move, this belief followed after I knew that “I was alight”; this instinctive movement aided the discomfort. Overall, I was quite surprised at some of the positions and movements that I ultimately found comfort in. Also, I wonder how many acutely injured people are not explicitly given that authorization at these early stages that, “yes, you can move.” The general anxiety of the ED is very dreadful: listening to other people in pain greatly increased my anxiety and perceived discomfort. There was a lot of concern about financials but the other driver was at fault, he admitted, was cited and has insurance. So that eased one of the biggest anxieties of the day: “how much is this going to cost me?”

Ultimately, I concluded this: we could greatly, appease patients and decrease the use pain meds if patients are given better attention during their time in the ED and providers do a damn good job of answering the patient’s question “Am I alright?”. I think much of my own education allowed me to answer this question myself, but I did find it surprising how much I had to pepper the MDs with questions to determine what they were thinking.

Overall, I got pretty banged up, my helmet was cracked and a sizable chunk taken out of it, my bike was finished.  We as therapist rarely get to experience the lives of our patients in extreme situations. I wrote this post on the day of my accident from my perspective as both the therapist and the patient, with full disclosure of my anxieties and revelations as they occurred to me then.  Hopefully providing anecdotal evidence of the body and mind in pain and what can help to resolve it.

About Eric Kruger

Eric KrugerErik is a blogger (The Physio Manifesto) and staff physio at Denver Health—the Rocky Mountain Region trauma hospital and community health safety net for Denver, Colorado.   Eric works with, the gamut of neurological, trauma, sports orthopedic, persistent pain and medically intensive patients.  When not working Eric enjoys a sophomoric interest most things adventuresome and recreational while constantly being embroiled in the question of: “What is next?”

You can follow my recovery at Soma Simple

 

 

Comments

  1. Hi Eric, That is a really interesting post. While I was working on a large RCT looking at ED management of whiplash injuries I talked to lots of patients who talked about their ED experiences and how anxious they were in those first few hours after their injury. I was really surprised that many of them did not have their fears allayed by their ED visit. During the study I also talked to lots of ED staff and was equally surprised to find how cynical they were about whiplash patients and they were just there to get reports for their insurance. Whiplash in general has had very bad press here in the UK recently due to massive amounts of insurance fraud. However, I am certain there are also a lot of genuine patients who are not receiving the reassurance and care they need because of this. I know there are time pressures in the ED but I completely agree with you – taking time to reassure patients they are alright very early on after injury can only help them to be less anxious and to reduce the amount of pain they experience early onand hopefully help them to recover quickly. However, in our study, we tried to implement an intervention in the ED that provided reassurance for patients early after their whiplash injury but it didn’t improve patient outcomes. The intervention relied on many ED clinicians changing their practice but I am not convinced we actually managed this. Do you have any suggestions for how we get ED clinicians to ensure “patients are given better attention during their time in the ED and providers do a damn good job of answering the patient’s question “Am I alright?”?

  2. Thanks for the response Esther. As I sit 4 months since the initial accident and I re-read my post written on the day of the accident, I must admit I struggle to find the same level of importance as I did then. Not to say I don’t feel the same. However, as I sit 4 mo. after the accident: having received some excellent care, out of the traumatic pain, many of the questions answered about the severity of my injuries and returned to a great deal of my functional activities; the whole thing does not seem quite as severe as it felt back then.
    I looked at the RCT that you (Esther) participated in. I recently lead a pain discussion at our hospital and was advocating for early (ED) intervention for PT. I think there are many confounding variables to assess when looking at one particular early intervention will have a meaningful impact given the total duration of recovery. With trauma, such as mine, such as many of the patients I treat often these questions of “Am I alright?” keep coming up. Sometimes I (as a PT) am sufficient to answer this question, and other times not. Then I have to go up the chain of command no matter what I believe. In other words the messenger matters. Also, integration and uniformity of the message also matter; across time longitudinally but also temporally in the same moment. This type of coordination I would think, as I ponder how to achieve this in our hospital setting, is very difficult. Not to mention add in whatever preconceived ideas/beliefs/justifications the patient may hold prior to visiting the ED.
    I guess what I am saying, that message is important but amongst a sea of other messages, the message that really counts may get drowned out. Figuring out how to make that message salient seems paramount. For example by controlling the environment to eliminate distractions, focused one-on-one attention that is patient enough to let the patient regain some locus of control rather than feeling like they are on a conveyor belt: exam bed, x-ray, ultrasound, resident consult, physician consult. These may all be pieces of the puzzle. Likewise the effect may be obscured by non-uniformity in patient follow up. Patients may get great ED care but be dropped into a nether land in the immediate weeks—creating a sort of regression to the mean scenario.
    I am not sure if many hospital systems rank these values (patient comfort, privacy, consistent patient education, one-on-one counseling) high enough. Things like coordination between multiple providers and the design of many EDs is for triage efficiency and not patient comfort contribute in subtle ways.
    The further I step back from the problem the more it seems like the problem of schools and child development. Are we putting too much pressure on our social institutions to solve problems that may not be economically feasible, at least given their current design of economic incentives? I know not the answer to that question but it is the big picture question I think one asks when looking at the design and meaning of an entire institution.
    Perhaps the answer to the question seems to sit at the nexus of values and science. How do we design systems (coordination of people and space) that reflect a certain value set? How do we test (i.e. use scientific method) if that value is being obtained? Then how do we test if that value translates into a testable effect against a different system with different values?