Pained: Folie a Deux

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **  

Marla was in pain. 

Pain is subjective. Heart rate and blood pressure tend to elevate with pain, but this is not definite. We attempt to quantify pain by using a scale of 1 to 10, with a "10" equivalent to childbirth or the passage of kidney stones. Again, this is subjective. It can be a challenge to evaluate and manage pain, especially with the growing issue of narcotic abuse.

Marla rated her pain as "100 out of 10", and writhed in pain as I obtained her medical history. Her pain was generalized -- she couldn't verbalize a specific part or region that aggravated her. Her husband held her hand, and interjected responses designed to guide my decision making. She needed pain medication, he said. Surely I understood. Marla looked at her husband before answering my questions.

I observed their interaction as I listened to her tachycardic heartbeat. Her husband was agitated, and rambled about getting rich from filing million-dollar lawsuits against the hospital. They had visited numerous emergency departments in the area, and one one understood their predicament. She was hesitant. Was she afraid of him?

Gut feelings are hardly admissible as objective medical findings or evidence in a courtroom, but I was suspicious of Marla's husband. I examined her carefully, searching not only for the source of her pain, but for signs of domestic violence. Her abdomen could be concealing a pregnancy or inflamed appendix, but could also hold welts. Her eyes may have the recession of dehydration or the pallor of anemia, but may also reveal the jaundice of healing bruises. Her bare arms were tattooed, but may have also been burned by cigarettes. I found nothing. 

Marla's husband grew impatient. He yelled in my face, demanding a prescription for Dilaudid to relieve his wife's pain. She flinched as he raised his voice. Was he using her to obtain narcotics? Did he force her to come to the ED?


I escorted her to the restroom with a specimen cup. Before she shut the door, I whispered the SAFE screen. Did she feel Safe in her relationship? Had her husband ever threatened or Abused her? Would her Friends or Family know if she were hurt by him? Did she have an Emergency plan? Her responses centered around the supportive nature of her relationship. She told me she would have never survived without his support. Her eyes were dull, but she begged me to believe her witness.

Still, I wasn't convinced. Were my suspicions valid? Perhaps my reaction was transference from my prior violent relationship, and I identified with Marla. Perhaps I was searching for the real reason for her vague symptoms and intense pain. Should I refer her to the police? A social worker? What would I say to them? I had no evidence to support my suspicions. I also had no evidence to support a prescription for narcotics.

I watched as they left the hospital, arm in arm, commiserating about the unfeeling doc who wouldn't give her Dilaudid. 

TIH: Tant (Tent)

This was it. We had eagerly awaited the day when we would enter the "DPs" (displaced person camps) that had been shown behind news anchors reporting on the slow recovery following the earthquake that shook Haiti on January 12, 2010. We had heard of the conditions -- the sweltering tents, the shortage of clean water, the lack of toilets, the abundance of crime secondary to resource shortages. From my vantage point, I believe the team wanted to be part of the earthquake relief efforts. We wanted to feel that we had impacted those most destitute among the residents of Haiti. 

To accommodate the needs of those we were visiting, our team was split in 2. The first group set up clinic in a trio of abandoned, gutted buses left baking under the Caribbean sun. David, our security director and guide, pointed out a few positive signs -- heavy tents were slowly being replaced by 10' x 15' plywood box houses. These were not spacious, not cool, but at least the wood houses provided shelter from the wind and rain. 

The second group traveled a few blocks down to another camp, where we established a camp in a community building. The building's hot tin roof was unkind to those inside, but we made due. We hastily set up in order to begin seeing patients. 

Right away, the difference was noticeable. The people who visited our clinics were weaker, more somnolent, in greater need of care. Security guards were employed to identify patients in need of immediate care, and were triaged to the front of the line. Many needed assistance walking, as they were too woozy or weak to maintain balance. The lack of hydration, underneath the baking sun, inside a heavy canvas tent was a perfect formula for heatstroke. We supplied patients with cups of clean water, but they needed more aggressive methods. In the US, patients with suspected heatstroke may be provided with ice packs, fans, cotton gowns, or even cooling baths. But, this was Haiti. Our suffering patients needed hydration, so we set up a makeshift ward, using wooden pallets as beds and hanging IV saline bags from nails in the wall. 

The patients rested while their family members or friends wiped their brows. One after another, weak patients stumbled towards our makeshift hospital room. Would we have enough IV fluids for all of them? How many needed care in a true hospital? 

The heat was taking a toll on me as well. I began feeling queasy and light-headed. Our team leader Amy voraciously protected us from becoming patients ourselves by insisting upon breaks, water intake, and lunch. My body appreciated the cool water, but after eating, emesis et al were certain. (David teasingly nicknamed my symptoms "Papadoc's revenge"). I asked for the toilet. In the DP camp, the toilet stalls were locked by key, to avoid vandalism, and to ensure that they were clean for the American medical mission team. While gripping my stomach, I retrieved the key. I unlocked the stall door, and walked in. 

TIH

[to be continued...]