COLUMN: Feel the Pain of Living

From Tim Zeigler's "Turn Your Head and Cough?," Fall '94 Watching the news or walking the street brings the knowledge of much pain and suffering, an abundance of unmet need, and the huge capacity of humankind's indifference to it all. It is no bold revelation that, in general, life is simply not fair -- true justice is somewhat randomly distributed. What is disturbing is the frequent and extreme nature with which life is proven to be unfair. Upon the uncontrollable elements of natural disaster and disease, we can heap humankind's ability to be perfectly shitty to each other. It is a world where little boys can be drowned at the bottom of boat ramps by their own damn mother. Indeed, Perry (Farrell), nothing's shocking. Medicine is one particular field that affords a front row seat to the many consequences of all this fate and folly. Whether by chronic disease or acute occurrence, the sick and injured experience the harsh reality of their own mortality -- the fragility of being a physical entity subject to the effects of the passage of time and the laws of physics. This awareness remains even with those who will fully recover. For others, there are new limitations that can impact upon work and leisure, perhaps even threatening the independent existence so long taken for granted. And there is pain. Physical, emotional, and intellectual. Chronic, acute. Sharp, dull. Intermittent, constant. Pain of living, pain of dying. To experience it all, to fully empathize with all the distress to which you are exposed is to invite burnout. Survival becomes dependent upon limit setting, a method of separating that which you acknowledge (and treat) from that which you feel. Certain levels of pain are simply taken for granted, especially if some relief can be offered. Patients recovering from abdominal surgery will not be anxious to do many sit-ups for awhile. Get thee to some morphine, go. Another defense is the use of pet phrases and acronyms that sterilize the injuries and procedures of the raw human pain they actually entail. To say that a pedestrian struck by an automobile has "an open, bumper fracture" of the leg is much less disturbing than the fact that the jagged edges of the patient's tibia and fibula have torn through the skin. Finally, and perhaps the least savory, there is the timely use of medical slang. A patient with multiple, severe medical problems that require intensive (and possibly futile) management is referred to as "a train wreck." A patient that has begun a slow, progressive slide towards eventual death is described as "circling the drain." The uninitiated may deem it a dreadful form of dehumanizing the sick and trivializing their suffering. I beg to differ. The humor is gallows. Any "laughter" that is perceived is rueful, steeped in the bitter edge of our eventual powerlessness. Any casual callousness is a form of compensation, a filing away of feelings to be dealt with "later." If every doctor, nurse, and therapist went down with their patient, there would quickly be nobody left to order tests on the ones who were still alive. So distances are maintained and barriers erected, selective defenses to help filter out the white noise of anguish that surrounds you. At the least, you must save enough of yourself to continue to rise from bed, go to the hospital, and treat your patients well. The needs of the many ... blah, blah, blah. Just as surely as the defenses must be built, they will occasionally be broken. Whether suddenly overwhelmed or slowly eroded, experiences do come that are felt to the core. The first trauma patient I ever saw instantly redefined my upper limit for horror. It was nearly three years ago, only my second month of clinical rotations and my first day (hell, my first 15 minutes) with the trauma surgery service. Found in a crackhouse, the victim had been shot execution style in the head, wounds which proved to be fatal shortly after his arrival. Disturbing, but not shocking. After all, nothing's shocking. While assessing his injuries, one of the surgeons described "multiple defensive wounds to the upper extremities" -- a harmless phrase devoid of implications of pain. In perhaps the coldest moment I have ever known, I then saw the patient's hands and forearms. They had holes in them. Many holes. The realization came in a sudden, uncontrolled flash. The person is on the ground staring up into the barrel of the gun, crazed with fear and screaming "no, no, no..." There is an overwhelming want to simply disappear, to be anywhere else, someplace where a mother's hug could still protect. The outstretched hands are opened pleadingly, trying to form some protective barrier from the gun and, at the same time, seeking mercy. There is none. The bullets come, erupting through the backs of the hands. In a final desperate gesture the arms are drawn back and wrapped over the face. It is futile, like turning your head from an A-bomb. My mind shuddered at these thoughts as I slammed a mental door on my empathy. But the coldness of this full realization would never be completely gone. No amount of clicking my heels while saying "There's no place like home" purged the demons or brought back Kansas. The chill is renewed with every patient who appears with these tell-tale injuries, whether by shooting, stabbing, or beating. Cold world, very cold world. In life, as in medicine, it should never be a choice between the extremes of feeling everything or feeling nothing for those around us. There is a middle ground to be tread upon, a never-ending balancing act that allows life to be lived, rather than merely endured. On those days when the attitude that nothing's shocking is proven utterly wrong, stagger through until you can retreat to home and curl into a ball around whatever or whomever makes you happiest. At all costs find redemption, a reason to save yourself. I can usually think of a few... Tim Zeigler is a fourth-year medical student from Williamsport, Pennsylvania. Turn Your Head and Cough... appears alternate Wednesdays.