Recently I have had to deal with a patient who refers to herself as my "worst nightmare". I knew she would be difficult before I ever did her surgery. She had warned me that she always had a lot of pain and it was difficult to control. I knew she would need more TLC than most patients.
I always call outpatients the night of surgery. It helps me sleep better and hopefully them/their families too. The night of her surgery (and I have learned to double check phone numbers where they will be), I called three separate times over a 2 hour period to two numbers. No one answered any of them. I left a message that "If there are any problems tonight, please, have me paged through the Medical Exchange at ****. I will check on you again in the morning." That night it was quiet.
I called her the next morning and this time she answered.
"I'm in so much pain."
After going through a list of questions to make sure there were no other issues (no undue swelling, no fever, etc), "Have you tried taking the Xanax with the Percocet?"
"No. I didn't know I could do that."
I had written the Xanax prescription after seeing how she dealt with the pain in the recovery room. Nothing we tried had seemed to make her comfortable until we tried it. I mean nothing including morphine. And physically she appeared okay.
I explained that she could. That the Xanax would help her nerves and help her rest. "So why don't you try that. I'll call you again tonight." She agreed.
I called back that night (Friday). Things seemed to be better. Saturday was quiet. Sunday, just past noon, the pager goes off. I called the number.
"Dr. Bates, it's your worst nightmare. The pain is horrible and I don't have any pain medicine left."
I go through the same list. No undue swelling, no fever, etc. So I offer to call in some Darvocet (and do so). I don't offer to meet her and write a new script for the Percocet. I don't suggest that she go to the ER. Two hours later, the pager goes off again. Same patient.
"Dr. Bates, I'm so sorry. It's your worst nightmare again. I don't know what to do. The pain is so bad."
This time I firmly tell her that she will have to tough it out until tomorrow (Monday) as I can't phone anything stronger in for her. She will have to make due with the Darvocet. (By my count, the Percocet should have lasted her until Monday or Tuesday).
Nothing more from her until first thing Monday morning when she calls the office. "Dr. Bates, it's your worst nightmare. I am in so much pain."
"You are no where near my worst nightmare, but we won't go there. Why don't you come into the office so I can see you. You will have to come into the office before I give you anything more for pain."
She comes in. Her exam is benign. She is healing as expected. I touch the operative area gently--she flinches. I leave it and keep talking to her. She visibly relaxes, as the time passes. I keep up a constant patter. I remove her stitches and tape the incision. I deliberately touch the area again with slightly more pressure. This time there is less flinching. I keep talking to her. Then one more time palpate the area. This time pointing out how she allows me to do so.
I give her one more script for Percocet and Xanax. I caution her to take them as prescribed, not more often. I bring up the young actor, Heath Ledger, who recently "overdosed" on prescription medications. She says she didn't realize you could take too many. She did fine from that visit on.
So for her I think that much of her pain was in her head. I think she "thought" she hurt more than she "actually physically" did. I don't mean to belittle her pain, but she had had a few bad experiences with pain, so she ANTICIPATED that each new event would be as bad or worst. I think that "fear" adds to her pain.
I try to get patients to realize that there will be pain, but that each day will get a little better. I don't try to make "light" of it, but to get them to distract themselves. Or to "reassure" themselves that it is not a permanent state. Postoperative pain (I know there are exceptions) is not a permanent state. It will go away.
As far as being my worst nightmare--not even close. Some of my "worst" nightmares would include an abdominoplasty patient dying of a pulmonary embolism (PE) 2-4 weeks after surgery, any patient getting toxic shock (was consulted after the fact on a patient once who needed a gastrocnemius flap to cover her knee joint after surviving TSS post-knee surgery), or this.
Or if we're talking non-patient related then this (snakes wrapped around you).