Pain Management in Difficult Situations

A reader writes: "I just came back from an elective in Nepal in orthopedics. A lot of what you describe (about Guatemala) sounds eerily familiar... especially what you mentioned about pain management. If the situation in Guatamela is anything like it was in Nepal, I think it's not that they're more stoic there... they tolerate the pain because there is no choice. And I think that tolerate is probably the wrong word... I'm sure it has the same negative effects on a patient there as it would here. In Nepal, we didn't always have anesthesiologists or a GP with us, and ortho surgeons are not allowed to administer procedural sedation. Strictly speaking, they're not supposed to do bier blocks or nerve blocks either. Which meant that we ended up doing a lot of closed reductions without any anesthetic. I can't imagine how the patients felt, but I have to say that I was just horrified. I wonder if you had similar feelings, and if so, how did you deal with them?"

Whenever a health care provider doesn’t have the equipment or drugs needed to optimally manage a patient, he or she must make due with what is available. Sometimes this means that you can manage the problem fully, but sometimes it is only possible to achieve a less-than-desired result. I am a bit surprised that the orthopedic surgeons were not allowed to administer local or regional anesthesia, because they are usually trained to do so. In any event, if no one was available to provide significant pain management, then one would have to decide how best to proceed – allow the victim to endure the persistent pain and possible adverse outcome of a nonreduced fracture, or proceed with a painful intervention and know that as soon as the bones were properly aligned, the pain would rapidly diminish. I have been in that situation many times, most often on the athletic field, where a quick reduction (usually of a dislocation) is momentarily painful, but solves the situation.

There are other techniques that sometimes diminish pain for the victim. Ice packs properly applied make a difference, as can emotional distraction. Still, without “real” pain medicine, moving a broken bone really hurts. I’ve been there myself with a fracture-dislocation of my ankle, and the narcotic injection was most appreciated.

When I wrote that the patients were more stoic, I did not mean to imply that they didn’t feel the pain. Many of these persons do not have easy access to medical care or the copious number of pharmaceuticals (including pain medication) that we expect in the U.S. So, they are indeed more stoic, complain less, and are more accepting of a delay to therapy and relief than are most persons in our culture. Given their attitude, the pressure is even greater on the providers to work diligently to make these patients more comfortable, because they may not be fully expressing their true needs.

How do I feel when I’m caring for someone and I can’t do everything I would like to do? If I think the outcome will be acceptable, I live with it. If things are going poorly, I get frustrated, unhappy, and sometimes angry (at the situation, or even myself, for not being able to improve the situation). But I always do my best to hide any negative emotions from the patient, family, bystanders, and other health care providers. Much of the time when I practice medicine, I am in charge, and if I “lose it,” nobody benefits.

Tags: Guatemala, pain, wilderness medicine, outdoor medicine, healthline

Labels: Guatemala, Nepal, pain, pain management

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