Pain is Temporary

I think that’s one of the hardest things for patients to understand. Kids in particular have a hard time with this. I had to relocate a dislocated shoulder for a 15-year-old girl who was in a lot of pain. She had dislocated her shoulder during swimming practice. She was very anxious, but she was also very anxious about us placing an IV or giving her pain medicine before we pulled on her shoulder. Her shoulder was clearly hurting. The sooner we can get it back in place, the better.

Sometimes dislocated shoulders need IV pain medicine or even sedation because the patient cannot tolerate the pain. I usually present those options to the patient:

We do it now. (Fastest option)

We put an IV in and give you some pain medicine and then do it. (Slower, plus an IV.)

We put in an IV and put you to sleep briefly. (Slowest, plus an IV, and highest risk.)

We sedate patients regularly for various procedures, but there is a risk every time. Most of the time, everything goes smoothly. But the risks of an adverse reaction to the medication, decreased breathing, or hypotension are real. They are rare but real.

Additionally, it takes time to get all the necessary monitoring equipment in place, assemble the personnel to help, and sometimes move to a different room that has all our supplies in case something goes wrong. Plus, you’re usually in the ER longer because you have to wake up from the sedation.

So the patient has a choice: endure their current level of pain and likely some very brief increased pain while doing the procedure (usually less than a couple of minutes), but then feel much better quickly. Or they can endure the pain they have until the more complicated solutions happen.

Fortunately, we were able to convince this patient to let us pull on her shoulder. In this case, we got it back in place within 10 minutes of my initial conversation with her. That’s generally the best option. Her pain was immediately better—no pain from an IV and no risk of sedation.

I had a more difficult experience with a 10-year-old boy who dislocated a finger. Relocating fingers is usually very quick. The pain can be worse very briefly, but once the finger is back in place, the pain improves. We spent over an hour trying to convince him to let us pull on his finger. Mom tried, I tried, the nurse tried… but he was too anxious to let us do anything.

Dislocated fingers don’t need IV pain medicine and certainly don’t need sedation to relocate. Most of the time, we can anesthetize just the finger for pain relief, but that procedure is painful as well. It involves a needle. Injecting anesthetic medicine is the same as going to the dentist—the initial injection hurts just before the area goes numb.

This patient would not let us do anything involving needles, and the ER visit dragged on unnecessarily.

Ironically, after the patient finally let us relocate his finger, he wanted to leave immediately. After a dislocated joint is relocated, an X-ray is almost always done to confirm it looks better, and then the patient gets discharge paperwork. He made a comment along the lines of, “What took so long? Why are we still here?”

I wanted to say the truth, i.e., you’re here because you wouldn’t let us do the thing we knew needed to happen the minute you got to the ER—you whined about it for over an hour.

Instead, I just apologized for the delay and the process.

And left my shift a little more bitter.