Kristy woke up this morning at 4:30 am, after Tori called out her name. Tori – you see – kicks her covers off at night and then gets cold. At the age of 3 she is rarely successful in covering herself back up, so Kristy and I are up 3-4 times per night to assist.
Anyway, this morning when Kristy got up, she let out a small yelp in discomfort. When she returned to bed she sat at the edge and violently rotated through her trunk side-to-side approximately 10 times and lied down again.
“What are you doing?” I asked my pediatric PT wife who does not share many of my intellectual interests.
“Ugh, I slept wrong on my neck and it is killing me. It’s all out of whack. My whole spine has been popping and clicking recently…something is just not where it needs to be.”
I remained silent, but couldn’t fall back to sleep. I took Keitel for a walk instead.
While on my walk, I remembered a conversation about pain that I was having with my father last weekend. Much like conversations with Kristy, conversations with my father will often degrade quickly to one party stating they ‘don’t believe’ something, and another party trying to share compelling data or information to help the other appreciate that belief is often a proxy for a lack of understanding – which, as you might imagine, usually does not end well. That is how I see it, anyway.
In this most recent conversation though, we were talking about the many factors that influence a patient’s pain experience. I had mentioned that, as a culture, we exercise a great amount of hubris when we claim that we understand how pain comes to be, when it is simply a small aspect of our conscious experience, which -last I checked – scientists still don’t understand, either.
“How is it then that everyone in the world, doctors included, gets it wrong?”
I failed in my response. I talked about Descartes and dualism and about the flawed thinking that has continued for hundreds of years as a result. I talked about there not being ‘pain receptors’ that ‘tell you that you hurt’. I won’t go into the details; they are not important and I know that most reading this have had similar conversations with their own families, patients or acquaintances.
Regardless, he couldn’t, or didn’t want to, understand. Conversations between family, after all, are filled with motivated reasoning (not that I am not immune from falling prey to similar motivations, myself.)
On my walk this morning, I thought of something that I could have said that might have made sense to him:
What you need to understand, Dad, is that nociception – the signals from those nerve endings in your hip are just dummy lights, nothing more.
Remember my ’87 Caravelle that had the temperature light that would always turn on and we kept replacing the thermostat until we figured out the computer was broken, then we just kept driving it because it was cheaper not to get it fixed? Sure the light came on, but we were able to make an assessment and determine if that signal had any value – in that instance, we quickly learned that it had no value and I learned to simply ignore it.
Or how about when you are driving around town in one of your vehicles and the ‘low fuel’ light turns on? Whether you decide to fill up now or later depends on the vehicle you are driving, how far you need to go and what neighborhood you are in. If you are driving the pick-up, you know that you can not drive as far as in the Elantra before you run out of fuel, so the vehicle you drive – to some extent – changes the meaning of the light. If you are only a few minutes from the house, you might be able to run a few errands over the next couple of days before filling up. Meanwhile, if you are on the south-side and would prefer to avoid the risk of getting shot when you step out of the vehicle, you would probably keep driving until you are in a safer neighborhood. Even still, there are times when the light will turn on and off , simply by parking the car facing up or downhill – with the actual fuel in the tank changing.
The point is, nociception – those signals that originate in your hip (for example) and arrive at your brain after traveling through the spinal cord – are only dummy lights to the unconscious mind. The brain still gets to decide what it wants to do with the information once it gets there.
This metaphor will not work for Kristy when she rises again, later this morning. Perhaps I can come up with something else that might work for her, or (as was the case with my father) maybe the idea will come to me 5 days later. In the end, it probably won’t matter – like most of my patients, she may feel better by the time I figure it out anyway.