under-standing-pain

Starry Night by Vincent van Gogh. What emotions does it evoke?

I am reminded of this one day working at the hospital. My assistant and I are treating a patient while standing. The dental chair is a real marvel. Some of them nowadays have an impressive catalog of configurations. Some of them have a slim profile that allows you to sneak your lower body just under it without that precarious feeling only a dentist knows well. You know, that feeling we sometimes get like the patient is so close yet so far and no posture feels comfortable. This is even assuming your patient doesn’t have vertigo or some issue preventing them from reclining. My most dreaded scenario is working on an upper left molar on patient who is unable to recline too much, who happens to have a short neck, macroglossia and a hypersensitive gag reflex. What can be performed in 15 min then requires triple the time, all the while straining all the muscles that are on and off bothering you week in and week out until you go see your massage therapist to deliver you from the agony. And if you’re not working with your favorite assistant who doubles as your mind-reader, then all the more….cumbersome.

At the hospital I often treat patients standing up. Even when they don’t have physical limitations to demand it. I am not totally sure why. It might be because my own chair does not raise enough for me to feel ergonomically stable. For both my feet to be planted. For my tibia to be at a 97 degree angle with my femur (at least in the sagittal plane); a slight tilt forward of the seat, just before that threshold where your brain warns you that it feels like you’re sliding off. May be it’s because the hospital setting inherently keeps you on your toes. May be… I just need to invest in one of those saddle chairs.

I must confess. Every other Thursday, when I am working a full day at the hospital, I cannot help but feel slight anxiety. It is more physically and mentally demanding; any of my hospital colleagues can surely attest to this. My hospital patients are the more memorable ones, some the most stoical. I feel as though my services their are somehow the most impactful. Imagine having to allocate 4 hours or more of your day to make a trip to the dentist because you have mobility issues and rely on assisted transportation to get places. I often see some patients waiting lonesomely for their ride back home. I can only imagine what their other errands look like. It is very humbling. Those are the patients who need even more intent listening. Those are the ones who really appreciate it when you listened to them, because so many health care professionals barely listened to them along the way. Those are the patients who test your assistant’s patience with you because they talk, seemingly, for ever, and bog down the turn over of the operatory in preparation for next equally demanding patient. I can’t blame them. I work with some incredible assistants whom are often willing to share this responsibility.

I am reminded of that standing moment. Somehow, when you raise your chair to your working, standing height, somehow that feels more personal and less intrusive. Not sure where that feeling comes from, but it is certainly real for me. During that moment, I was attempting to deliver an upper partial denture to one of my favorite patients, who suffers from debilitating head and neck pain, seemingly iatrogenic in origin. All the while, I am preoccupied with the possibility that despite my well-intentioned goal of perserving their teeth and improving their chewing, this denture might in fact cause them more pain. Just as I get ready to try it in for the first time, they tell me they are considering Physician-assisted Suicide. They were burdened by their pain. They were curious by it. I thought they had been dealing with it well. Using different modalities, including mindfulness and cognitive behavioral therapy. They were attuned to it. They theorized in an attempt to demystify it, suggesting that perhaps “pain mimics elements of addiction” neurologically. I couldn’t help but be intrigued, almost convinced, by that statement. It seemed to have some logical merit. Every time I had seen this patient, I thought of the immense responsibility to treat them and in a manner as to minimize their experience of pain. When they revealed that incredible thought with me, all of that responsibility I felt became that much more real. It is as if someone hit that tare button on a scale and it magically dropped to zero. I don’t know if it was a fear of this now uncovered reality, or fear of an abrupt end to a relationship that up until now felt steady. I thought (I hoped) I had read their needs well.

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