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Pain Overlooked – Imperfect Technology

Richardson, Michael G. MD

doi: 10.1097/ACM.0b013e318192cf05
Other Features: Teaching and Learning Moments

Dr. Richardson is associate professor, department of anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

As always, I review his chart before I meet him. What a fantastic computerized medical record system … instant access, point-of-care information, making what we do safer, more efficient and complete. Whoa, quite an extensive record since his motorcycle accident. Months later, 188 separate entries. Many fractures. Many details. Intervening months, dozens of clinic visits…. Today, he returns for L2 kyphoplasty. Persistent pain since his accident. PRN Lortab. Small incision, prone, straightforward.

Holding room slot one. We shake hands. He appears his age of 57 years. Friendly, affable, appears well five months later. “Looks like you’ve had quite a rough time since the summer. How’s your recovery coming along?” I inquire with empathy. I select words carefully, hoping that, in our brief minutes, I will connect. If he detects my effort to know his important details, he might infer that I care, or at least that I’m trustworthy and competent.

“Oh, it’s coming along,” he slowly nods, his gaze suddenly distant. “How’s the pain been?” I attempt to engage him. He returns, realizes I’m referring to his orthopedic injury, “Oh. My back. I’m managing. But it’s been difficult.” “Oh?” I sense something more.

“I wasn’t alone when I crashed. My wife was with me,” he pauses. “The next day was our 29th wedding anniversary. That’s the day she died.”

I draw closer, the paperwork in my hands drops away from this sacred moment. I can’t find a single word. I look into his eyes, and manage a whisper, “I’m so sorry.”

He gazes away, “Strange thing is that my daughter arrived at the scene right after it happened. I heard her, ‘That’s my Daddy! And that’s my Mama!’” “How was it that she was there?” I’m incredulous at the enormity of it. He looks at me, “She lives in the same town, just happened to be driving by.” “My God …” I’m overwhelmed. “How’s she doing?”

“Not well.” His face looks exactly like the worst kind of suffering would look. “She doesn’t talk about it, but I know she’s having a real tough time.”

“Is she getting any help?” “I don’t think so.” Has this tragedy torn them apart? Is his suffering doubled, from the pain of his loss and the guilt of taking his daughter’s mother from her? “There are people who can help you and her through this …”

After leaving that moment, I reflect on the privilege of this work, the space I’m allowed to enter, to hear him, to be present. But, I’m uneasy, bothered by the fortuity that should not have been. Granted, I made a smooth recovery, but I bumbled into his world. I should have known. I reviewed his records; how did I miss the only detail that matters in his life right now?

I return to his records to seek my error. I scrutinize the entries…. There it is!

Entry # 42 – Discharge summary, a hidden sentence provides a clue: “recommend brief inpatient rehab, but patient requests home health PT/OT to attend his wife’s funeral.”

Entry #132 – “Incoming Correspondence,” third paragraph: “Patient having difficult time handling depression issues from accident. Has taken himself off antidepressants a few times only to experience extreme grief. Suggested psychological intervention, but patient resistant to this option at this time.”

I cut myself some slack, just a little. The information is there, but so deeply buried. And, I’m only human, I rationalize. But this system is mine, too. I can’t help but accept some responsibility. I amend the “social history” hoping that someone, sometime, will read it and be moved to work towards this man’s healing.

Social History: The motorcycle accident occurred on Jun 8. His wife died the next day. It was their 29th wedding anniversary.

Michael G. Richardson, MD

Dr. Richardson is associate professor, department of anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

© 2009 Association of American Medical Colleges