A recent experience has led me into the heart of a number of medical experiences.  For families in our practice, I wanted to be sure you knew that I am very fortunately quite fine.  For all readers of Real Answers, I thought it might be helpful to share some of these experiences and what they have taught me so far.  No one wants to be in a position where they need any medical care and that certainly includes me. But it turns out that we all do at sometime or another, and as a doctor I think it’s important to learn what life is like as a patient in the American medical system so that we can improve on those experiences to the best of our ability.  With all that in mind here is the story of a recent fall and the subsequent needs for care.

The Fall

This story begins with what was to be an exciting day in Columbus Ohio. As part of my work with the American Academy of Pediatrics, I was visiting two very exciting programs in Columbus on December 4th.  One is a program devoted to reducing the chance of babies of color dying before their first birthday, a risk that is double that for white babies, across America.  The US Army is one of the only groups of people in the country to which this difference is almost nonexistent.  It turns out that in Columbus, Ohio an obstetrician has put together an extraordinary program that engages community resources so effectively that the  white-black difference in infant mortality has actually been substantially reduced.  The other program was planning to visit is called PACT, and it has transformed one of the poorest neighborhoods in Columbus into a middle-class place where people prosper and crime is nearly eliminated.

On arrival in Columbus, I was at a gas station filling my car, place the pump in my car and walking two steps to sit in my car and wait for the filling to be completed. One of those steps landed in a strip of gasoline spilled before I arrived. I suddenly found out gasoline is extremely slippery and my feet flew backwards leaving me horizontal in the air and very soon afterwards dropping rapidly to the ground. The good news is that almost all of my body is perfectly fine. No harm to my head, back, right arm or leg. The bad news is that the fall dislocated my left shoulder which was very painful for a couple of hours until it was put back in place at the Ohio State Wexner Medical Center. At the same time, the fall fractured part of the head of my humerus and both forearm bones, and caused the number of tears in the joint.

Some Observations

I have always felt very strongly that one of the main reasons to be a doctor is to reduce suffering and promote good health. As with all work, we sometimes succeed but not always.  The point is to always strive to do better. My recent experiences with the fall and its subsequent injuries have taught me many things about how our medical system does wonderful things, and at the same time that there are some ways it is organized get in the way of doing better.

My first set of observations have to do with the experience of acute pain. I imagine that everyone experiences pain in some way or another. It’s hard to go through any number of years without some bumps or painful illnesses.  Certainly as a doctor, I have shared many many very painful experiences with many many families.  But for whatever reason, I have been spared truly extreme pain in my own personal experience.  After this fall, I got to experience about 2 hours what I would consider truly extreme pain. I do not share this fact to upset anyone, I am most fortunate this experience only lasted a couple of hours and that since that time I have been quite comfortable despite the injuries that occurred.  So I share these observations with the hope that how are medical systems approach acute pain can be improved, not to be upsetting.

What I really learned is that a shoulder dislocation can hurt tremendously, and the pain can be ended dramatically by placing the shoulder back in joint.  At least for me, the pain was severe enough that provision of opioids in the emergency room had no impact on the pain at all.  But after waking up after mild sedation for the replacement of the arm into the shoulder joint I was amazed to find that so much of the pain had gone away. Again I’m very grateful that I had a resolution of this part of the crisis in less than 2 hours from the time of the fall.  This is a sign that the medical system ultimately worked for me, and worked well. At the same time, I do believe that there could be significant reductions in that time.

The 9-1-1 system works very well, an ambulance arrived shortly after the call was placed which was immediately after the fall, and the team provided prompt transportation to the emergency room.  I do wonder since the cure for this horrible pain is a simple physical manipulation of the joint, whether in ambulance crew could be trained to reduce the dislocation in the field. This sort of service could end the pain within minutes rather than hours.  The main reason I believe this would be bad idea is that the reduction often has to be done under sedation and sedation in the field is a risky proposition.

Leaving aside the question of whether the system could be improved by joint reduction in the field, let us think about how emergency room service is organized.  The ambulance drivers ascertained that my shoulder was out of joint moments after arrival and so the emergency room staff were well aware of the situation even before I arrived.  it would make the most sense for a system of care to be organized to rapidly find out if there’s any reason not to proceed with immediate reduction of the joint , and if no such reason is found, reduce the joint as soon after arrival in the ER as possible.

Again my overall sense is that the ER provided thoughtful and prompt care, my observations are really musings on how systems can work even better to respond to these situations.  With that in mind,  I will share my sense that it took a rather long time to register me, during which time I was asked to spell my name and wait as everyone does for the next doctor to be available.  It also made sense the process required me to have my joint x-rayed to prove that a dislocation was indeed present.  After all relocation of a dislocated shoulder require sedation and one should be sure that a dislocation is present before sedation administered.  At the same time, I do wonder if a system of care in which thoughtful medical professionals can ascertain a dislocation is present and take action to resolve the crisis within minutes rather than hours could be workable.  Once the pain is resolved taking time for a distraction and collection of other possibly relevant information can be taken so much more comfortably.

Of course these thoughts are relevant to a wide range of medical needs. Thinking about how to respond to so many situations to achieve resolution as efficiently and rapidly as possible is something every system of care should be thinking about. I’m sure we have opportunity in our own practice to make progress in this direction, and hopefully people do appreciate that we have tried to organize care with this in mind all along.

The last observation I’d like to share this time, is a new appreciation for severe pain. As mentioned above, as physicians we help the unfortunately large number of people who have or continue to experience significant pain. This is a problem I hope we always have cared about. But my own experience of extreme pain has taught me something extremely valuable. That is the overwhelming power of pain, the more extreme of course the more powerful.  This is a fact that everyone knows, and certainly one that I have been aware of. But experiencing it, actually experiencing it, has led me to a new level of understanding that I certainly plan to carry forward as I care for anyone else unfortunate enough too also experienced severe pain.

BOTTOM LINES

1. Of course, pain is a terrible experience, the more severe the more terrible.
2. It rests on the shoulders of the medical profession to make sure that the way care is delivered shortens the time anyone has to suffer pain.  

To your health,
Dr. Arthur Lavin