How can you bump into invisible people, but still not notice them

As usual, I will start my blog post with a reference to a TV show or movie. If I were more the philosopher, I would question whether we are the TV show, and in fact the TV show is the reality. After that I would ask you to snatch a pebble from my hand, but I really do digress.

One of the fascinating things to me, in retrospect when watching the original Star Trek series, was the medical ward. When a patient would lie down on one of the examining beds, the patient’s vital signs would immediately appear on the screen above. Considering that this was a show from 50 years ago, it really was quite amazing as to how the creators visualized the future of everything.

One of the indicators over the beds was for pain. As the nurse would walk by, he or she could see whether the patient was in pain by looking at one of the indicators on the screen. I don’t know if the creators of the show dealt with the whole neuro-psycho-biological issue of pain, i.e., how much of pain is the physical stimulation of pain fibers versus how much of pain is the interpretation within the brain of those stimuli. Just like with our vision, there may be a specific object in front of us that we are looking at, but we “see” something totally different because of the way our visual brain center interprets the neural stimuli from our retinas. But once again, I digress.

In any case, the idea of being able to measure pain just as we measure blood pressure and pulse is game changing. The simple reality is that the majority of patients go to the doctor because something hurts. Of course, there are the regular yearly visits to make sure that all is okay, but the majority of the time, people think of their doctor, or of any doctor, when they suddenly have chest pain or abdominal pain or start to vomit for no apparent reason.

Being able to measure the pain of a patient would not be for the purpose of identifying fakers. Certain people experience more or less pain, or tolerate pain better, for the exact same injury. Claiming that the patient doesn’t have a damaged knee just because they manage their pain better, would be foolish. But for children, older patients, patients who for whatever reason are unable to properly express their pain, such a sensor would be invaluable. As usual, I suspect that it will be approximately 20 years, i.e., 10 to 30 years, before we have a pain sensor that is not interventional, i.e., that does not require the insertion of needles into our brains.

What happens today? How is pain assessed today? There is no question that between local anesthesia and opiates, we have the ability to control pain quite well. But how do we know who really is in pain and more so, how much they are suffering? The simple answer is, we don’t.

Early on in medical school, you are already introduced to the concept of drug seekers, i.e., people who present to the emergency room looking for opiates because of a chemical dependency. There are a whole range of “tricks” that users learn, in order to get physicians to write them a prescription for pain medication. My training was in urology, and one of the tricks in this field was to prick your own finger and to squeeze a drop of blood into the urine cup. The blood would show up on the analysis and along with the claimed severe flank pain, the doctor would assume that the patient has a kidney stone and give an opiate injection. Just as an aside, this has changed as, these days, the first line of medications for kidney stone pain are not opiate-based. But the drug seekers know how to work around this.

Chronic pain sufferers, for whatever reason, quickly develop a reputation for seeking powerful pain medication. Sometimes, when you look at the medical record of such patients, all you see is line after line after line of documentation concerning prescriptions for various opiates. These days, there is the option of using medical marijuana to control pain, and the concern over falsifying need has grown even more.

There are many doctors, young and old, who will always be suspicious of such patients. Pain patients simply get used to hearing phrases like “you don’t look so bad today, I guess you’re feeling better” and “I can’t give you any more opiates so you’ll just have to manage with Tylenol” and so on. Chronic pain patients will also hear far too often that “you’re not in pain, you’re just depressed and that makes you think you are in pain”. Imagine telling a psychotic patient that they are just paranoid and that they don’t need to take their antipsychotic pills. Imagine telling such a psychotic patient “just get over it” or “you’ll just have to learn to live with it.” I will admit that there are very few chronic pain patients who aren’t depressed by virtue of their chronic pain and being treated like a pariah. But again, that’s equivalent to saying to a postoperative patient, “the reason it hurts is because you just had surgery. That doesn’t mean you need pain medication”.

I would argue that of all things that doctors fail at, managing pain appropriately is at the top of the list. There is tremendous research going on now in all areas of neurobiology that are opening our eyes to the way our brains and bodies respond to any form of attack, i.e., knife wounds, and infection and so on. What we need is a non-interventional way of measuring people’s pain. It doesn’t have to be wireless in version 1.0. It can definitely be the size of an ECG machine that requires its own cart to be moved around. But what we need is a device that can be placed on the head or somewhere else on the body that can give us a numerical measure of a person’s pain. Once again, a low number does not necessarily mean that the patient is not experiencing pain. But a high number should make a doctor very suspicious that pain control is inadequate.

Pain patients tend to be ignored both in-hospital and in the community. If simple medications don’t help to control the pain, doctors feel impotent in their treatment of these patients. At the same time, there is regularly published research that speaks to the risks and dangers of opiate medications. It is hard to describe the feeling a person has, when they are in significant pain, know that a couple of pills of Vicodin could make the pain go away, but no physician is willing to prescribe it. The patients feel ignored, marginalized, and yes, depressed.

I know one patient who chronically suffered for years from pain, who lost a significant amount of weight because of it. People being who they are would greet him with a positive face and a pat on his belly and say something like “you look great.. You must be feeling better. Keep it up”. Once again, it is hard to describe how painful this dismissive attitude is. There are unquestionably pain patients who do overplay their pain, not to receive extra medications, but just to get the pain medications they merit. And yes, if a pretty woman in high heels walks into a male doctor’s office and complains of bad back pain, the likelihood that she will get a prescription for whatever she wants is much higher than for an old, hunched over, long-suffering man. Prejudice in medicine work both ways.

I don’t know if it’s appropriate to pray that a solution be found. What we need is a startup that has identified this as their focus, and then for this startup to get the funds it needs, possibly from someone who is both wealthy and a chronic pain suffer. I guess it can’t hurt to pray. I just don’t want someone thinking that I’m talking to myself or to a delusional character secondary to all of the opiates I’m taking.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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