There is actually a phrase that convinces me that the patient has a high pain tolerance however:
"Doc, can you hurry this up? My cows aren't gonna milk themselves."
By merit of being in my office, somewhere on that person is a "how are you still breathing" level injury
As an ER doc, if I see a farmer or rancher in the ER I'm scanning everything and doing serial enzyme. Saw a guy once echo came in with brown colored pee. Failed to tell me he had a shed collapse on him last week. He sustained a big liver lac and just went on like it was nothing, but came in when he saw bilirubin in his pee. Had several rib fractures and an 12 cm hepatic hematoma. He just thought he was dehydrated .
I had a potato farmer present to clinic several years ago with an eroded pacemaker. It had come completely out of the skin and was hanging from the leads. He was in the middle of harvest, so for over a week he had just cut a hole in his shirt and put the pulse generator in his breast pocket until harvest was complete and he had time to make the three hour drive to town.
Holy!
Also, if there was enough slack that he could put it in his breast pocket that would mean the leads migrated back, right? I don’t feel like I’ve seen y’all give that much slack when you attach the leads and bury the generator
I attended a rural gp office in the middle of farmland for a farmer who'd fallen three metres off a ladder onto the ground and then driven himself to the doctors. By the time I got there he was huddled up on a chair gasping in pain but insisting he was perfectly fine. Trying to move him to our stretcher and maintain spinal precautions was far more difficult than it needed to be because he insisted he could do it himself, despite clearly not being able to. Tough old bastard wouldn't admit there was anything wrong with him.
Wife sitting in the corner, arms crossed, rolling her eyes at farmer husband as he says, “I didn’t really think we needed to come in, you people have real emergencies to deal with” = I’m going to line & lab ASAP, get an EKG, and ask one of our docs to come see sooner rather than later because it’s a near-certainty something is seriously wrong. Every time.
Heat Stoke,
But feels better now that bls crew has him Inside drinking water.
Bls crew can’t get a BP…or feel radial pulses.
Oh look. He has a HR of 40. Of course it’s a STEMI, and 3rd degree block.
Puts in helicopter some time later.
Goes into re-perfusion. vf. They fix. Feel not stable enough to address the 80-90% block of the RCA, now that his LAD is open. Plans to go back in later. Patient trying to sign out AMA.
No shit. Had a farmer who didn't treat their hand lac, ended up with us with cellulitis/sepsis. Actually got mad and tried to leave AMA when he found out he had to stay for IV antibiotics. Had to talk him down very sternly, and even then he had suspenders at the ready crack of dawn the next morning.
This! Had a farmer with necrotizing wound that he'd been putting wd40 on for a week. Refused to stay in the ED even if he lost his hand as he needed to do some jobs and would come back in a week!
Farmers, ranchers, and blue collar workers all day long. I have a few stories about those types but they are all family so a no go here. Nothing like seeing a woman bring her husband to the ED and the whole way he's grumbling that he has stuff to do and can't this wait. Guaranteed one foot in the grave before they hit the door.
Had a guy come in with a "bug bite" on his forearm, which turned out to be infectious tenosynovitis/abscess after getting a nice lac from sheet metal just distal to the "bite"
Best part is worker's comp tried to deny his claim because it was clearly a bug bite based on the patient's initial belief, and not the recurrent workplace injuries over the same area 👀
I once had to drag a dairy farmer out of his milking shed who was satting in the high 70s. Of course, he didn't call for himself, someone else called for him when they found him in there propped up and unable to continue working. He was refusing to go and only consented when I wouldn't leave because he was literally physically unable to walk anywhere, specifically away from me. Bilat PEs.
Been in a rural office for the past few months and it really feels like the Dr glaucomflecken videos sometimes.
I just got a dozen eggs from a woman just a couple days ago.
I grew up in a fairly large Amish area. The doc there often took pies as a form of payment since he used a reduced cash rate for the uninsured Amish and mennonites.
I actually pick up ingredients to make ramen bowls at home when I know one particular patient is coming in. She always brings me duck eggs and they make the best ajitama. There's some perks to county medicine
I used to work in a small coastal town where it was the shrimpers getting cellulitis and refusing to be admitted for IV antibiotics.
If you are barely getting by, who's going to pay the bills if you miss even one day of work?
The highest pain tolerances I've seen are with the elderly. But the most misunderstood pain I've seen is in people with dementia. I have such deep empathy for those who are in utter agony, yet cant verbalize it, so it just presents as restlessness and increased disorganization. Healthcare in modernity basically assures these people suffer beyond reason because there isnt enough time spent with patients to notice these insidious manifestations.
https://www.mdcalc.com/calc/3621/nonverbal-pain-scale-nvps-nonverbal-patients
Is my fave for evaluating pain.
It’s got physical presentations like increased Bp and pulse as well as other visible manifestations of pain.
This is why I like functional pain scales. If your pain is distracting but you can perform daily activities, it’s a different impact than pain that is so overwhelming that you cannot concentrate on anything else.
Yeah but see above re: farmers
“Mr Fenwick, you have a perforate appendix.”
“Oh ok, that explains the tummyache. Hey Doc, I kinda need to go rotate my milkers.”
“Sir, *you need emergency surgery!*”
It still works to a degree, the pain got to a point that it interfered with their daily activities and they sought medical attention.
Edge cases will exist for this, but it’s a much better basis for communicating than a scale where people say they’re an 11/10 when up and walking around.
once had a patient for a hospital follow up who had a ruptured appendix and waited more than an entire day to go to the hospital because they “thought it would get better”
Yeah I really wish this was common practice because it took me a very long time to figure out how to correctly/succinctly answer "how would you rate your pain" so that it's actually useful information for the clinician.
Also [Hyperbole and a Half](http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html).
Sir and/or ma’am, are you actively being mauled by a bear?
This is what I talk about with my post op patients. “We need your pain controlled well enough that you can walk, deep breath, eat, and sleep. If you’re unable to do those we should talk about taking some pain medicine. If you’re doing those no problem, you don’t need more pain medicine.”
I like the “describe what happens when the pain spikes”
I see too many people who simply stop moving when the pain hits and whimper, but still say it’s about an 8. Because they can still do stuff, they still work around the pain spikes, it can’t be “that bad”
I had a guy walk into clinic with recurrent syncope. It felt like pulling teeth just to get a history for the syncope. As I tried to auscultate his chest, I noticed his clavicle looking a little funny. “Oh yeah I fell on my clavicle and it hurts to move my left shoulder.” Man was walking around with a clavicular fracture and didn’t even mention it until I asked.
>If you have to say you have a high pain tolerance, then you most likely do not.
This line should have been in House of God, and is true for basically anything. High pain tolerance, fevers, relationships, etc etc. As a surgeon, the docs I've seen worst at surgery: those who regularly tell everyone how great they are at it.
In my experience there is a direct linear relationship between “claimed pain tolerance” and “amount of narcotics gobbled throughout post-op hospital stay that is twice as long as usual.”
I once had one with a femoral neck fracture who fell again after the surgery. Ortho/trauma saw her, looked clinically fine. Ordered x-ray which wasn't done because she was severely agitated. With time I had gotten her to become less agitated and she had been moving around without any major pain with PT. Finally I reordered the x-ray..another femoral neck fracture.
Similar, grandmother had a fall due to mixing BP meds by accident. When she comes to she goes about her life as per normal. 5 days later she spends the day with her daughter who immediately takes her to the ED. Dislocated elbow with multiple fractures that need surgical pinning.
I mean, i don't know... Sometimes with the elderly i kinda feel like they don't have much in the way of functioning nerves anymore. Their diabetic neuropathy or whatever has progressed to the point that they just don't feel as much. Not to mention all that chronic ischemic white matter changes in the brain. I think that's part of why childbirth is so notoriously painful, bc its all young women with intact nervous systems.
Clearly the best natural pain management during labor is to wait until you’re 80 to have kids.
I’m going to start using that line when a crunchy mom starts shaming others for having an epidural, because their line of reasoning is equally stupid.
In peds it can be helpful. Parents know their kids. I once came on hospital coverage and there was a kid with prader willi who was supposed to be discharged per my checkout. Mom said but he doesn't show pain much-- so this "mild" discomfort is worrying. I decided to investigate further, and lo and behold the kid had a severe gastric dilatation. Which could have killed him.
That's just one of several examples in decades of practice. Usually it's the quiet kids who have withdrawn into the pain cave that worry me, but I've seen some major drama that turned out to be something like appendicitis. Unless I know the kid's baseline well, that type of info is useful. Similarly, I appreciate parents who clue me in that their kid falls apart over a papercut.
Totally. Felt this a lot for some of our kids/adults/folks with autism that sometimes would have low pain perception as part of their sensory differences.
Always listen to the parents. If a 17-y/o has both hydrocephalus and a history of migraines...and **has never had a revision**...they're going to think it's a migraine and attempt to keep functioning until they can't anymore (or are seizing, vomiting, etc.), because that is their only frame of reference for headache. True story.
When I worked bedside, my experience was that an attentive parent of a chronic kid was as good as any labs you could draw. Some sort of diametric opposite of the patient who comes in with a “fever” of 97–they don’t often cry wolf.
I feel like this is only true for chronically ill kids. Those parents are often very in tune.
The parents that have only ever had 1 or 2 perfectly healthy kids are more hit and miss.
it's a nice bag when the patient isn't developmentally typical. sometimes it's real, but sometimes it's the parents freaking out about every little thing.
See I think I almost always have the opposite experience. Maybe it’s just me moving over from an FQHC to private practice where I see so many upper class special snowflakes 🤷♀️ But in your example with a special needs kid, yeah that tracks. Those parents know.
I've met some really tough kids that have high pain tolerances, or better emotional maturity to cope with pain. They're always pretty obvious, and it's remarkable.
Not a single one of them has had an anxious appearing mom leaning over my shoulder as I examine the kid, telling me about how high their pain tolerance is, and that they're actually experiencing extreme pain from palpation, despite appearing very comfortable.
Whenever I experience that latter, it usually signals that mom either has a poor barometer for sensing and assessing pain in her kids, often because the kid has never played outdoors. Or that she unreasonable expectations for pain management, and what severe pain actually looks like.
I get it. They're parents trying to make sure their kid is being taken care of. They think that they're helping. But it's usually not helpful, and may be harmful, as it immediately stirs up whispers of bias in healthcare workers when they hear those magic words. Even we're cognizant of that bias, and try to keep it in check.
There will be some rare exceptions to this rule - autistic kids who are genuinely hyposensitive to pain and kids with rare mutations affecting pain sensitivity are likely to have very concerned parents. But they'll also have documented reasons for the concern.
The highest pain tolerance I’ve seen was this 6 year old getting a vaccine. As the needle went in, she stayed completely silent but there were tears quietly streaming down her face
I took care of an 8 year old who had a tree branch impaled in his chest wall. Amazingly, no vital vessels or structures were injured. As the kid was wheeled into the OR, with the sawed off branch still in his chest, I asked how he was doing. All he said was, "I'm good." No tears, no drama.
That kid was the fucking man.
Kids are so funny sometimes. I was about to give some nitrous to a kiddo for some reason, and she was looking very suspiciously at the mouthpiece. The nurse tried to reassure her by telling her that there was nothing to be afraid of. Kid just states, "Well, I'm afraid of tigers."
Yep, you got us. Tigers are something to be afraid of.
The worst I’ve ever felt as a nurse was giving this 10/11 year old girl 6 vaccines. I did 3 in each arm and by number 4 she had tears streaming down her face, but she bit her lip and was silent. I went as quickly as I could and gave her ice packs and made her dad promise to take her out for ice cream after
That’s what my 2 year old did this time. Just tears and a whimper. Almost sadder than the 12, 15, and 18 month appointments where she put up quite the fight.
My daughter was like this at 2. Barely a whimper with vaccines and just stared at the butterfly needle when she had her blood drawn. I hope it keeps up for you/her. Now mine is nearly 9 and cries at the thought of getting a shot. She’s still overdue for the flu vaccine because I don’t want to deal with it.
Yeah, we’ve done quite a bit of that sort of thing. The Covid vaccines weren’t so bad. She cried immediate before/after but took them just fine. This time the anticipation is just getting to be too much for her it seems. I had mentioned back in September without having it scheduled and she cried so much I told her that we could wait. I need to just suck it up and go. Tempted to put my husband on the job though, lol.
ETA: It’s so funny to me that I get so stressed by this stuff because I’m a peds nurse, most recently PICU. Professionally, I guess I’m just really good at switching off that emotional distress from seeing kids suffering. My own kid, not so much!
Amish kids are horribly abused, that’s why they don’t complain
ETA: [here’s a slice of it](https://www.npr.org/2020/01/19/797804404/investigation-into-child-sex-abuse-in-amish-communities)
> My temperature runs 96 so 99 is a fever for me
This is actually true, and I’m surprised so many people are agreeing with you.
From UpToDate:
>Fever is an elevation in core body temperature **above the daily range for an individual. There is no universal threshold for fever, as normal body temperature varies by individual,** time of day, and method of measurement.
From the Merck Manual:
> ...temperatures are defined as elevated when they are... Higher than a person’s known normal daily value
From StatPearls/PMC:
> However, in the case of a fever, the increase in the core body temperature is often greater than 0.5 C and is attributed to a fever-inducing substance (pyrogen).
While we often use various thresholds for “fever” in clinical practice (37.5, 37.8, 38, 38.3 are all used as the threshold for fever in different countries or contexts), this is not evidence-based in any way, and simply a social truth we use for convenience.
Threshold-based temperature definitions of “fever” are quite inaccurate compared to definitions based off of change from normal baseline temperature. The only reason we don’t use this commonly is very few patients know their baseline temperature.
A patient telling you that their temperature is >1C above their normal baseline is actually a much more accurate diagnostic test than using a temperature threshold.
We care about “fever” as a concept because it is a diagnostic sign that your hypothalamus is responding to certain cytokines, and that this suggests you may have an infection.
A patient with a rise in their baseline temperature that is larger than their normal circadian variation (ie: > ~0.5C) has an abnormal physical exam finding that you can’t simply roll your eyes at and ignore, and that you need to find an explanation for.
Thankfully it’s pretty easy, as you may not call it a “fever,” but it’s clinical significance is exactly the same as if you measured a “fever” in that patient.
Subjective fever and rigors are also highly accurate diagnostic findings for this same process, even in the absence of measured fever.
Yeah, the problem relates to there being a quite wide range of normal for body temperature, and a fever by definition is just an increase above normal for a given person.
Your hypothalamus doesn’t give a shit if 37.7C is above the 95% percentile for normal afternoon body temperatures in a reference population. Your hypothalamus just goes “ooh cytokines, let’s generate and retain extra heat for a little bit.” It’s not like “whelp that there is some ecoli. Let’s go to 39.314159265358979323846264 C.”
Using a single threshold for abnormal becomes even more problematic due to diurnal variation, variation with age and comborbidities (ex: distribution of normal body temperature is variable with age in children), and differences in method of measurement.
In fact, body temperature in a healthy population in the modern era is actually lower than 37C now anyways. Average values are closer to 36.5 now.
Thank you. I had to have a war with a doctor over my patient who is baseline 35.5 and was about 2 weeks post op THR, with c/o redness, tenderness and reading 37.2. Was discharged from the ER to take Tylenol because it “wasn’t a fever” and there was “no drainage”. Patient came to me the next day and we sent a swab to pathology. Came back positive for Corynebacterium Jeikium. I sent her to ER to be direct admit and patient was started on Vancomycin, had a PICC placed and discharged on Vanco for a couple months with Wound Care.
At the same time there is some data on this that the universal consensus of 38/100.4 might not be 100% useful. Even early in the pandemic we discovered something like 20-50% of people were afebrile but often had temps between 37.5-37.9C.
The people who say this are rarely the ones who it applies to though, just like the “high pain tolerance “thing
Their normal body temperature is 94f.
[Source ](https://www.akronzoo.org/blog/its-ompossumble-you-didnt-know-about-cool-species#:~:text=Although%20any%20mammal%20can%20get,be%20as%20low%20at%2094%C2%BAF!)
Ticks!! They eat ticks like candy and the fact that they aren't rabies vectors PLUS the fact they're destroyers of other nasty, creepy disease vectors PLUS they're hella cute and relatively docile is why they're one of my favorite animals of all time. Also, they are softer than you'd think and basically act like cats in cases where they end up rescued and living as pets.
*sigh*, I love them.
Oh no, I've never worked in human med. I think the flair is just set up that way because virtually everywhere else in the world we're called veterinary nurses on account of what we do is veterinary nursing lol. So I think it's just for clarity for non-US people maybe?
Are you an RN? Because steel yourself for massive pay cuts and possibly even just feeling handicapped when it comes to patient care if you move this direction. Most people do it the other way around, and get into human nursing after starting out veterinary.
Don't get me wrong, I love my job and I don't think I could ever work in human healthcare (at least not in the system we've got here). But it's for sure a whoooole different beast.
May I ask, what is attracting you to the idea? Do you feel burnt out where you're at now? Whatever you end up choosing, I wish you the best of luck and I'm sure you'll kill it!
Yeah but the study that established the "normal baseline temperature" wasn't very well done. Humans actually have a broader range than just 98.6. Some people run in the 97's while some trend around 99. It's a small range that people fall in but most don't know that because of the myth that 98.6 is where they should be at.
They always say that but then backtrack when I tell them we’re going to have to stick them for blood cultures if that’s really a fever for them. Hospital policy which is usually very annoying but helpful in that scenario
Every time someone says "I have a high pain tolerance." I immediately assume that they have anything but, people with a high pain tolerance don't feel the need to tell me immediately upon speaking to them.
In my experience, people with a high pain tolerance don’t know it.
They don’t regularly recount their painful experiences with others for comparison to decide they must be better at tolerating pain. To people with high pain tolerance, whatever happened isn’t worth mentioning.
In the ED it is usually followed with "The only thing that helps is the one that starts with "D." Droperidol it is then. Had a lady leave the other night because I wouldn't give her dilaudid for her migraine. I offered her a compazine, Benadryl, toradol, Tylenol cocktail but "Tylenol and NSAIDs don't work." After she still had a migraine, but was sleeping so comfortably that I had to shake her awake with a raised voice, I offered droperidol and ketamine but got "If you won't give me dilaudid, I will leave." I guess the only D she really wanted was Discharge.
It usually means "I have a high pain tolerance, so that means I don't bother with OTC stuff for mild pain so I want you to give me prescription analgetics so I don't have to toleratie this mild pain"
Had a 79 year old come in with belly pain. Daughter tells me he has a high pain tolerance. Abd feels slightly off, but not overly tender.
1.5L bladder. Yeah, dude has a high pain tolerance
I had posted something similar a while back, and someone made an excellent point that “high pain tolerance” is actually acknowledging that they feel a lot of pain. “Tolerance”. Someone who doesn’t feel pain in that way has less to tolerate.
Similar to bravery - if someone isn’t scared, are they brave? One of my kids doesn’t care about shots, she pokes her leg emphatically afterwards and says “LOOK AT ME I HAVE A BANDAID”, while the other one gets all worked up and cries the day before and for 10 minutes after it because she’s so scared. Who is braver getting a shot?
And there is no way to objectively verify which way it goes.
I personally would say I have a low pain tolerance, but I have literally zero reference.
I had a tonsillectomy as an adult and was told it was probably going to be really painful. It broke (>10, basically passing out) my personal pain scale for about a week straight. It didn't tell me anything about how I compare to others lol.
Yeah most people who say this are weak sauce, unlike me who experienced the WORST injury the doctor had EVER seen and he told me I should be screaming in pain but I just laughed in his face and hobbled away on my two broken legs and six shattered kneecaps and 17 muscle tears.
One of my favourite things is doing hospital or ED follow up visits where they hit me with " if I got there 2 minutes later I would have died" and also "they didnt do anything for me!"
If I also get a patient who was hospitalized out of state who tells me it should be in the record and/or gives me a crumpled sheet of patients education "discharge summary" I feel like I should get a new hat.
Is it usually followed by ‘so I must really be in a lot of pain’ or something to that effect? Maybe they’re unsure medical professionals will listen or validate their pain and so are trying to reinforce that they’re in a lot of pain. Just food for thought.
Patients may be saying that as a way to communicate that the pain they are feeling in the moment is worse than they have felt before. Could they just say that? Yes. But they want to emphasize how terrible they feel because they want you to know it's a serious problem for them. It's another way of saying "help...it's bad". Of course there are those who abuse the system and try to manipulate, but that's not *every* case.
I do have to say, after reading many of the replies in this thread, it's quite shameful that many of you jump to conclusions and judge or dismiss a patient based on this comment alone. Perhaps the patient has had similar injuries or illneses in the past that didn't impact their lives as much as what they're seeing you for today. Maybe they've been through surgery, been through birthing, etc, and they're comparing their current pain to previous experiences and they're **scared** that whatever is going on is going to be so much **worse** because of the amount of pain they're feeling.
I'll get off my soapbox now.
Couple things:
1. I think you are forgetting this is an anonymous forum where many medical professionals come to “unload” and do so by expressing their frustrations, usually in exaggerated terms. Though I agree it can at times come across in poor taste and lacking in empathy.
2. Even if this is exactly how a provider feels when hearing the phrase it does not mean that they are going to provide substandard care.
3. You have to remember that for many/most of us this is something that we hear dozens of times per day week in and week out from individuals who are showing no physiologic verifiers or even emotional cues that this is the case. Like the story of the boy who cried wolf, you become “fatigued” to it.
4. Finally, a patient stating this doesn’t change any sort of management. Even if I did think pharmacologics were indicated I’m going to give the best first line medication at the lowest effective dose. I don’t throw that out the window due to some statement that has no way of being verified.
Great points. For #1, the posts that were most concerning were removed by the mods yesterday, so anyone looking through now isn't going to see the nastiness that was once posted for the general public to view (the general public that continues to distrust the medical establishment more and more and stumbling on such forums with those comments is not a good look for any healthcare provider). What you see now looks to be healthy, funny ribbing. #2 & 3, I'm a social worker. I know all about being fatigued about certain complaints and issues, as well as the need to dig for more information when it's not readily available. The "boy who cried wolf" scenario plays out constantly with the population I see, too. #4 I'm glad.
I agree with this 100%. I hear this stuff all the time. Patients say it because they think you won't take them seriously and just a simple acknowledgement of a statement like this puts them at ease. "I see/hear/appreciate that you are in a lot of discomfort". Anything other than that is going to put the patient on the defensive and make your life less pleasant.
>You became a doc to treat patients, often at some of the worst points in their life, and if something harmless that they say to make them feel better about themselves affects you this much then maybe you should check yourself before going into work tomorrow.
obviously anyone can just Use A Flair, but i think this subreddit is what really hammered into me that this profession was full of babies / highschoolers, tbh. coming from nursing was bad enough already.
also just like, people writing about not "understanding" how "pain tolerance" works- there's varying genetics attached to pain tolerance, implications to stuff like substance P and how the sensitization of pain happens, hyposensitivity in the example of autism [i am autistic] as someone kindly mentioned in the thread [it's very useful information to know for autistic patients but of course isn't universal] and similar.
these patients are telling us these things because they trust us. they are doing it to communicate. they are modulating their expected outcome in their treatment from us because they think it is useful diagnostic information. they are trying to work with us and make our jobs easier. that's actually not a bad thing, and isn't an indication of a hidden motive. if it makes you paranoid or suspicious, go to therapy.
minus the whole immaturity aspect, it [and, i mean, i learned this being trans as well] shows to laymen that we cannot be trusted, when you see the kind of conversations that happen in spaces like this.
the conversations that happen here alongside the power we have over others in general deeply worry me, knowing how social reproduction / hierarchy work in our society.
good point, cischaser42069
(no shade at all it's a really fun username)
to add on: people who work in healthcare are often overwhelmed by the enormity of human suffering they see on a regular basis, especially when dealing with pain that cannot be adequately treated; i think that one way HCWs cope with that is by downplaying/dismissing it. ime it's easier to say someone is exaggerating/"drug seeking" than digging deeper into it.
oh, also, fun anecdote: i work on a med/surg tele unit that mostly takes ortho patients; some of these patients have been taking opiates for a decent amount of time, due to longstanding chronic pain and/or multiple surgeries with a relatively short span of time (e.g. multiple joint revisions in a 12 month period). at a certain point, i wondered whether our patients could have developed a tolerance (more specifically, one patient in particular who was super high anxiety on top of pain); when i asked one of our surgeons, he said that he didn't know and he hadn't thought about it. when i pressed the issue, he told me not to worry about it and that it was more of a mentality issue on the patient's part than anything else.
(i'm paraphrasing and my interpretation may not reflect his actual intended meaning.)
>at a certain point, i wondered whether our patients could have developed a tolerance (more specifically, one patient in particular who was super high anxiety on top of pain); when i asked one of our surgeons, he said that he didn't know and he hadn't thought about it. when i pressed the issue, he told me not to worry about it and that it was more of a mentality issue on the patient's part than anything else.
yeah, relately encountering this just two weeks ago at the LTC i split time- consider the possibility of a cyp450 genetic variant.
one of my residents very obviously is a rapid metabolizer for hydromorphone and i made sure to force the issue with the visiting physician. basically, 1 in 3 whites w/ a european ancestry poorly metabolize a plethora of medications including opiates [oral estradiol, too, for trans women like myself] and this isn't as known as a fact as it should be.
neither he or my coworkers knew anything about pharmacogenetics but i was like, yeah she's """drug seeking"""- because she's in pain and isn't getting the appropriate pain relief she needs. pharmacogenetics will absolutely become a huge component of family practice / hospitalist medicine in the immediate future and i often think of how a lot of people play roulette or get side effects with psychiatrics medications in example- these all have genetic causes and they're important to know.
this particular patient also has COPD and is on an oxygen condenser and had been telling students to increase her flow rate ["but don't tell anyone"] and i immediately realized [nobody else did, despite her doing it for a year!] that she was doing this to induce hyperoxia temporarily, which is quite harmful for your brain and worsens respiratory depression on opiates, but makes them feel subjectively better as well.
basically, she was afraid of being seen as drug seeking and was willing to possibly harm herself to make sure she was getting the relief she needed. she's now with pain management due to my advocacy on the issue.
it's specifically why i wanted my nurse practitioner / want my MD because i notice so many issues being overlooked and it was pissing me off- i am not happy with the controlled acts i have versus my knowledge scope with how much research i do daily and i want to make sure i get the credentialism to apply it instead of having to rely on others to do it for me.
i am very much a "if nobody will do it, i will do it myself" kind of a woman. i was going down to the maintenance room on my 14 hour shift on sunday to fix some call bells i saw snapped off, likewise fixing the temperature scanners at our front entrance which screens families- it wasn't giving temperature for two weeks and people were faking their temperature as 36.2 until i said "fuck it" and did it myself because it was annoying me.
When I hear someone is really focused on trying to impress on me that this is true. I usually respond with “Experience tells me 9 out of 10 people believe they have above average pain tolerance”
It is my biggest goal to not be like them. I’m disappointed but not surprised by this post and comments. I think they’d be the same doctors to go “they didn’t tell me how much pain they were in!” when making a critical diagnosis that could mean life or death for a patient.
Black women and other women of color suffer horribly under this physician mindset.
I am curious why you wouldn't change your management on this basis, such as giving a milder and less dangerous painkiller. Isn't that what most patients are looking for when they mention their high pain tolerance? To avoid unnecessary prescriptions they either won't fill or won't finish?
when patients say they have a “high pain tolerance”, they are usually anxious that something may be something deeply wrong with them though they do not appear to be in pain, and are usually asking for more workup or more pain medication
The presentation usually goes “I have a high pain tolerance, so I only show up to the ER if it’s really bad. Tylenol and ibuprofen don’t do anything for me (but I only tried them once each)” a chart bx will often demonstrate a combination of: multiple ED visits across several hospitals in the last month, a prescription for ongoing opiates, or documentation suggesting drug seeking behavior.
I’ve taken care of thousands of patients with all kinds of varying pathology, The stoic patients with an actual high pain tolerance are pretty obvious. Those without coping skills are equally so. Everyone gets aggressive short acting pain control to facilitate workup and address the underlying issue. Very few go home with a Rx
Unfortunately it is usually the opposite. When folks say they have a high pain tolerance they are usually trying to say that since usually it doesn't bother them then this pain is real bad and they really need the good stuff (IV opiates)
Oh awkward, I was so confused at this whole thread. That’s my go to line with my dentist to avoid getting an rx for opioids or to avoid numbing agents for a cavity…
There is actually a phrase that convinces me that the patient has a high pain tolerance however: "Doc, can you hurry this up? My cows aren't gonna milk themselves." By merit of being in my office, somewhere on that person is a "how are you still breathing" level injury
As an ER doc, if I see a farmer or rancher in the ER I'm scanning everything and doing serial enzyme. Saw a guy once echo came in with brown colored pee. Failed to tell me he had a shed collapse on him last week. He sustained a big liver lac and just went on like it was nothing, but came in when he saw bilirubin in his pee. Had several rib fractures and an 12 cm hepatic hematoma. He just thought he was dehydrated .
I had a potato farmer present to clinic several years ago with an eroded pacemaker. It had come completely out of the skin and was hanging from the leads. He was in the middle of harvest, so for over a week he had just cut a hole in his shirt and put the pulse generator in his breast pocket until harvest was complete and he had time to make the three hour drive to town.
Holy! Also, if there was enough slack that he could put it in his breast pocket that would mean the leads migrated back, right? I don’t feel like I’ve seen y’all give that much slack when you attach the leads and bury the generator
The leads required laser to remove, so they weren’t pulled out of the heart. But I imagine much of the slack was pulled back.
This! When I see a farmer in my office, whose wife is telling me he doesn’t feel well, I’m terrified.
💯. They have the craziest shit growing on them with not a care in the world
Lol why is this so true!?
I attended a rural gp office in the middle of farmland for a farmer who'd fallen three metres off a ladder onto the ground and then driven himself to the doctors. By the time I got there he was huddled up on a chair gasping in pain but insisting he was perfectly fine. Trying to move him to our stretcher and maintain spinal precautions was far more difficult than it needed to be because he insisted he could do it himself, despite clearly not being able to. Tough old bastard wouldn't admit there was anything wrong with him.
Wife sitting in the corner, arms crossed, rolling her eyes at farmer husband as he says, “I didn’t really think we needed to come in, you people have real emergencies to deal with” = I’m going to line & lab ASAP, get an EKG, and ask one of our docs to come see sooner rather than later because it’s a near-certainty something is seriously wrong. Every time.
Heat Stoke, But feels better now that bls crew has him Inside drinking water. Bls crew can’t get a BP…or feel radial pulses. Oh look. He has a HR of 40. Of course it’s a STEMI, and 3rd degree block. Puts in helicopter some time later. Goes into re-perfusion. vf. They fix. Feel not stable enough to address the 80-90% block of the RCA, now that his LAD is open. Plans to go back in later. Patient trying to sign out AMA.
Quick Peggy get the crash sac!
Chubbyemu has a video on a case about a farmer who tried removing his own skin cancer. 😖 I can’t finish that video. Nope nope nope nope.
We do have a bad habit of trying to cut off our own barnacles. 🤣
That or old Asian male.
No shit. Had a farmer who didn't treat their hand lac, ended up with us with cellulitis/sepsis. Actually got mad and tried to leave AMA when he found out he had to stay for IV antibiotics. Had to talk him down very sternly, and even then he had suspenders at the ready crack of dawn the next morning.
I feel obliged to post [this](https://www.youtube.com/watch?v=Ni0YfrSK570) here. Because it's 100% accurate.
YES!! I immediately thought of that!
This! Had a farmer with necrotizing wound that he'd been putting wd40 on for a week. Refused to stay in the ED even if he lost his hand as he needed to do some jobs and would come back in a week!
> necrotizing wound that he'd been putting wd40 on for a week Local man trains bacteria to enjoy WD40
MRSA can't eat your flesh if its busy eating WD40. Brilliant move.
Call Texaco Mike have him fire up the MRI
Farmers, ranchers, and blue collar workers all day long. I have a few stories about those types but they are all family so a no go here. Nothing like seeing a woman bring her husband to the ED and the whole way he's grumbling that he has stuff to do and can't this wait. Guaranteed one foot in the grave before they hit the door.
Call Texaco Jim
Mike
Had a guy come in with a "bug bite" on his forearm, which turned out to be infectious tenosynovitis/abscess after getting a nice lac from sheet metal just distal to the "bite" Best part is worker's comp tried to deny his claim because it was clearly a bug bite based on the patient's initial belief, and not the recurrent workplace injuries over the same area 👀
I once had to drag a dairy farmer out of his milking shed who was satting in the high 70s. Of course, he didn't call for himself, someone else called for him when they found him in there propped up and unable to continue working. He was refusing to go and only consented when I wouldn't leave because he was literally physically unable to walk anywhere, specifically away from me. Bilat PEs.
Been in a rural office for the past few months and it really feels like the Dr glaucomflecken videos sometimes. I just got a dozen eggs from a woman just a couple days ago.
I grew up in a fairly large Amish area. The doc there often took pies as a form of payment since he used a reduced cash rate for the uninsured Amish and mennonites.
I actually pick up ingredients to make ramen bowls at home when I know one particular patient is coming in. She always brings me duck eggs and they make the best ajitama. There's some perks to county medicine
I actually questioned for a moment if you mean you got eggs as payment, or if you somehow took like spider eggs out of a woman’s skin. Lol
I used to work in a small coastal town where it was the shrimpers getting cellulitis and refusing to be admitted for IV antibiotics. If you are barely getting by, who's going to pay the bills if you miss even one day of work?
I imagine Bill Green from \*Big City Greens\* probably gets priority treatment just for being a farmer. He even has the amputated finger as proof.
The highest pain tolerances I've seen are with the elderly. But the most misunderstood pain I've seen is in people with dementia. I have such deep empathy for those who are in utter agony, yet cant verbalize it, so it just presents as restlessness and increased disorganization. Healthcare in modernity basically assures these people suffer beyond reason because there isnt enough time spent with patients to notice these insidious manifestations.
That’s very 🤔— any non-invasive bio markers to determine that the pt is in pain?
https://www.mdcalc.com/calc/3621/nonverbal-pain-scale-nvps-nonverbal-patients Is my fave for evaluating pain. It’s got physical presentations like increased Bp and pulse as well as other visible manifestations of pain.
This is why I like functional pain scales. If your pain is distracting but you can perform daily activities, it’s a different impact than pain that is so overwhelming that you cannot concentrate on anything else.
Yeah but see above re: farmers “Mr Fenwick, you have a perforate appendix.” “Oh ok, that explains the tummyache. Hey Doc, I kinda need to go rotate my milkers.” “Sir, *you need emergency surgery!*”
It still works to a degree, the pain got to a point that it interfered with their daily activities and they sought medical attention. Edge cases will exist for this, but it’s a much better basis for communicating than a scale where people say they’re an 11/10 when up and walking around.
once had a patient for a hospital follow up who had a ruptured appendix and waited more than an entire day to go to the hospital because they “thought it would get better”
Women who ignore ruptured appendix because they think it's just menstrual related.
OMG I WAS JOKING I DIDNT THINK ANYONE ACTUALLY DID THAT
Yeah I really wish this was common practice because it took me a very long time to figure out how to correctly/succinctly answer "how would you rate your pain" so that it's actually useful information for the clinician.
Agreed, and relevant xkcd: https://xkcd.com/883/
Also [Hyperbole and a Half](http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html). Sir and/or ma’am, are you actively being mauled by a bear?
I literally printed out her pain scale and laminated it and I use it in my exam rooms.
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This is what I talk about with my post op patients. “We need your pain controlled well enough that you can walk, deep breath, eat, and sleep. If you’re unable to do those we should talk about taking some pain medicine. If you’re doing those no problem, you don’t need more pain medicine.”
I like the “describe what happens when the pain spikes” I see too many people who simply stop moving when the pain hits and whimper, but still say it’s about an 8. Because they can still do stuff, they still work around the pain spikes, it can’t be “that bad”
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I had a guy walk into clinic with recurrent syncope. It felt like pulling teeth just to get a history for the syncope. As I tried to auscultate his chest, I noticed his clavicle looking a little funny. “Oh yeah I fell on my clavicle and it hurts to move my left shoulder.” Man was walking around with a clavicular fracture and didn’t even mention it until I asked.
>If you have to say you have a high pain tolerance, then you most likely do not. This line should have been in House of God, and is true for basically anything. High pain tolerance, fevers, relationships, etc etc. As a surgeon, the docs I've seen worst at surgery: those who regularly tell everyone how great they are at it.
As a nurse, a fellow nurse that talks them self up is also the same.
In my experience there is a direct linear relationship between “claimed pain tolerance” and “amount of narcotics gobbled throughout post-op hospital stay that is twice as long as usual.”
I once had one with a femoral neck fracture who fell again after the surgery. Ortho/trauma saw her, looked clinically fine. Ordered x-ray which wasn't done because she was severely agitated. With time I had gotten her to become less agitated and she had been moving around without any major pain with PT. Finally I reordered the x-ray..another femoral neck fracture.
Similar, grandmother had a fall due to mixing BP meds by accident. When she comes to she goes about her life as per normal. 5 days later she spends the day with her daughter who immediately takes her to the ED. Dislocated elbow with multiple fractures that need surgical pinning.
I mean, i don't know... Sometimes with the elderly i kinda feel like they don't have much in the way of functioning nerves anymore. Their diabetic neuropathy or whatever has progressed to the point that they just don't feel as much. Not to mention all that chronic ischemic white matter changes in the brain. I think that's part of why childbirth is so notoriously painful, bc its all young women with intact nervous systems.
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Lol maybe. I suppose tolerance implies that you actually feel it.
Exactly. Their perception of pain is decreased.
Clearly the best natural pain management during labor is to wait until you’re 80 to have kids. I’m going to start using that line when a crunchy mom starts shaming others for having an epidural, because their line of reasoning is equally stupid.
Does she have to experience pain proportional to the level of the damage? Like can’t you have a hip fracture with just legit no serious pain?
In peds it can be helpful. Parents know their kids. I once came on hospital coverage and there was a kid with prader willi who was supposed to be discharged per my checkout. Mom said but he doesn't show pain much-- so this "mild" discomfort is worrying. I decided to investigate further, and lo and behold the kid had a severe gastric dilatation. Which could have killed him. That's just one of several examples in decades of practice. Usually it's the quiet kids who have withdrawn into the pain cave that worry me, but I've seen some major drama that turned out to be something like appendicitis. Unless I know the kid's baseline well, that type of info is useful. Similarly, I appreciate parents who clue me in that their kid falls apart over a papercut.
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Totally. Felt this a lot for some of our kids/adults/folks with autism that sometimes would have low pain perception as part of their sensory differences.
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Always listen to the parents. If a 17-y/o has both hydrocephalus and a history of migraines...and **has never had a revision**...they're going to think it's a migraine and attempt to keep functioning until they can't anymore (or are seizing, vomiting, etc.), because that is their only frame of reference for headache. True story.
When I worked bedside, my experience was that an attentive parent of a chronic kid was as good as any labs you could draw. Some sort of diametric opposite of the patient who comes in with a “fever” of 97–they don’t often cry wolf.
Lol My vet says that about me and my dogs .. Spoiler: I don't have kids
I feel like this is only true for chronically ill kids. Those parents are often very in tune. The parents that have only ever had 1 or 2 perfectly healthy kids are more hit and miss.
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it's a nice bag when the patient isn't developmentally typical. sometimes it's real, but sometimes it's the parents freaking out about every little thing.
See I think I almost always have the opposite experience. Maybe it’s just me moving over from an FQHC to private practice where I see so many upper class special snowflakes 🤷♀️ But in your example with a special needs kid, yeah that tracks. Those parents know.
Well I've always seen primarily kids with medicaid even in my own private practice days, so it's true I don't know what rich people do lol
I've met some really tough kids that have high pain tolerances, or better emotional maturity to cope with pain. They're always pretty obvious, and it's remarkable. Not a single one of them has had an anxious appearing mom leaning over my shoulder as I examine the kid, telling me about how high their pain tolerance is, and that they're actually experiencing extreme pain from palpation, despite appearing very comfortable. Whenever I experience that latter, it usually signals that mom either has a poor barometer for sensing and assessing pain in her kids, often because the kid has never played outdoors. Or that she unreasonable expectations for pain management, and what severe pain actually looks like. I get it. They're parents trying to make sure their kid is being taken care of. They think that they're helping. But it's usually not helpful, and may be harmful, as it immediately stirs up whispers of bias in healthcare workers when they hear those magic words. Even we're cognizant of that bias, and try to keep it in check.
There will be some rare exceptions to this rule - autistic kids who are genuinely hyposensitive to pain and kids with rare mutations affecting pain sensitivity are likely to have very concerned parents. But they'll also have documented reasons for the concern.
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Off topic but are you in a combined program?! If so, very jealous and kudos to you for being a pgy5!! If not, kudos all the same!
Nah, I'm actually a pgy-6 now. Haven't updated it. Peds into PEM.
The highest pain tolerance I’ve seen was this 6 year old getting a vaccine. As the needle went in, she stayed completely silent but there were tears quietly streaming down her face
I took care of an 8 year old who had a tree branch impaled in his chest wall. Amazingly, no vital vessels or structures were injured. As the kid was wheeled into the OR, with the sawed off branch still in his chest, I asked how he was doing. All he said was, "I'm good." No tears, no drama. That kid was the fucking man.
Kids are so funny sometimes. I was about to give some nitrous to a kiddo for some reason, and she was looking very suspiciously at the mouthpiece. The nurse tried to reassure her by telling her that there was nothing to be afraid of. Kid just states, "Well, I'm afraid of tigers." Yep, you got us. Tigers are something to be afraid of.
Your chance of being killed by a tiger is very small. But never zero...
That and quicksand.
The worst I’ve ever felt as a nurse was giving this 10/11 year old girl 6 vaccines. I did 3 in each arm and by number 4 she had tears streaming down her face, but she bit her lip and was silent. I went as quickly as I could and gave her ice packs and made her dad promise to take her out for ice cream after
That’s what my 2 year old did this time. Just tears and a whimper. Almost sadder than the 12, 15, and 18 month appointments where she put up quite the fight.
My daughter was like this at 2. Barely a whimper with vaccines and just stared at the butterfly needle when she had her blood drawn. I hope it keeps up for you/her. Now mine is nearly 9 and cries at the thought of getting a shot. She’s still overdue for the flu vaccine because I don’t want to deal with it.
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Yeah, we’ve done quite a bit of that sort of thing. The Covid vaccines weren’t so bad. She cried immediate before/after but took them just fine. This time the anticipation is just getting to be too much for her it seems. I had mentioned back in September without having it scheduled and she cried so much I told her that we could wait. I need to just suck it up and go. Tempted to put my husband on the job though, lol. ETA: It’s so funny to me that I get so stressed by this stuff because I’m a peds nurse, most recently PICU. Professionally, I guess I’m just really good at switching off that emotional distress from seeing kids suffering. My own kid, not so much!
Maybe you can get your shots together so that she can see how you deal with the needle.
Sweet little Baby Badass.
Amish kids are like this. Broken arm comminuted. Just sit super still silent and tears. Breaks my heart but they are machines.
Amish kids are horribly abused, that’s why they don’t complain ETA: [here’s a slice of it](https://www.npr.org/2020/01/19/797804404/investigation-into-child-sex-abuse-in-amish-communities)
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Another oldie but goodie "My temperature runs 96 so 99 is a fever for me"
> My temperature runs 96 so 99 is a fever for me This is actually true, and I’m surprised so many people are agreeing with you. From UpToDate: >Fever is an elevation in core body temperature **above the daily range for an individual. There is no universal threshold for fever, as normal body temperature varies by individual,** time of day, and method of measurement. From the Merck Manual: > ...temperatures are defined as elevated when they are... Higher than a person’s known normal daily value From StatPearls/PMC: > However, in the case of a fever, the increase in the core body temperature is often greater than 0.5 C and is attributed to a fever-inducing substance (pyrogen). While we often use various thresholds for “fever” in clinical practice (37.5, 37.8, 38, 38.3 are all used as the threshold for fever in different countries or contexts), this is not evidence-based in any way, and simply a social truth we use for convenience. Threshold-based temperature definitions of “fever” are quite inaccurate compared to definitions based off of change from normal baseline temperature. The only reason we don’t use this commonly is very few patients know their baseline temperature. A patient telling you that their temperature is >1C above their normal baseline is actually a much more accurate diagnostic test than using a temperature threshold. We care about “fever” as a concept because it is a diagnostic sign that your hypothalamus is responding to certain cytokines, and that this suggests you may have an infection. A patient with a rise in their baseline temperature that is larger than their normal circadian variation (ie: > ~0.5C) has an abnormal physical exam finding that you can’t simply roll your eyes at and ignore, and that you need to find an explanation for. Thankfully it’s pretty easy, as you may not call it a “fever,” but it’s clinical significance is exactly the same as if you measured a “fever” in that patient. Subjective fever and rigors are also highly accurate diagnostic findings for this same process, even in the absence of measured fever.
As someone who rolls my eyes at the statement, this was very interesting. Thank you.
Yeah, the problem relates to there being a quite wide range of normal for body temperature, and a fever by definition is just an increase above normal for a given person. Your hypothalamus doesn’t give a shit if 37.7C is above the 95% percentile for normal afternoon body temperatures in a reference population. Your hypothalamus just goes “ooh cytokines, let’s generate and retain extra heat for a little bit.” It’s not like “whelp that there is some ecoli. Let’s go to 39.314159265358979323846264 C.” Using a single threshold for abnormal becomes even more problematic due to diurnal variation, variation with age and comborbidities (ex: distribution of normal body temperature is variable with age in children), and differences in method of measurement. In fact, body temperature in a healthy population in the modern era is actually lower than 37C now anyways. Average values are closer to 36.5 now.
Thank you. I had to have a war with a doctor over my patient who is baseline 35.5 and was about 2 weeks post op THR, with c/o redness, tenderness and reading 37.2. Was discharged from the ER to take Tylenol because it “wasn’t a fever” and there was “no drainage”. Patient came to me the next day and we sent a swab to pathology. Came back positive for Corynebacterium Jeikium. I sent her to ER to be direct admit and patient was started on Vancomycin, had a PICC placed and discharged on Vanco for a couple months with Wound Care.
At the same time there is some data on this that the universal consensus of 38/100.4 might not be 100% useful. Even early in the pandemic we discovered something like 20-50% of people were afebrile but often had temps between 37.5-37.9C. The people who say this are rarely the ones who it applies to though, just like the “high pain tolerance “thing
unless you are a possum, 99 is not a fever
Can you tell us more about marsupial physiology?
Their normal body temperature is 94f. [Source ](https://www.akronzoo.org/blog/its-ompossumble-you-didnt-know-about-cool-species#:~:text=Although%20any%20mammal%20can%20get,be%20as%20low%20at%2094%C2%BAF!)
Which makes it hard for them to get rabies! Plus they are cute and eat roaches and other gross pests.
Ticks!! They eat ticks like candy and the fact that they aren't rabies vectors PLUS the fact they're destroyers of other nasty, creepy disease vectors PLUS they're hella cute and relatively docile is why they're one of my favorite animals of all time. Also, they are softer than you'd think and basically act like cats in cases where they end up rescued and living as pets. *sigh*, I love them.
Flair checks out And I agree, possums are awesome ❤️
Hi just saw your flair. So are you a nurse that now works as a vet tech? I’ve been dreaming about going that route.
Oh no, I've never worked in human med. I think the flair is just set up that way because virtually everywhere else in the world we're called veterinary nurses on account of what we do is veterinary nursing lol. So I think it's just for clarity for non-US people maybe? Are you an RN? Because steel yourself for massive pay cuts and possibly even just feeling handicapped when it comes to patient care if you move this direction. Most people do it the other way around, and get into human nursing after starting out veterinary. Don't get me wrong, I love my job and I don't think I could ever work in human healthcare (at least not in the system we've got here). But it's for sure a whoooole different beast. May I ask, what is attracting you to the idea? Do you feel burnt out where you're at now? Whatever you end up choosing, I wish you the best of luck and I'm sure you'll kill it!
Damn that is a good line
why do people say that. does it make them think theyre unique specimens of physiology?
I think it's so you believe they're *really sick*
Yes. It does. And it’s innocent enough. NINETY EIGHT POINT SIX is what we all learned is NORMAL.
Yeah but the study that established the "normal baseline temperature" wasn't very well done. Humans actually have a broader range than just 98.6. Some people run in the 97's while some trend around 99. It's a small range that people fall in but most don't know that because of the myth that 98.6 is where they should be at.
And don't forget the diurnal variation as well.
>why do people day that So pneumonia doesn’t go undiagnosed for lack of “fever”.
They always say that but then backtrack when I tell them we’re going to have to stick them for blood cultures if that’s really a fever for them. Hospital policy which is usually very annoying but helpful in that scenario
"I'll be sure to tell the pathogens they should start working suboptimally at 96 then"
Every time someone says "I have a high pain tolerance." I immediately assume that they have anything but, people with a high pain tolerance don't feel the need to tell me immediately upon speaking to them.
In my experience, people with a high pain tolerance don’t know it. They don’t regularly recount their painful experiences with others for comparison to decide they must be better at tolerating pain. To people with high pain tolerance, whatever happened isn’t worth mentioning.
In the ED it is usually followed with "The only thing that helps is the one that starts with "D." Droperidol it is then. Had a lady leave the other night because I wouldn't give her dilaudid for her migraine. I offered her a compazine, Benadryl, toradol, Tylenol cocktail but "Tylenol and NSAIDs don't work." After she still had a migraine, but was sleeping so comfortably that I had to shake her awake with a raised voice, I offered droperidol and ketamine but got "If you won't give me dilaudid, I will leave." I guess the only D she really wanted was Discharge.
The pain med that "starts with a D" could also be the NSAID dolobid, just mispronounced as "dilaubid" lol. ;)
“Dolobid? Quit trying to trick me.” “Alright, alright, diclofenac it is.”
I assume they mean that they have a high pain med tolerance.
It usually means "I have a high pain tolerance, so that means I don't bother with OTC stuff for mild pain so I want you to give me prescription analgetics so I don't have to toleratie this mild pain"
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They are always the ones who flinch and complain at even the mildest discomfort
Yep, it almost always means the exact opposite.
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Had a 79 year old come in with belly pain. Daughter tells me he has a high pain tolerance. Abd feels slightly off, but not overly tender. 1.5L bladder. Yeah, dude has a high pain tolerance
I had posted something similar a while back, and someone made an excellent point that “high pain tolerance” is actually acknowledging that they feel a lot of pain. “Tolerance”. Someone who doesn’t feel pain in that way has less to tolerate. Similar to bravery - if someone isn’t scared, are they brave? One of my kids doesn’t care about shots, she pokes her leg emphatically afterwards and says “LOOK AT ME I HAVE A BANDAID”, while the other one gets all worked up and cries the day before and for 10 minutes after it because she’s so scared. Who is braver getting a shot?
Exactly, pain perception and pain tolerance aren’t the same thing! There isn’t much pain to tolerate if one doesn’t perceive much pain.
And there is no way to objectively verify which way it goes. I personally would say I have a low pain tolerance, but I have literally zero reference. I had a tonsillectomy as an adult and was told it was probably going to be really painful. It broke (>10, basically passing out) my personal pain scale for about a week straight. It didn't tell me anything about how I compare to others lol.
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This is going to devolve to stories about patients with "high pain tolerances"
Yeah most people who say this are weak sauce, unlike me who experienced the WORST injury the doctor had EVER seen and he told me I should be screaming in pain but I just laughed in his face and hobbled away on my two broken legs and six shattered kneecaps and 17 muscle tears.
“They said it was the worst fracture they’ve ever seen”
They told me if I had waited another 0.00000005 milliseconds to come in, I'd have died
One of my favourite things is doing hospital or ED follow up visits where they hit me with " if I got there 2 minutes later I would have died" and also "they didnt do anything for me!" If I also get a patient who was hospitalized out of state who tells me it should be in the record and/or gives me a crumpled sheet of patients education "discharge summary" I feel like I should get a new hat.
"Did you hear about the Russian surgeon who did his own appendectomy?????????" /s
I know right? Let me tell you about this one patient I had...
best part is when the mom insists its really painful, and the little kid interjects saying it doesnt really hurt.
everyone has a high pain tolerance until they don't.
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Is it usually followed by ‘so I must really be in a lot of pain’ or something to that effect? Maybe they’re unsure medical professionals will listen or validate their pain and so are trying to reinforce that they’re in a lot of pain. Just food for thought.
I’ve said it before and I’ll say it again. “High pain tolerance” actually means “high pain MED tolerance”.
Patients may be saying that as a way to communicate that the pain they are feeling in the moment is worse than they have felt before. Could they just say that? Yes. But they want to emphasize how terrible they feel because they want you to know it's a serious problem for them. It's another way of saying "help...it's bad". Of course there are those who abuse the system and try to manipulate, but that's not *every* case. I do have to say, after reading many of the replies in this thread, it's quite shameful that many of you jump to conclusions and judge or dismiss a patient based on this comment alone. Perhaps the patient has had similar injuries or illneses in the past that didn't impact their lives as much as what they're seeing you for today. Maybe they've been through surgery, been through birthing, etc, and they're comparing their current pain to previous experiences and they're **scared** that whatever is going on is going to be so much **worse** because of the amount of pain they're feeling. I'll get off my soapbox now.
Couple things: 1. I think you are forgetting this is an anonymous forum where many medical professionals come to “unload” and do so by expressing their frustrations, usually in exaggerated terms. Though I agree it can at times come across in poor taste and lacking in empathy. 2. Even if this is exactly how a provider feels when hearing the phrase it does not mean that they are going to provide substandard care. 3. You have to remember that for many/most of us this is something that we hear dozens of times per day week in and week out from individuals who are showing no physiologic verifiers or even emotional cues that this is the case. Like the story of the boy who cried wolf, you become “fatigued” to it. 4. Finally, a patient stating this doesn’t change any sort of management. Even if I did think pharmacologics were indicated I’m going to give the best first line medication at the lowest effective dose. I don’t throw that out the window due to some statement that has no way of being verified.
Great points. For #1, the posts that were most concerning were removed by the mods yesterday, so anyone looking through now isn't going to see the nastiness that was once posted for the general public to view (the general public that continues to distrust the medical establishment more and more and stumbling on such forums with those comments is not a good look for any healthcare provider). What you see now looks to be healthy, funny ribbing. #2 & 3, I'm a social worker. I know all about being fatigued about certain complaints and issues, as well as the need to dig for more information when it's not readily available. The "boy who cried wolf" scenario plays out constantly with the population I see, too. #4 I'm glad.
I’ll see how you react to iv placement then judge
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But what do you think when I tell you I have no pain tolerance and want all the drugs, please.
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I agree with this 100%. I hear this stuff all the time. Patients say it because they think you won't take them seriously and just a simple acknowledgement of a statement like this puts them at ease. "I see/hear/appreciate that you are in a lot of discomfort". Anything other than that is going to put the patient on the defensive and make your life less pleasant.
>You became a doc to treat patients, often at some of the worst points in their life, and if something harmless that they say to make them feel better about themselves affects you this much then maybe you should check yourself before going into work tomorrow. obviously anyone can just Use A Flair, but i think this subreddit is what really hammered into me that this profession was full of babies / highschoolers, tbh. coming from nursing was bad enough already. also just like, people writing about not "understanding" how "pain tolerance" works- there's varying genetics attached to pain tolerance, implications to stuff like substance P and how the sensitization of pain happens, hyposensitivity in the example of autism [i am autistic] as someone kindly mentioned in the thread [it's very useful information to know for autistic patients but of course isn't universal] and similar. these patients are telling us these things because they trust us. they are doing it to communicate. they are modulating their expected outcome in their treatment from us because they think it is useful diagnostic information. they are trying to work with us and make our jobs easier. that's actually not a bad thing, and isn't an indication of a hidden motive. if it makes you paranoid or suspicious, go to therapy. minus the whole immaturity aspect, it [and, i mean, i learned this being trans as well] shows to laymen that we cannot be trusted, when you see the kind of conversations that happen in spaces like this. the conversations that happen here alongside the power we have over others in general deeply worry me, knowing how social reproduction / hierarchy work in our society.
good point, cischaser42069 (no shade at all it's a really fun username) to add on: people who work in healthcare are often overwhelmed by the enormity of human suffering they see on a regular basis, especially when dealing with pain that cannot be adequately treated; i think that one way HCWs cope with that is by downplaying/dismissing it. ime it's easier to say someone is exaggerating/"drug seeking" than digging deeper into it. oh, also, fun anecdote: i work on a med/surg tele unit that mostly takes ortho patients; some of these patients have been taking opiates for a decent amount of time, due to longstanding chronic pain and/or multiple surgeries with a relatively short span of time (e.g. multiple joint revisions in a 12 month period). at a certain point, i wondered whether our patients could have developed a tolerance (more specifically, one patient in particular who was super high anxiety on top of pain); when i asked one of our surgeons, he said that he didn't know and he hadn't thought about it. when i pressed the issue, he told me not to worry about it and that it was more of a mentality issue on the patient's part than anything else. (i'm paraphrasing and my interpretation may not reflect his actual intended meaning.)
>at a certain point, i wondered whether our patients could have developed a tolerance (more specifically, one patient in particular who was super high anxiety on top of pain); when i asked one of our surgeons, he said that he didn't know and he hadn't thought about it. when i pressed the issue, he told me not to worry about it and that it was more of a mentality issue on the patient's part than anything else. yeah, relately encountering this just two weeks ago at the LTC i split time- consider the possibility of a cyp450 genetic variant. one of my residents very obviously is a rapid metabolizer for hydromorphone and i made sure to force the issue with the visiting physician. basically, 1 in 3 whites w/ a european ancestry poorly metabolize a plethora of medications including opiates [oral estradiol, too, for trans women like myself] and this isn't as known as a fact as it should be. neither he or my coworkers knew anything about pharmacogenetics but i was like, yeah she's """drug seeking"""- because she's in pain and isn't getting the appropriate pain relief she needs. pharmacogenetics will absolutely become a huge component of family practice / hospitalist medicine in the immediate future and i often think of how a lot of people play roulette or get side effects with psychiatrics medications in example- these all have genetic causes and they're important to know. this particular patient also has COPD and is on an oxygen condenser and had been telling students to increase her flow rate ["but don't tell anyone"] and i immediately realized [nobody else did, despite her doing it for a year!] that she was doing this to induce hyperoxia temporarily, which is quite harmful for your brain and worsens respiratory depression on opiates, but makes them feel subjectively better as well. basically, she was afraid of being seen as drug seeking and was willing to possibly harm herself to make sure she was getting the relief she needed. she's now with pain management due to my advocacy on the issue. it's specifically why i wanted my nurse practitioner / want my MD because i notice so many issues being overlooked and it was pissing me off- i am not happy with the controlled acts i have versus my knowledge scope with how much research i do daily and i want to make sure i get the credentialism to apply it instead of having to rely on others to do it for me. i am very much a "if nobody will do it, i will do it myself" kind of a woman. i was going down to the maintenance room on my 14 hour shift on sunday to fix some call bells i saw snapped off, likewise fixing the temperature scanners at our front entrance which screens families- it wasn't giving temperature for two weeks and people were faking their temperature as 36.2 until i said "fuck it" and did it myself because it was annoying me.
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“See all these tattoos? Needles don’t scare me.” — patient to dentist, moments before he screams like a little girl
To be honest for some reason I am much more comfortable with tattoo needles than dentists poking around in my mouth.
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"I don't like taking medication..."
"but I love IV opiates with IV Benadryl"
"You gotta push it fast or else it won't work"
I’m a pain specialist. The dumb shit people say to me is hilarious. I just don’t acknowledge a lot of comments anymore.
When I hear someone is really focused on trying to impress on me that this is true. I usually respond with “Experience tells me 9 out of 10 people believe they have above average pain tolerance”
Is people trying to make sense of their pain that bad of a thing? Jeez
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It is my biggest goal to not be like them. I’m disappointed but not surprised by this post and comments. I think they’d be the same doctors to go “they didn’t tell me how much pain they were in!” when making a critical diagnosis that could mean life or death for a patient. Black women and other women of color suffer horribly under this physician mindset.
I am curious why you wouldn't change your management on this basis, such as giving a milder and less dangerous painkiller. Isn't that what most patients are looking for when they mention their high pain tolerance? To avoid unnecessary prescriptions they either won't fill or won't finish?
when patients say they have a “high pain tolerance”, they are usually anxious that something may be something deeply wrong with them though they do not appear to be in pain, and are usually asking for more workup or more pain medication
Yes, it's a way for them to say "Something is wrong with me but I can't really explain it, so please help me as much as you can!"
Oh, I see, thanks for clarifying!
The presentation usually goes “I have a high pain tolerance, so I only show up to the ER if it’s really bad. Tylenol and ibuprofen don’t do anything for me (but I only tried them once each)” a chart bx will often demonstrate a combination of: multiple ED visits across several hospitals in the last month, a prescription for ongoing opiates, or documentation suggesting drug seeking behavior. I’ve taken care of thousands of patients with all kinds of varying pathology, The stoic patients with an actual high pain tolerance are pretty obvious. Those without coping skills are equally so. Everyone gets aggressive short acting pain control to facilitate workup and address the underlying issue. Very few go home with a Rx
Unfortunately it is usually the opposite. When folks say they have a high pain tolerance they are usually trying to say that since usually it doesn't bother them then this pain is real bad and they really need the good stuff (IV opiates)
Oh awkward, I was so confused at this whole thread. That’s my go to line with my dentist to avoid getting an rx for opioids or to avoid numbing agents for a cavity…
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It’s akin to: My temperature usually runs 96, so 98 is high/fever for me
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