Saturday, 16 January 2016

Back Pain: A Tale of Two ER Visits

Imagine this:

You are 25 years old. Your back has been hurting lately and it's been getting worse. You haven't seen your doctor about it yet. You've been pushing through it, popping over the counter painkillers, and hoping it'll get better. Then one day at work it suddenly gets a lot worse. The pain extends down your leg, and your leg gives out under you. You can't ignore this anymore. Your over the counter drugs aren't even touching the pain and you feel like you can't take it anymore. You call your partner, who drives you to the hospital. 

Now imagine you get into the emergency room and the nurse says "oh man, you must have a herniated disc" with a look of absolute pity. You wait a few hours to be seen by a resident doctor, who does an exam that you can only describe as excruciating. He says you need an MRI and tells the nurse to give you narcotics. The narcotics kick in and you finally fall asleep, leaving your partner to sit there wide awake wondering what's going on. A while later, another doctor comes in and does the same excruciating exam. Even with narcotics this one hurts. You try to tell them that the resident already did this, so please don't do it again, but the doctor proceeds anyway. You wait another few hours and get your MRI. Another doctor comes in and again examines you in the same, horribly painful way. This doctor says "it's definitely a severe herniated disc. This pain is never going to go away unless you have surgery. But the reality is there's way too many people with painful herniated discs. If a surgeon will even take you, it'll be at least a two year wait. If you had neurological symptoms, then you could get surgery right away. But since it's “only” pain, good luck. Here's a prescription for two days worth of narcotics. I can't give you any more because I don't know you, so I can't be sure you won't abuse or sell them. Follow up with your family doctor.” Later you call the family doctor, only to find out she's on vacation for three weeks, and the covering doctor does not prescribe narcotics. 

Can you imagine the feeling of absolute helplessness and frustration that you would feel? The key message you receive seems to be “your pain is here to stay, and we don't care.” 

Now imagine this version of the story:

When you get to the emergency room, the nurse reassures you. She tells you they have very good doctors here, and they'll be able to figure out a plan for how to deal with this. You wait a few hours to be seen by a resident doctor, who explains that he needs to do an exam to figure out whether there are any neurological symptoms accompanying your pain. The exam is painful for you, but he’s compassionate about it. After the exam, he tells you that the good news is he isn’t seeing any neurological deficits, and because of this he doesn't recommend advanced imaging, like an MRI. He explains that you could have a herniated disc. He also explains that research is now showing that a lot of people who have herniated discs don’t actually have any symptoms, and doing surgery on the people who are having pain is not necessarily helping them. Sometimes it even makes their pain worse. He does prescribe appropriate pain medication to help you get through this current bout of pain, but he also tells you that there are many strategies that can be used to better manage the pain, and medication is only a part of the answer. He tells you that the emergency room is great for dealing with medical emergencies, and it’s good you came here to rule out any neurological symptoms. But at this point, there are better places to further assess the cause of your pain and help you learn how to deal with it. He refers you to a pain specialist who can help you along the way and also advises you to follow up with your family doctor. He tells you to come back to the ER if you do develop neurological symptoms.

What do you think you might feel in this scenario, and what overall message would you receive this time?

Click to enlarge.

What are the differences?

In the first example the whole situation is the opposite of how we would like to see pain treated. There is no empathy or reassurance. The wording used only increases the threat value of the symptoms. (“Oh no, this is really bad!”) This can take a nervous system that’s already on high alert because of the sudden worsening pain and escalate the system’s response. It also does not provide any hope that things can change. (Which could be argued to add a whole new threat: this will NEVER go away!)

In our ideal situation the client is treated with caring, respect and compassion. Decisions are discussed with the client and education is provided. The overall approach hopefully made the client feel supported in a scary situation. 

Points to ponder:

We’ve packed a lot of concepts into these two short examples. These topics could be posts in themselves, but we just wanted to introduce the ideas here. We would love to hear your thoughts on them.

1.) Respecting the client - In the first example we saw three different doctors do the same painful exam three different times. We totally understand each doctor wanting to an assessment before they make decisions. But if a colleague just did the very same thing, you trust their judgement, and the assessment is very painful for the it necessary? At this point what are you looking for with your assessment and is it a good reason/justification to put the client through the assessment? If it is necessary, explaining the benefits to to the client might put them at ease. 

2.) Language - As we mentioned above, the language clinicians use to describe the pain can either reassure or terrify the person in pain. Clinicians are often rushed, trying to see many people in a short time frame. However, in our example above, it really wouldn’t take any longer to communicate in the encouraging manner used in the second scenario.

3.) Imaging - Imaging for pain is a topic that is currently being researched and discussed. As Bronnie Thompson so succinctly stated “We know that most people with back pain are not going to benefit from having X-ray, CT or MRI because these images either don’t show anything useful (no image shows pain) or show something irrelevant that might look interesting but is actually unrelated to back pain. We know this, and there have been numerous treatment guidelines and algorithms and education indicating not to give imaging for low back pain without neurological changes” (Thompson, 2016).

4.) Surgery - Again this is a topic that is currently being researched and discussed. There are many articles on this topic, and some suggest that surgery has been “overprescribed” (Senelick, 2014).

5.) Pain Education -  Educating the client on their own condition can begin at any stage and with any health care provider. While there may not be time to address it in detail in the emergency room, it can be further explored with healthcare providers who specialize in pain. These could be physicians, occupational therapists, physical therapists, psychologists, physiatrists, pharmacists, or a team of providers working together.

And a parting thought:

The first scenario is based on a real story. We don’t share it as a criticism, but as a starting place for a discussion on how pain is approached in assessment and treatment. For health care providers, we hope to draw attention to the impact your information and language can have on clients and their outcomes. If you’ve happened to be the client or family in an ER visit that resembles the first one, please don’t give up. There are health care providers out there who are treating people with compassion, kindness, and care.  And there IS hope that your pain and your life can get better.

Diagram by Ashley and Colleen at Reclaiming Life. Graphics from

Senelick, 2 (2014). MRI Back Scans Do Not Predict if you Need Surgery. Retrieved from on January 16, 2016

Thompson, B. (2015). HealthSkills: How to Spend Money You Don’t Need To. Retrieved from on January 16, 2016