"Just a Little Pressure..."

[chaser08]

Dr. Cox asked for med student questions, so here's one that's been bugging me forever: When you're about to do a procedure that's invariably going to cause pain, why do you say, "You're just going to feel a little pressure"? I've heard it from a lot of different doctors, but, in my experience, surgeons are notorious.

So what's up with that? Why not just tell them, "This is going to hurt like hell - but don't move, dammit!"?

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[Anka]

I've heard everything from "You're going to feel a little pressure" to "This is going to hurt." If something is going to be painful, I always warn the patient and tell them what to expect, e.g. "Some patients tell me it hurts when I take out their chest tubes. Other people don't feel much pain at all. However, people tend to feel a lot better once they're out. The pain is kind of like stubbing your toe -- it will hurt a lot but only for a breif moment, and then the pain will go away. [If they have a PCA or PCEA I add 'you might want to press your pain button now so once I'm set up it will be working']." The sort version is "This is going to hurt a bit, but I'll be quick."

Anka

 

[Blade28]

Pressure is when you've numbed them up, but they still feel deep pressure - like if someone were pressing their finger into you, hard.

Not painful, just uncomfortable.

 

[filter07]

Because telling them it will hurt increases their anxiety and tends to make them hurt more. If you tell them it will hurt you are only trying to clear your conscience, not do what's best for the patient. Most times I prefer to be the jerk that doesn't warn patients about something painful than being the nice guy who makes his patient hurt more.

 

[chaser08]

Pressure is when you've numbed them up, but they still feel deep pressure - like if someone were pressing their finger into you, hard.

Not painful, just uncomfortable.

I understand the difference between pain and pressure - but people don't usually wince or moan when they're in "pressure."

The whole numbing up thing is another issue - doctors rarely wait for the lidocaine to take effect. That's another thing I don't get, but that's a subject for another thread.

 

[chaser08]

I've heard everything from "You're going to feel a little pressure" to "This is going to hurt." If something is going to be painful, I always warn the patient and tell them what to expect, e.g. "Some patients tell me it hurts when I take out their chest tubes. Other people don't feel much pain at all. However, people tend to feel a lot better once they're out. The pain is kind of like stubbing your toe -- it will hurt a lot but only for a breif moment, and then the pain will go away. [If they have a PCA or PCEA I add 'you might want to press your pain button now so once I'm set up it will be working']." The sort version is "This is going to hurt a bit, but I'll be quick."

Anka

I like this. I think I'll use it. I think it's honest enough (clears my conscience ) and it gives the patient the hope that they'll be one of the ones that doesn't feel much pain.

 

[Anka]

Because telling them it will hurt increases their anxiety and tends to make them hurt more. If you tell them it will hurt you are only trying to clear your conscience, not do what's best for the patient. Most times I prefer to be the jerk that doesn't warn patients about something painful than being the nice guy who makes his patient hurt more.

I've heard this point of view expressed, but am not sure I agree with it. Who knows, perhaps with more experience I'll come to it also. The problem I've found is that patients who are in the hospital for a long time, exposed to pain without warning or after being falsely calmed many times get incredibly anxious about even minor procedures. And they don't trust you when you say "it's not going to hurt" anymore.

Anka

 

[Winged Scapula]

Like Blade says, many procedures only involve the sensation of pressure after the area has been infiltrated with local. And a deep feeling of pressure can be uncomfortable but most people don't say it hurts or causes pain (unless you're standing on their toes).

I tend to tell people that there will be some burning with the injection of the local, but that it will be momentary, and that I have a lot more if they are uncomfortable and need more. Its a fine line between being dishonest and lying about pain, and scaring them.

For procedures that don't involve using LA (ie, removing drains, chest tubes, etc.) I tell patients that its hard to know if or how much pain that they will have - some do, and some don't, but that every one I've done the procedure on that has had some pain, said it only lasted a few seconds.

And I agree, I have never seen anyone wait long enough for the local to take effect.

 

[DoctorMunchkin]

For chest tubes and such, I tell them it will hurt, but it will feel so much better when it is out. "Yes, this will hurt. Some patients say it doesn't, but some say it hurts like the dickens. However, I will be quick and it always feels better once it is out. It won't hurt for long after I am done." That way they are ready for the pain, I have not lied to them, and they have some happy end point to look forward to. Usually it works. Sometimes they appreciate the honesty, sometimes they don't. But they all say it feels way better when it is out.
And try to do it when their mom is not in the room. I don't know why, but guys (and many girls) are WAY worse when mom is around than if they aren't there!

For local, I infiltrate ("Your going to feel a little stick and a big burn, ma'am/sir"), then turn to set up my field, tray, etc. I try to give the local time to work, but for somethings (like abscesses) it just doesn't work because of the acidic environment. Again, I try to warn the patient. I paint a bad picture, thinking that if the patient doesn't think its as bad as I say, well, then I look pretty good!

You will develop your own technique, but it won't work every time. And always remember to take the JP off suction before you pull. I think that does hurt worse!

 

[njbmd]

Like Blade says, many procedures only involve the sensation of pressure after the area has been infiltrated with local. And a deep feeling of pressure can be uncomfortable but most people don't say it hurts or causes pain (unless you're standing on their toes).

I tend to tell people that there will be some burning with the injection of the local, but that it will be momentary, and that I have a lot more if they are uncomfortable and need more. Its a fine line between being dishonest and lying about pain, and scaring them.

For procedures that don't involve using LA (ie, removing drains, chest tubes, etc.) I tell that its hard to tell if or how much pain that they will have - some do, and some don't. But that everyone I've done the procedure on that has had some pain, said it only lasted a few seconds.

And I agree, I have never seen anyone wait long enough for the local to take effect.

For chest tubes and such, I tell them it will hurt, but it will feel so much better when it is out. "Yes, this will hurt. Some patients say it doesn't, but some say it hurts like the dickens. However, I will be quick and it always feels better once it is out. It won't hurt for long after I am done." That way they are ready for the pain, I have not lied to them, and they have some happy end point to look forward to. Usually it works. Sometimes they appreciate the honesty, sometimes they don't. But they all say it feels way better when it is out.
And try to do it when their mom is not in the room. I don't know why, but guys (and many girls) are WAY worse when mom is around than if they aren't there!

For local, I infiltrate ("Your going to feel a little stick and a big burn, ma'am/sir"), then turn to set up my field, tray, etc. I try to give the local time to work, but for somethings (like abscesses) it just doesn't work because of the acidic environment. Again, I try to warn the patient. I paint a bad picture, thinking that if the patient doesn't think its as bad as I say, well, then I look pretty good!

You will develop your own technique, but it won't work every time. And always remember to take the JP off suction before you pull. I think that does hurt worse!

Absolutely good advice above. I also tend to move a bit more quickly on the things that I know are painful such as entering the pleural space on chest tube insertions and going through the skin on arterial blood gas draws. Sometimes a lot of pain of short duration is better than constant pain. I always tell my patient that the local is going to burn at first as many people feel that when you say "anesthetic" that means "no pain". Like DoctorMunchkin, I always wait for for the local to take effect too.

 

[maxheadroom]

When I'm working with my junior residents, I always have them numb up the patient first, then go fill out whatever paperwork/prescriptions, and then come back. Part of that is to give the Epi a chance to kick in -- I've become a true believer that you really do need to wait at least seven minutes to get a real benefit.

 

[MossPoh]

My favorite was when the surgeon that did a procedure on me said "This will hurt *pause for 3 seconds* A LOT"

I think my pride was hurt more than anything being left laying there pantless, pasty a$$ to the door and having the pretty nurse laugh. Who leaves the door open? Honestly...

 

[smq123]

I think my pride was hurt more than anything being left laying there pantless, pasty a$$ to the door and having the pretty nurse laugh. Who leaves the door open? Honestly...

My resident made a big deal about ALWAYS closing the door, especially if it involved removal of clothes! No one needs to feel like a medical freak show for the whole hallway to enjoy.

 

[StickMe]

Ha. I hear "Stick and a burn" all the time and now use it regularly. Sometimes out of context even.

 

[LovelyRita]

I usually say, "this is going to hurt you more than it's going to hurt me."

j/k. but have been tempted.

When pulling drains/chest tubes I tell the patient that this is not the most comfortable thing you are ever going to feel, but I will be gentle and quick.

And I usually use the reverse psychology on some needle sticks and say it's going to be a huge big pinch, then like njbmd, go quick and then they are usually surprised it's not that bad.

 

[MossPoh]

My resident made a big deal about ALWAYS closing the door, especially if it involved removal of clothes! No one needs to feel like a medical freak show for the whole hallway to enjoy.

I mean, I do have a GLORIOUS badonkadonk, but when there is a drainage tube dangling out like a tail...not so much.

 

[eclcell]

Because telling them it will hurt increases their anxiety and tends to make them hurt more. If you tell them it will hurt you are only trying to clear your conscience, not do what's best for the patient. Most times I prefer to be the jerk that doesn't warn patients about something painful than being the nice guy who makes his patient hurt more.

I do think the patients own anxiety contributes to the level of pain they sense or at least subjectively sense. As much as what you tell the patients, I think its important that you appear knowlegable and conifdent and not like the procedures makes you nervous too. On a side note, I've also noticed that the number of tatoos a person has and the number times of times a person has used IV drugs seems to be indirectly proportional to their pain tolerance, especially when your about to I+D their abscess that they gave themselves. Why is that?

 

[SocialistMD]

I did a little case series my intern year with the patients on whom I removed a drain/tube. Most of them simply said it feels "weird," so that is what I tell my patients now. Most of them agree. Yes, there are those who feel pain and there are those who feel nothing, but for most, it is just a very odd sensation.

 

[Blade28]

Ha. I hear "Stick and a burn" all the time and now use it regularly. Sometimes out of context even.

Ah yes, one of the many little "lines" we use on the poor patients...

"Just a little stick and a burn, sir!"
"You'll feel pressure, that's all! No pain."
"Almost done!"

 

[Winged Scapula]

Ha. I hear "Stick and a burn" all the time and now use it regularly. Sometimes out of context even.

My partner says "pick and a burn" which always sounded weird to me.

 

[MossPoh]

sounds weird to me too....

 

[McDizzy]

Whenever I inject local and a patient is awake I tell them that they are going to feel a pinch and a burn.

 

[DrDawg]

I did a little case series my intern year with the patients on whom I removed a drain/tube. Most of them simply said it feels "weird," so that is what I tell my patients now. Most of them agree. Yes, there are those who feel pain and there are those who feel nothing, but for most, it is just a very odd sensation.

For drains/tube removal I always tell patients it nauseating, but not painful, and passes quickly. A few times I have said it may cause discomfort and some people asked for local. Having never had a tube or drain I felt local would hurt more, and then waste time. Occasionally give a little Morphine thou. Having used local on myself before (without epi) in takes effect pretty quick. I typically use twice what any other reasoniable person would use.

I have an attending that always says "just a little prick in the a**"

 

[dpmd]

Being a huge wimp for pain myself (and having had the pleasure of getting a chest tube emergently, along with various other painful procedures), I tell the patient what I think the accurate assessment is. For JP and chest tube removal I tell them its going to feel like I am ripping their insides out, but that it only lasts a moment and then feels better. For a chest tubes I always premedicate with an opiate, but for JP's I don't unless the patient has demonstrated they are a wimp like me. For chest tube insertions that can be done a little slower I do the local, dissect, local, repeat prn method and have had nearly painless insertions (won't work if you need to get the thing in now). I premedicate everyone I can. I even medicate the kiddos, although I know some people just hold them down and take care of business.

 

[mfreema1]

Post call some slang usually comes out. My favorites so far have been, "This is going to suck" and "This'll hurt like a mo-fo".

This isn't exactly the same as taking out a drain, but something funny I did say to a patient and her mother post-call.

I had a constipated patient who just wasn't pooping after getting laxitives. We decided to give her an enema the morning that she'd get discharged. I went in to let the patient know what was coming, and she asked me whether, if she could poop on her own, could she not have the enema.

I told her that if before she got the enema, she could get provide for us a great big log, we'd hold the enema. My senior told me later that he would've described it as something other than "a great big log"....but it was something that 12 y/o understood.