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Pain in the pneumothorax

By Megan McAndrew Cooper

Two years ago, I took up riding horses again, after a 35-year hiatus. I had just gone through a particularly difficult period in my life, and riding proved a remarkable antidote to the lingering sadness of pain and loss. I have learned all over again how lovely it is to put my face against the warm side of a horse's neck, how exhilarating it is to canter up a hillside, how satisfying it is to share a passion with a teenage daughter. Unfortunately, I have also learned that 52- year-old bodies are different from those of 15-year-olds: we don't, as more than one person has observed, bounce the way we used to.

I confirmed this observation twice last year. The first time, in January of 2002, I lost my balance and fell off a very tall horse, hitting the dirt of the indoor arena hard enough to break four ribs on my right side. The second time, in October, I fell off a much smaller horse and became involved with a tree on my way to the ground, breaking a rib on my left side.

The doctor explained that the pain would last for about an hour, a good 40 minutes of which had already elapsed.
Illustration: Suzanne DeJohn

Medical vocabulary: Along the way, I expanded my medical vocabulary: I can now use the word "pneumothorax" in a sentence. But please don't ask why this keeps happening. It just does.

What's been interesting (aside from learning that the reinflation of a lung is the only pain even remotely rivaling that of childbirth) is how different the experience of being injured, and in the hospital, can be—even when the injury is more or less the same. And what's even more interesting is that what makes a difference is not how kind people are (they are almost always kind) or what the accommodations are like (the food is rarely a high point) or how much pain you're in (it hurts either a lot or really, really, really a lot), but how much control you feel you have over what's happening to you. Really.

To begin with, it's the difference between having to ask for pain medication and being able to give yourself more when you want it. During my first hospitalization, I stayed overnight in DHMC's Coronary Care Unit (CCU). In the CCU, I had an intravenous line and I could ask the machine for a bolus of morphine if I thought the pain was worse. Every time my nurse, Betsy Maislen, came to check on me, she told me I could ask for more or ask more often, but I didn't need more—probably because I knew it was right there if I did want it.

Dreadful hour: On my second hospitalization—which was much less dramatic in some ways—I was admitted to a medical floor. There, a machine in the hall refused to dispense my drugs until the prescribed four hours had passed. For two days, there was, over and over, a long, dreadful hour between when the last dose had begun to wear off and when the next dose would be available. If I wanted more morphine, I had to ask a nurse, who had to go ask a doctor. I hated asking, and I'm sure they hated the sight of me at the nursing desk.

There had been a really bad hour in the CCU when my lung was reinflated by means of suction applied through a chest tube. I vocalized a good deal during this time, and eventually my friend Carolyn, embarrassed, went out into the hall, collared a doctor, and asked him to please do something. The doctor came in to my room and stood at the end of my bed. He told me what was happening. He acknowledged that it was extremely painful. He explained that the pain would last for about an hour, a good 40 minutes of which had already elapsed. And he told me that the only way he could relieve my pain entirely would involve intubating me—which he'd do if I wanted.

His explanation didn't make the pain any better, but it made me better. I had less than 20 minutes to go, and I definitely didn't want to be intubated. I was involved in the decision, or at least felt as if I was. I felt I could have said, "Go ahead, intubate me." (I don't know if he would have, but I believed I'd made a choice. It worked.)

A night nurse in the CCU also showed me how to disconnect my chest tube so I could get out of bed myself to go to the bathroom. I'm the world's worst bedpan-user, so both the nurses and I benefited from my mobility, which didn't require asking anyone for help. I was judged competent to do something that seemed exotic to me.

Decisions: In the CCU, the person I saw most was Betsy Maislen, who seemed to be able to decide whether I needed oxygen (we agreed that I'd get along without it), when I could go home, what monitoring was necessary and what wasn't any more. On the medical ward, it seemed necessary for all those decisions to come from somewhere else; everything took a long time, and I cried a lot.

I work with a very nice man who believes that the solution to much of what's wrong with American medicine could be cured by shared decision- making—that is, doctors and patients sharing solid information about what to expect from various treatment options, and then making an informed decision as a team about what to do. But I think it should go a little further—I'd like shared power. When I controlled my own pain-management in the CCU, I used less morphine than they expected. When I had to ask the nurse, every four hours, for more pills, I demanded as much as was prescribed and wanted a great deal more. The difference is that in the first situation, I could do something for myself, and in the second, I had to ask someone else to do it for me. I wasn't part of the team taking care of me.

I know that not every patient, and not every situation, lends itself to shared power—there are emergencies, and people are stressed, and hospitals have systems. But most of the time, even if I don't get to be the quarterback, I'd like to be part of my own team.

"Point of View" provides a personal perspective on some issue in medicine. Although Cooper is the editor of the Dartmouth Atlas of Health Care and a frequent contributor to Dartmouth Medicine, she writes here not as a journalist but as a patient.

If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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