Painful Yarns

by G. Lorimer Moseley

  The overwhelming response to surviving a bite from such an animal is something like ‘my giddy aunt that was close!’ But there is a sequel to the snake bite story. It occurred about 6 months later. I was walking again in a National Park inside Sydney. Lane Cove national park. One of the many things I love about Sydney is that it is such a beautiful city. It really is. Not just for its harbour, which is appropriately famous, nor for its beaches, which are also pretty well known, but also for the unsung national parks within its boundaries. There is Royal National Park at the southern end of Sydney. From the northern end of the Royal NP one can sit and watch the jumbos come into Kingsford Smith Airport and Sydney city’s tallest buildings are clearly visible in the background. Two hundred and thirty years ago the original Australians would have stood in the exact same place and watched in wonder at the Endeavour and its fleet as they washed into Botany Bay. Overdressed pale-skinned men, as badly suited to this country as it is possible to be, would have been staring back in equal wonder at the unfamiliar landscape of‘Terra Australis’.One can walk for two days in Royal National Park, never be more than 20 km from the CBD and only meet the occasional fellow walker. I love Sydney.

  This one fine November day however, I was walking in Lane Cove National Park. Lane Cove NP is less than 10km from the CBD and about half way between the coast, a natural barrier to Sydney’s eastward expansion, and Sydney’s geographical centre. Once in the park, one can easily become convinced that the urban sprawl is miles away, even though it is literally surrounding you, less than a kilometre away in most directions.

  Figure 4 The nasty customer that got me

  It is important for this story to point out that I was walking with a small party, one of whom was a boring-talker. Everyone knows a boring-talker, although they may never have realised it. Boring-talkers are those people who, no matter what they are talking about, make it completely and utterly boring. Bores you almost to tears. Well I know one such Boring-talker, who I will refer to as Helen. That is not her real name. In my talks I use her real name but she might just read this, so I have called her Helen. I so-happened to be in a conversation with boring-talker as we were walking along the windy track through Lane Cove NP. She was talking about something, but as it is impossible to remember anything without attending to it, and as it is impossible to attend to a boring-talker, I don’t remember what Helen was talking about. I do remember that she was talking, because I remember having to reply every few seconds with a “Right” or an “OK”, with the occasional ‘Really? Wow!”28

  Anyway, as I was walking, I remember, this time quite clearly, feeling a really sharp prickling pain on the outside of my left leg, just above the ankle. If I was distracted I may not have felt it. Distraction remains our strongest analgesic. However, thanks to Helen, I was not distracted!

  The pain was immediate and really intense. It was an electric, burning sensation that quite literally took my breath away. The pain shot up my leg like an electric bolt. It really really hurt. I couldn’t help but yell out, partly I think in shock but then in pain. I doubled over, fell backward onto a conveniently situated rock and gripped my leg. I couldn’t stop my face from contorting and my eyes switching between looking for the snake like a madman for sanity, and then clamping tight. I was in agony.

  I hadn’t just immobilised myself. I had mobilised the rest of the walking party. They were all attending to me. Jacko was on his mobile phone (the other side of having a National Park in the middle of the city) to the ambulance service: “Hurry! We have a bloke here who has been bitten by a snake, he has a minute to live!”29 Helen, I think, may still have been talking. Not sure. It wasn’t for a couple of minutes that anyone had a close inspection of the area, at which time we realised that I had indeed been scratched by a twig. There was a single, tiny scratch mark on my leg. I have drawn here another picture of what I think happened this time, biologically.

  figure 5 snake bite version 2

  The thing is, the first time, it didn’t really hurt. The second time, it did. It really hurt. More than that, the first time I had groin pain for about a week. The second time I had recurrent aches in my groin for about a week. This was after I knew it was a scratch from a twig. It was as though my brain, at a deeper implicit level, wasn’t convinced that I was completely safe from harm.

  so, what do the snake bite stories tell us about pain?

  The one sentence take home message: Pain depends on the brain’s evaluation of how much danger you are really in.

  I think pain is a pretty good indicator of the brain’s perception of tissue danger. That is, I subscribe to the notion, which is not my notion, but one I think is the best, that pain can be considered the conscious correlate of the brain’s implicit perception of how much danger the body part concerned is in. For different versions of this same notion, refer to the reference list at the back of this book. Another way of stating this, and the way I state it to patients, is that pain is determined by the brain’s answer to this question:

  “How dangerous is this?”

  If the brain has received danger messages from the nerves in the body that are designed to detect danger, then the question becomes:

  “How dangerous is this really?

  So, going back to the first snake bite story, the brain received the danger messages loud and clear, but concluded that it was not really that dangerous. In the second scenario, the brain received danger messages from a similar location and concluded that the situation was potentially life threatening. What better way than undeniable agony to make me, the organism, limit the danger by:

  stopping

  making everyone else stop

  taking the weight off the leg

  looking around for the snake, possibly to avoid a second bite, or to avoid another person getting bitten

  It seems to me, to be a very effective system.

  “How dangerous is this really?”

  There are a few things about these stories that I point out to patients:

  That the brain did all this evaluation outside of my consciousness and outside of my control.

  That it happened in a split second.

  That it happened to me when I spend 40 hours a week30 studying this system. This is what I do. It is my job. And, despite that, my brain was still ‘tricked’.

  That I had pains in my groin for a week or so afterwards, even though I knew that it was a scratch and nothing to worry about. That I had those pains tells me that my brain was not convinced that there was indeed nothing to worry about. I find this point really useful with patients who are adamant in saying that they are quite happy to believe there is nothing wrong in their body. I use this example to demonstrate that there is a whole lot going on in your brain that you don’t know about, and only a tiny amount that you do.

  That the single experience in which I nearly died is enough to cause exquisite pain next time a similar situation occurs. This incredible adaptability is, I think, very cool. I tell patients that I think it is very cool too!

  mr hammerhead shark

  Or: Nociception is not sufficient for pain.

  Royal North Shore Hospital was, for a long time, Sydney’s biggest hospital. The emergency department had a huge waiting area, right next to where the ambulances would bring in the patients on those magic folding beds. I had noted the hospital’s design on a previous visit as a patient, when I popped my shoulder out playing Australian Rules Football on a ground just out the front. I thought it intriguing that the waiting area would have full view of the ambulance chute. Wouldn’t they want to keep it a bit private so that patients in the waiting area didn’t have to watch those, with injuries too severe to come in themselves, writhe and moan as they went through to theatre? I presumed so, but as I sat there waiting for someone to return my arm from where it was (protruding out of what looked like a tumour about midway between my nipple and the point of my shoulder) to where it should have been, I noticed that none of the people who came in with the ambulance seemed to be wr
ithing, or moaning. I thought this rather intriguing, so I took it upon myself to investigate this phenomenon more carefully once I was reshouldered.

  A few weeks later (not all that time was spent waiting for my turn in the emergency room!), I packed a couple of salad sandwiches, a space food stick (caramel), a couple of apples and a popper31 (orange and mango), and set off to Royal North Shore Hospital with this question in mind:

  “What is the writhe and moan ratio between patients coming in the ambulance with severe injuries and those walking into Emergency with mild injuries?”32

  I compiled a little table that I thought would encapsulate the main pieces of data. The tricky thing was to ask the patient some questions without getting in trouble with the staff. I was particularly concerned about the chief triage nurse. He was a really big fellow with a face like a pitbull. I could not understand why they would put such an incredibly intimidating-looking person on triage – perhaps to sort those in genuine need from those just coming in for a chat. My fears about him were allayed somewhat when I heard him offer one patient a cup of tea, which he did in a high, very feminine-sounding singing voice – a bit like Tinkerbell meets Sound of Music. Nonetheless, I was keen to be as discrete as possible in asking patients the necessary questions to complete my table. I kept my clipboard with me and stuck my University Library card in a plastic wallet and clipped it to my shirt. I asked them what they had done and how much did it hurt. Here is my table. I have put some of what I wrote that day in there.

  The most remarkable patient was the last one. He came in through the emergency department, having been driven there by the thrower of the hammer. That same hammer was now inserted through the side of his neck. It looked filthy – the tips of the curly bit were just poking out of the front of his neck, having entered from the rear. As he walked across the waiting area, he held the handle of the hammer out at right angles. There were groans and moans from the rest of us as we watched him – he, on the other hand, was as happy as Larry. Here is a reasonably faithful transcript of our conversation:

  LM: Crikey mate! What happened?

  Man with hammer in neck: Classic isn’t it?! Giorgio pretended to throw this hammer at me, which was a bit of fun, but he accidentally let go of the thing, which was a bit daft. Great shot but, wasn’t it? Straight through me neck – I gotta hold it out to the side so it doesn’t pull me off balance!

  LM: Doesn’t it hurt?

  Man with hammer in neck: Na – that’s the thing – it hurt when it went in but not that much – naagh, now it doesn’t seem to hurt at all – must have missed all me main bits.

  LM: Not at all? I mean it looks wrong.

  Man with hammer in neck: Not at all – hey. I got this great gag – Giorgio reckons it’s a classic.

  At this, the man with a hammer in his neck bent over forward so that his torso was horizontal. He put his right hand on his hip and pointed his elbow up in the air. He moved is left hand around so as to stabilise the hammer and then shuffled across the waiting room in a zig-zaggy kind of way.

  Man with hammer in neck: What am I? What am I?

  LM: I have no idea. A complete nutter?

  Man with hammer in neck: No, no – think about it! What am I?

  LM: (Giggling a little embarrassingly) I don’t know.

  Man with hammer in neck: Der der…..Der der…..Der der

  (At this point I need to tell you that the der der der der der der is my way of telling you that he did that noise from JAWS, when everyone was swimming in the water and you just knew that the mega-shark was getting close etc etc.)

  Anyway, continuing on….

  Der der Der der…….I’m a hammer-head shark yer goose!

  At that, Giorgio cracked up completely and had to sit down. Most people in the waiting room were laughing, except one guy who had more or less passed out at the sight of this fellow with a hammer hanging out of his neck playing charades in the waiting room.

  But here is the coolest bit – Mr Hammerhead shark spun around and hit his knee on the end of a table, at which he promptly swore and hobbled onto a seat, holding his knee, grimacing and saying:

  “Shit! My knee! Shit shit shit! Ow! Shit! SHIT!”

  The pitbull triage nurse was alerted by the waiting room commotion and then excited by the expletives. He looked up, saw a man with a hammer sticking out of his neck, sang “golly goonda my aunt jane” just like a Fairy Godmother might, called for the wardman and ran over to attend to Mr Hammerhead. There they were, the triage nurse, foaming at the mouth, looking like the front end of a woolly mammoth but sounding like Tinkerbell, and a man with a hammer stuck in his neck. Tinkerbell was waving his hands about singing “Don’t move your head! Don’t move your head!” while Mr Hammerhead was shouting at the top of his voice “It’s my friggin’ knee you moron! My friggin’ knee!”

  So, what has mr hammerhead got to do with pain?

  The one sentence take home message: Danger to your tissues doesn’t always mean it will hurt.

  There are two reasons that this story makes it into many of my sessions with patients. The first is that it is funny. At least I reckon it’s funny and most patients tend to at least get a giggle out of it. I find that getting a giggle makes the patient and me feel a bit more comfortable with each other. The second reason is that it is a perfect example of the fact that nociception is not sufficient for pain. It was not that Mr Hammerhead had no ability to feel pain, nor that he was temporarily rendered euphoric by circulating chemicals in his bloodstream (stress- induced analgesia). Those two things are ruled out by his outrageous response when he knocked his knee on the table.

  It is not that the hammer would have missed nociceptors33 when it went through his neck. On the contrary, there are thousands of nociceptors that would have been activated by the hammer. So much so that they would have, as we say in the scientific literature, gone bezerk.

  So, despite nociceptors going bezerk, Mr Hammerhead had no pain.

  Everyone has stories like this – I don’t have any that are as funny, but there is no doubt that this sort of thing happens in one form or another to most of us. Explain Pain has many amazing pain stories that show us that nociception is not sufficient for pain. That is the main message of Mr Hammerhead’s story I think – that nocieption is not enough. In order to experience pain, the brain has to:

  conclude that tissue is in danger, and

  conclude that you, the organism, should do something about it.

  ant fettuccine

  Or: Nociception is neither sufficient nor necessary for pain

  The Beautiful Anna, with whom I share my life, once got an ant in her ear. How this happened is somewhat of a mystery. One minute she was walking along as she had always been – ‘ant- free’ – and the next minute there was something scratching around in her ear. Neither of us knew it to be an ant, that became clear somewhat later on. I have never had an ant in my ear, but by all appearances it is a rather distressing experience. At first it was annoying, primarily because it was so loud, which I guess it would be because it is walking over your eardrum.

  We tried several means to get it out. I got Anna to shake her head violently from side to side as you might if you had a grasshopper in your hair. I tried to tempt it out by balancing a crisp on Anna’s earlobe and ruffling the packet. This I called the picnic approach. I even tried the vacuum cleaner. Anna lay on the couch with her ant-ear facing up. I placed my index finger over the edge of her ear hole so as to avoid the Hoover nozzle creating a seal and sucking her brains out34. The plan was that I would hold the nozzle vertically over her head and slowly move it closer and closer until she felt the little bugger stop his hanging on for dear life and slip up the ear canal like a beetle on the windscreen. We figured you would hear it scraping and possibly making a few little yelping-type noises.

  Funnily enough, none of our attempts were successful, although several times we thought it must have worked because the little bugger would be silent for a while. Anna would start to rela
x, wobble her head around a little and as soon as she said “I think it might be out” an almost deafening scrape or whack would tell her otherwise.

  It was not long before Anna’s ear began to hurt – a diffuse dull ache that slowly spread over a fair portion of the right side of her head. We began to wonder if this creature might have bitten her, or stung her and that perhaps the poison was starting to have an effect. She began to hold her head tilted a bit to the right and turned back a little. Her right shoulder started to lift up and come forward a little. Her posture was just like that posture you adopt when someone tries to poke you just behind your collar bone. Her right eye started to squint a little and her mouth tightened up just a touch on that side.

  As time progressed, the dull ache became stronger. It would become worse when she put her head down or moved it too quickly. It was time to see a doctor. We jumped in the car and drove to the local hospital. On entering the emergency department, we were quickly attended to by a charming fellow in a white coat, confident yet caring voice. There was no waiting for us this time. Despite there being several people in the waiting room, it seemed that obvious head pain or trauma gets prioritised. This is what our doctor said:

  Doctor: OK. What’s wrong with your head – there is obviously something going on. Is it your ear? (very encouraging)

  TBA: Yes, there is something, I think, in my right ear – I thought it might be a bug or something, but now the whole right side of my head hurts.

  Doctor: OK. Probably an ant. Lie down here with that ear facing up.

  Anna promptly followed his instructions and waited. He snuck into a nearby examination room. That he snuck in there did seem a bit odd but we quickly disregarded his sneakingness. He came back with a little bottle of olive oil.