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February 5, 2003

Pain and Forgetting

JAMA. 2003;289(5):617. doi:10.1001/jama.289.5.617

A man with a broken ankle lay grimacing in the trauma unit, his crooked foot bulging awkwardly. A self-assured orthopedic resident entered the suite as a nurse administered a syringe full of clear fluid, patting the patient gently on the chest after she had finished. Minutes later, the resident tugged at the man's foot while two interns applied traction. The man screamed in agony, writhing on the gurney. The procedure left him covered in sweat, weighted down with exhaustion, and battered by waves of pain.

Within 15 minutes, all signs of disturbance had vanished. The man's face held a serene look, a faint smile emerging every now and again. He answered the nurse's questions calmly, without irritation or any hint of the anguish he felt moments earlier. "So, when are they going to reset my ankle?" he asked. Learning that the procedure was already over, his initial response was disbelief and astonishment, followed by relief as he realized he would not have to suffer having his ankle wrenched back into position. Little did he know that only moments before his moans had echoed through the halls.

As a medical student, I have learned to keep my composure through a variety of unsettling situations. I assumed that this was yet another time when I would be best off holding my emotions in check. But later that day, I asked the nurse about the case. Why had the man forgotten the procedure? Why had his agitation evaporated so quickly, even as the bed sheets were still drenched with his sweat? She replied nonchalantly that he had been given midazolam for conscious sedation, further explaining that this drug blocks memory for a narrow window of time. Because the subject seemed so mundane to her, I just nodded, but I couldn't stop thinking about the case. It seemed everything but ordinary to me.

I supposed that the drug had eased the patient's anxiety and spared him the memory of the procedure. But, then again, I had witnessed the man writhing in pain. Where had that pain gone if not into memory? It was so difficult for me to believe that he had actually forgotten his pain that I began to wonder if I had misunderstood, or misperceived, his "painful" cries.

Perhaps there is a benefit to having one's memory cleared of a traumatic event. In a simplistic way, it seems ideal: to leave behind completely the memory of something terrible so that one is entirely unaffected by the event. Memory is the scaffolding upon which consciousness hangs, and consciousness is the foundation of experience. But is memory the only scaffold? Would traces of the experience emerge in the future, perhaps as vague feelings of anxiety or apprehension, perhaps as a nightmare? Might pain leave a lasting mark outside of consciousness and sensitize neural pathways, predisposing a patient to pronounced or lingering experiences of pain in the future? I found it almost inconceivable that pain could vanish, leaving behind not a ripple.

This patient's initial experience of the pain was unmitigated. Was the pain somehow less real, less harmful because he couldn't recall it? While I'm not sure of the answer to this question, from the standpoint of the caregiver, forgotten pain must seem a more benign variety. A patient's complaints are the primary way that his or her pain is registered. If there is no complaint of pain, perhaps there is no pain. Once the procedure was over, midazolam appeared to have functioned as a painkiller, although it is not. Might the drug's ability to strip the memory of pain and thus silence a patient's complaints be misconstrued as adequate pain management? Certainly the relief of anxiety about pain is a powerful benefit in itself, but it is not the same thing as relief of pain. While medical professionals may be spared the patient's complaints of pain, the patient is spared only the memory of it.