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.
Michael D. Hope. Pain and Forgetting. JAMA. 2003;289(5):617. doi:10.1001/jama.289.5.617