This won't hurt a bit.

I was making rounds the other day after lunch and was checking in on a patient who'd been awaiting a procedure.  The procedure was fairly straightforward and one that I've sent countless patients down to the interventional suites to have done.  Not high risk in its nature or even exciting to pique enough interest in a medical student to tag along. But for this patient, it was something that was necessary and frankly, was (at this point) the only reason for his hospitalization.

So my visit that afternoon was intended to be every bit as straightforward as his issue. More than anything, I just wanted to confirm that he'd left the floor and that he wasn't sitting there seething from the hunger of "nothing by mouth after midnight." Simple enough, right? I'd pop in, see the ruffled sheets and empty bed and then check the box on my little list.

As I approached the door, I saw a woman in brown surgical scrubs backing a stretcher out of the room. This was enough to make me check my box as the chocolate uniform is that of our hospital transport people. I was familiar with the woman pulling the rolling bed; she was someone I passed in the hallway nearly every day.

"Hey, Dr. Mannings!" she cheerfully announced.

"Hey there, ladybug!" I responded.  I decided in that instant that I liked the way her gold tooth sparkled when she smiled. "Are you coming from bed 2?"

"Yes ma'am!" she answered while rocking the stretcher from side to side to clear the door frame.

Right after that I realized that that question wasn't even necessary. Perched on top of the bed was my patient with his nurse fussing with oxygen tubing and IV lines behind him.

I nodded to his nurse and smiled. Then I took a step back to let them get out of the door while greeting my patient.

"Hello there, sir.  I was just coming to make sure that nobody left you up here hungry and waiting!"

He chuckled a bit and rubbed his stomach playfully.  This patient had some difficulty with communicating, so I took this gesture for the words that would have been harder for him to say.

"So you didn't eat anything, correct?"  I needed to still confirm this. He shook his head emphatically.  "Okay, good!"

My resident and intern had already explained the procedure to him at length. His nurse made certain that his oxygen was connected to the portable tank.  The transporter had completed a three point turn and had the wheels unlocked and ready to go.  Everything was set.

I smiled at my patient and patted his hand. "I will see you when you get back upstairs. It shouldn't take very long, okay?"

He nodded. The sweet woman with the golden tooth dug in her heel and shoved off with my patient.  Just as they turned the corner, she stopped rolling and looked back over her shoulder. "Dr. Mannings? He got a question for you."

I briskly walked over to him, taking a shortcut behind the nurses station to meet him face to face. "Yes sir?"  I looked carefully at his lips as he mouthed a question to me.

"IS IT *SOMETHING-SOMETHING*?"

I wasn't sure what he was trying to say.  "I'm sorry, sir. Repeat that a little bit slower?"

This time I made it out.

"IS IT GOING TO HURT?"

"Is it going to hurt?" I repeated, even though I knew that was exactly what he said. He nodded again, this time with his eyes wide and eyebrows perched upward.

I was just about to fix my mouth to say no when I instead paused to think about his question. Was this going to hurt?  Was it?  The truth is that I had no idea. I mean, my understanding of it was that he'd be numbed up and subsequently pain-free under such local anesthesia.  But the truth is that I didn't exactly know the answer to that. I really didn't.

"Sir? I know they numb you up before hand so that should make it not as uncomfortable.  I have had the numbing medicine before and personally think it kind of stings going in, but once you get numb it works pretty good."

There. I'd told him the truth about the part that I knew. He seemed to find that acceptable.

Today I'm reflecting on the simplest questions in the hospital to which we, okay I, don't know the answers. We can drop all sorts of science on the mechanisms of diseases and the side effect profiles of medications. We can spit the latest literature on the drop of a dime, including the number needed to treat or harm, for countless medical studies.  But funny that something so seemingly simple yet important as whether or not something hurts, we scratch our heads on--mostly because we've never thought about it.

Dang.

When I was a senior resident, I had this really eager medical student on my team. He wanted to go into internal medicine and was as bright-eyed and bushy-tailed as any learner I've ever seen. He was down for trying everything and was glued directly to my side throughout every last call that month.  This kid was ride or die when it came to patient care, and sopped up every drop that I had to teach him like some kind of biscuit on a plate of gravy.  Anyways. Several times that month, we had patients with respiratory problems who needed arterial blood samples taken. After multiple episodes of watching me do this emergently, the student was ready to move to the next step in the old "see one-do one-teach one" adage.  I promised that he could.

Then the next few times we needed an arterial blood gas, it was always an emergency so I was forced to bypass his wobbly novice hands and use the quasi-predictable pair connected to my own arms. I'd look over at him and feel bad each time, but knew that in these instances, it simply wasn't the time.  Poor kid. I really wanted him to have the experience, but not at the expense of derailing emergent care. Toward the end of the month, I had an idea.Why not let him do his first arterial blood stick in the most controlled environment imaginable?  Why not let him . . . . do one. . .on me? Of course!

Now. If you are shaking your head at the sheer stupidity of this idea, then you have either a.) had your radial artery on your wrist poked with a sharp needle, b.)  allowed a medical student to poke your radial artery with a sharp needle, c.) been in or around the block enough to know how assinine this is, or d.) all of the above. Turns out that your radial artery is protected by a whoooole bunch of nerve endings for a reason.

Sigh.

So in a quiet treatment room, I sat in front of my student, smugly talking him through his first art stick on me, his willing and fully cooperative patient. I had him place a rolled towel below the dorsal side of my wrist and even had him tape my finger tips down.  In all my infinite wisdom, I repeatedly told him that it was "all about positioning" and that "when done correctly" it really shouldn't be that uncomfortable a procedure.

Now here's a question:  How in the hell did I know that?  Answer:  I didn't.  The truth is that it was all my assumption (and everyone knows what happens when you assume.) I neglected to factor in that nearly all of the ABG's I'd done up until then were either on patients so acutely ill that a 22 gauge needle in the wrist was the least of their worries or who'd had such longstanding illness that they'd become a bit immune to procedures lower on the food chain. 

So there we sat. Me with my dorsiflexed wrist and taped down finger tips and him earnestly readying his hand with the needle-tipped syringe.  I smiled at him all confident-like and even added that the key is to be deliberate with procedures. Careful and deliberate.  Mmmm hmmm.

"Okay. Here we go," he nervously said with beads of sweat forming on his brow.  "Ready, set, go."

He followed my directions perfectly, deliberately inserting that needle--bevel up, of course--into my bounding and previously marked radial pulse.  His hand was steady and he clasped the syringe like some precious inkpen--just like he'd been instructed. He'd checked first to see if his patient was rotated and made certain that the position was perfect.

But none of that mattered. In went that needle . . . . carefully. . .deliberately. . .and---

"AAAAHHHH!!! LORD HAVE MERCY! STOP! STOP! STOP! OO-OO-OOOOOO!!! OH LOOOOORD!!!! GET-IT-OUT! GET-IT-OUT! GET-IT-OUT!!! STOP-STOP-STOP!!!!"

Yes. That is what I said through a blood-curdling scream coupled with a few choice expletives. Because seriously? It hurt EXACTLY like hell. Wait, I take that back--I don't know about that either. But damn, it hurt. I'm not sure that I have ever experienced a more painful thing in my life next to having a nine pound two ounce baby.  And to this day, I maintain that getting an arterial blood sampling is right up there with child labor with a nine pound two ounce baby--which is something I sho 'nuff DO know something about.

What the hell? I had no idea before that stupid little scheme of mine that this procedure was so painful! Just thinking about it brings tears to my eyes and makes me shiver.  I have never seen the arterial blood draw the same, and never, ever order one unless it is absolutely, positively, irrevocably necessary to patient management.

Now I know. That procedure? Um yeah. . . it hurts.

The only way an art stick won't hurt: If you're dismembered.

Later that afternoon, I stopped back by my patient's room to check on him.  He was happily eating a reheated tray of food and seemed glad to see me.

"Well? Did it hurt?" I asked him.

He held up his finger and his thumb and mouthed "JUST A LITTLE BIT."

I put that on a post-it note in my head and paused for a moment, remembering his respiratory problems.  Pointing at my wrist, I queried, "Sir? Did it hurt as much as getting an artery blood sample?"

He waved his hands and shook his head fast and furious. He squeezed his eyes shut, winced and mouthed in words unmistakable:

"OH HELL NO!"

We both laughed because for once I knew first hand exactly what the patient meant.

***
Happy Sunday.

Check out the lady's expression on the ABG instruction video. She is trying so hard not to cuss the woman out. I am wondering how much they paid her for this and pray to the heavens they got it in one take!