Macho, Macho Man!

You know the type. The guy who drives a 6 ton pickup truck with the bed lifted 5 feet off the ground, fat tires, and a "Fear This!" sticker in the rear window. If you are 65 or older, you have probably noticed this guy driving 10 feet behind your bumper in a brazen attempt to demonstrate his manliness and ownership of the road you dared to drive on with your little 7-year-old Toyota Camry. Or you may have noticed his more sophisticated cousin, wearing a white coat with a stethoscope around his neck, telling you to be a man, stop whining, and learn to cope with the pain. It is amazing how tough some people are when it comes to dealing with someone else's pain. We should all, men and women, girls and boys, aspire to such manliness.

Having a chronic "pain" "condition" (ever notice how manly doctors always put those two words in quotes?), I have often wondered how "Real Men”(TM) cope with pain. Since the medical profession is filled with Real Men, who are always quick to impart their wit and wisdom on the ability of lesser beings to cope with pain, I thought it would be good to begin my search there, especially since they are the self-syled experts on pain and how to deal with it.

Fortunately, it didn't take too long for a good, manly doctor to oblige me, in this case the author of "Scalpel and Sword," a medblog which like many medblogs is often highly critical of all you wusses out there with your "pain." Here he recounts his harrowing tale of pain, terror and eventual triumph as he battled that bane of human existence known as the toothache:

I started to feel the pain during my 45 minute drive home. The skin over my cheek was still totally numb, but my tooth and jaw were aching. I noticed that I was becoming unusually irritated with the idiot drivers who impeded my progress to the pharmacy. I gave my prescription to the pharmacy tech (while feeling a little self-conscious about filling a narcotic). The pain was getting so bad, it began to make me nauseated, so I asked for a prescription pad so I could write myself some Zofran too. "Are you going to wait for the prescription?" she asked. I wanted to yell at her and say "Can't you see me wincing and squeezing my temples? That means yes!" But it might have made my face hurt more, so I just nodded meekly and walked away to pace the aisles....

Vicoprofen, not so amazing. There is still no way I can sleep with this much pain, even though I have only had a total of six hours sleep the past two days. But it's tolerable. Barely. If I didn't have that prescription, I would probably have to go to the ER myself, another "drug-seeker with a toothache."

Okay, nothing unusual here. Basic case of severe tooth pain, easily relieved with a mild narcotic, which we have all experienced at some point in our lives. Of course, his toothache is real as opposed to that of the "drug-seekers" who show up in his ER. But wait, the plot thickens:

The next day, my tooth began hurting again. Not just my tooth, but the entire half of my face. And not just hurting, but HURTING! I called my dentist in the afternoon, and he was nice enough to come in after hours and give me another nerve block, which totally relieved my pain....for two hours. Then it came back worse than ever. My dentist had given me some of the anesthetic to inject myself as a nerve block, but it just wasn't working. I was writhing in agony, crying out with intolerable pain.

So I went to the ER where I work, tears rolling down my face the whole way, running red lights and speeding recklessly to the hospital at 3 am (emphasis mine). My dentist had called one of his colleagues who had agreed to see me in the morning, but I just could not wait. One of my partners took pity on me and gave me a shot of Demerol which allowed me to catch a couple of hours sleep. I'd never had it before. It did help my pain, but I didn't get a "buzz" and it really didn't seem to be the sort of thing that people would malinger for. Maybe it's more enjoyable if you aren't really in pain.

Then I had the root canal, and here I sit back home praying that that horrible awful pain doesn't come back. I have an entirely new respect for dental pain, my fellow patients, and I will not make you wait ever again before medicating you.

UPDATE: Amazingly, 18 hours later, I have zero pain except with pressure on the involved tooth. I really had serious concerns that there might be another coexisting condition (trigeminal neuralgia, brain tumor, aneurysm?) that we were missing, but it seems that it all came from that rotten tooth and exposed nerve.

I had hoped Dr. Scrooge here would have had a Dickensian moment having been visited by the Ghost of Toothaches Past, and indeed he promises to never make his dental patients wait again (which begs the question why he ever made them wait in the first place). But within days of writing this post, he is back in form, swaggering with faux machismo, and accusing people with migraines, fibromyalgia and low back pain of having low tolerance for pain:

In my experience/opinion, it seems that many patients with chronic painful conditions of unclear etiology (fibromyalgia, some chronic back pain, and atypical "migraines" for example) who require large amounts of narcotics often have rather low tolerances for pain, and the true pathology may in fact be a hypersensitivity to what most would consider normal stimuli.

Ironically, these patients will usually claim that they have a "high pain tolerance" when in fact the opposite is true. They do tend to have high narcotic tolerances though. People with truly high pain tolerances don't often require narcotics at all.

So I guess the fact he needed Vicuprofen and a shot of Demerol to deal with his pain means he doesn't have much tolerance for pain himself, particularly as his toothache only lasted a few days. Now, don't get me wrong, I know that tooth pain can be severe, even excruciating, and I don't begrudge anyone, not even Dr Scrooge here, a visit to the ER for enough painkillers to get that pain under control. I don't consider it a reflection on anyone's "manliness" that they would want something for that pain, particularly as there is no sane reason not to control the pain. Scalpels' reaction, with the exception of speeding and running red lights, was perfectly normal and acceptable in my view. Here's what Scalpel thinks of other people forced to go his route:

Oh, and if a patient has multiple ER visits for other painful conditions (toothache, "migraine," back pain, etc.) that is another big red flag. Drug seekers often move from one painful alibi to another. But all of their visits involve something that hurts REALLY BAD!!!!, and often they have little objective evidence of disease or injury.

It has to strike you as rather ironic that this supposed tough guy would criticize anyone else for their ability to tolerate pain, when he basically freaked out over a toothache. When I described this story to a close friend of mine who has fibromyalgia, low back pain and who just happens to be nursing an abscessed tooth at the moment, and also what this guy has to say about fibro patients, her response was, "What a fucking pussy! I have an abscessed tooth right now and the pain of that isn't even close to my fibromyaglia and back pain! I'd like to see how he deals with my pain!" I couldn't agree more. I should point out that I also have fibromyalgia, low back pain and have just had two root canals done, and that tooth pain is nothing compared to the pain of fibromyalgia or low back pain, particularly after you've been dealing with it for decades, let alone a few days. The McGill Pain Index agrees with me, rating chronic low back pain as considerably higher than a toothache.

In all the years I have been to chronic pain and fibromyalgia support groups, I have never met a single person whose tolerance for pain was so low he would speed and run red lights to get to the ER, putting other people's lives at risk, particularly if he knew that he would be able to get treated from the moment he walked in the door, unlike most people who risk having to wait for hours in agony just to be labeled a "drug-seeker" and sent home with a handful of Tylenols. Most have the equanimity to at least wait for the light to change. Indeed, I have been amazed and inspired by just how much many of these people have been able to endure and still retain their sanity, sense of humor and an attitude of compassion towards others.

If you read some of what Scalpel writes on his site, you'll see he takes a particular delight in applying the "drug-seeker" label and blacklisting pain patients who he feels have lied to him in any way to get relief for their pain. The Wikipedia defines pain tolerance as "the amount of pain that a person can withstand before breaking down emotionally and/or physically." Judging by this doctor's panicked and frantic behavior, it is clear the pain broke him emotionally in a matter of days, even having him imagining he had a brain tumor, aneurysm, or trigeminal neuralgia.

It may take months or years of unremitting pain like that to break a person physically, but he'll have to get a visit from the Ghost of Fibromyalgia and Chronic Low Back Pain Yet to Come to find out what that's like. If this is how he deals with a toothache, he better hope and pray he never gets that visit, because he won't last an afternoon before he snaps. I watched a beloved friend with fibromyalgia die of lung cancer recently, and she dealt with that ordeal with more dignity, grace and equanimity than this guy dealt with a toothache. Though I can imagine what would have happened if she had come to Scalpel's ER complaining of fibromyalgia and chest pain. As it was, she waited for 5 hours before they took a chest X-ray, after which the ER doc casually announced she had lung cancer. Friend of Scalpel's, no doubt.

You should read some of Scalpel's comments about chronic pain and fibro patients at his site. I've given some links her for you to follow if you're interested, but for now, here are some highlights from those pages:

"The Objective Pain Scale:"
"ER Dogma:"
"The Flow Stopper:"
"Pain Management:"

Everyone's pain is 10/10, get in line. If you aren't screaming, it isn't a 10.

The longer your list of allergies to medications, the more likely you are to have a psychogenic cause of your physical complaints.

If you think you have a "high pain tolerance," you probably don't. If you think that you have a low pain tolerance, you are likely correct. People with a high pain tolerance don't even mention that term.

Oh, and if a patient has multiple ER visits for other painful conditions (toothache, "migraine," back pain, etc.) that is another big red flag. Drug seekers often move from one painful alibi to another. But all of their visits involve something that hurts REALLY BAD!!!!, and often they have little objective evidence of disease or injury.

If you are able to sit still and keep quiet, you probably aren't in as much pain as the other guy (or as much pain as you think you are in, for that matter). If you aren't screaming, it isn't a 10. If you aren't vomiting, it isn't a 9. Simple enough for me.

Annoying ranters are usually the people who have no objective evidence of disease (like many chronic painers). They tend to have multiple nonphysiologic complaints and heavy psychogenic overtones to their complaints. Fortunately, they often tend to get so worked up they leave prior to evaluation by a physician, cursing and yelling on the way out. We don't miss them. My motto is "if you are sick, you'll stay."

There is no moral or legal requirement for physicians to administer or prescribe narcotics to patients who repeatedly present to the ER, even for visible reasons like dental caries. We certainly aren't obligated to give narcs for clinically subjective conditions like fibromyalgia or migraines.

I personally don't blacklist drug-seeking patients if they "piss me off." Only when they lie to me in an attempt to obtain narcotics. Good luck prosecuting that. If they piss me off, they may just leave empty-handed, but they will still get a bill.

And all a suicide threat will get you is a psych eval and possibly an involuntary hospitalization. But usually not, because it's obvious that someone making such a threat is just being manipulative.

Perhaps its easier for someone like you (who actually has structurally identifiable causes of pain) than someone with fibromyalgia (who is widely considered to have simply a psychiatric problem) to cope with pain. But I doubt it.

I think that pain is like many other neuropsychophysiological conditions that test the human will and our ability to persevere. Some people forge ahead despite their handicaps, and some people curl up into a ball and blame society for their ills.

I think you get the picture: standard, loudmouth macho posturing from medicus fuctardicus arrogansis. You should read some of the comments from the other mouth-breathing Neanderthals at that site, as well.

I have often wondered what makes so many doctors and nurses behave with such casual cruelty to people whose only crime is they are suffering and want relief. I think Scalpel's website gives some telling insights into this kind of behavior and the root causes of it, which in my opinion is a basic insecurity about one's masculinity coupled with narcissism, sadism and fear. Women are clearly prone to this shortcoming as well. They see people coping with horrible, constant pain, and deep down inside they know they would never be able to endure pain like that and still function, so they need to convince themselves that the person is just a weakling and a faker and couldn't possibly be in that much pain. The alternative is a mature confrontation with one's own human limitations, which all of us with chronic pain have been forced to make, but that rarely happens with doctors. It's only when they've been through it themselves and have a little humility beat into them that they, sometimes, begin to see the light. There is an interesting article about the roots of sham machismo at Orcinus. This quote is from "Sara"

My first husband -- who as a Latino, a clinical psychologist, and the son of a Marine Corps drill instructor, knew a thing or two about the anatomy of macho -- used to say that the first rule of real macho was that those who possess it never need to prove it to anyone. If you have to prove it or put it out on display, you don't have it in the first place. And if you are intimidated by seeing it in others, you aren't even in the ballpark.

I may not be a "Real Man" myself, or know what a man really is. I certainly have my share of insecurities. Years of unrelenting pain have broken me physically and mentally, and I am not ashamed to admit that. I am sure there are men and women out there who are stronger than me and who could have handled my ordeal better than I have, but I dealt with it the best I could. No matter how tough you are, or how tough you think you are, severe chronic pain, left untreated, will eventually break you. Water wears away granite in time.

But I know what a real man, and for that matter, a real woman, is not. He is not someone who needs to brag, and swagger, and question anyone else's manliness. He doesn't need to abuse people in horrible pain or accuse them of being whimps or fakers, or question their ability to take pain, just so he can feel good about his own questionable masculinity. He is not cruel, or cowardly, or manipulative, but can deal with other human beings with fairness, grace, equanimity and compassion. He doesn't need a 6 ton pickup unless he's in the construction business, and never needs to tailgate old ladies. He never needs to tell someone in chronic pain to "be a man" or "take the pain." He doesn't whine about a toothache and then turn around and tell people who have dealt with the ordeal of fibromyalgia, migraines or low back pain for years that they have a low pain tolerance.

All these doctors and nurses you see out there with their adolescent macho posturing, looking down their noses in arrogant haughtiness at people who have dealt with horrible pain for years, condemning them for being "weak," or "lazy" or unable to tolerate pain, refusing to treat their pain, accusing them of being drug seekers and psychiatric basket cases, blacklisting them so they can never get their pain treated anywhere...all these guys are clearly compensating for their own inadequacies in the manhood department. And yeah, I'm talking about women, too. A sorry, pathetic lot of swaggering punks who are insecure about their masculinity, and think tough talk and cruel, arrogant, macho behavior is a substitute for genuine manliness. Sorry, assholes, but it's not.

That this behavior is so commonplace in the medical field is a sad reflection on that profession.