Reducing Pain and Anxiety During Reduction of a Fracture
The following case utilized the psychological techniques of PsychoNeuro Pain Response™ (PNPR™)—also known as Talking Away Pain™ (TAP™)—together with deep breath-ing to reduce the pain and anxiety of a teenager with a fractured wrist so that it could be safely and successfully set at the tournament medical facility rather than the usual hospital emergency department. PNPR1,2 is a combination of safe, well-known mental interventions—such as cognitive restructuring (restructuring thoughts), neurolingusitic programming (changing feeling, seeing or hearing modes of receiving information), and systematic desensitization (replaying a scene in the mind until it no longer causes stress)—that are taught to the patient.
History. The patient, a 15-year old male, injured his left wrist while playing soccer at the Schwan’s USA Cup Soccer Tournament in July 2002. Upon arrival in the medical facility, the patient was very anxious and experiencing significant pain. Inspection of the left wrist revealed obvious deformity with swelling localized to the distal radius. The patient demonstrated active range of motion of his fingers with intact distal neurovascular status.
Physical Exam. The patient presented with complaint of immediate onset of pain and severe deformity following a fall on his extended left wrist. Range of motion of the L-wrist was limited due to pain, without associated distal numbness or paresthesia.
Imaging. X-rays showed evidence of a displaced fracture of the left distal radius with volar angulation of the proximal aspect of the distal fragment in addition to a nondisplaced ulnar fracture.
Diagnosis. A displaced fracture of the left distal radius with volar angulation of the proximal aspect of the distal fragment in addition to a nondisplaced ulnar fracture.
Treatment. There were two options: 1) transport and treat the patient in an emergency department (hospital ER), or 2) treat the patient at the Schwan’s USA Soccer Cup Tournament medical facility (MF). “This type of fracture,” stated Dr. Peter Parten, an on-site orthopedic surgeon, “is typically treated in the emergency department, with reduction of the fracture under IV sedation and application of a local lidocaine hematoma block.” However, Dr. Parten felt that the procedure could safely be attempted at the MF if: 1) the mother and patient agreed to have the procedure at the medical facility, and 2) a local pain management specialist (referred to as “specialist” throughout this document) was able to reduce the patient’s anxiety and pain sufficiently so that he would remain calm and in control of his pain long enough to permit the local hematoma block.
Preparing the Patient
The specialist was apprised of the situation and felt that it was possible to reduce the patient’s anxiety and pain using psychological techniques. He had the patient moved to the bay where the appropriate equipment and materials were located and asked him to lay on the treatment table. The bay was at the end of four other bays and consisted of sheets on the sides and front with a block wall at the back. Other than providing visual privacy, the bay was open to all surrounding sounds.
The surgeon introduced the specialist to the patient and then everyone, except the patient and specialist, left the bay. The specialist questioned the patient about how he felt, his level of pain, and what he had been told about his injury. The patient responded that he was told that a bone in his arm was broken and that it would need to be set. He also indicated that he was scared and in a lot of pain. He asked if it was a bad break. The specialist told him that it was not bad and asked if he would he like to see the X-rays. He did, and the specialist showed him the break. The patient was relieved that it was not bad, but he was still anxious. The specialist told him that his mother was close by, the orthopedic surgeon was one of the best in the area, and the assisting staff was excellent. He told the patient that he would explain his options to him and his mother, and it would be up to them to decide what was the best option. With this information, the patient exhaled deeply and became much less anxious.3
The specialist proceeded to outline the options to the patient: 1) he could be transported to a local ER by ambulance, where he would be given a local and general anesthesia, or 2) he could have the bone set there at the MF. Still exhibiting anxious and scared feelings, he asked where and how far the ER was and what would they do at the ER.
The specialist explained that the ER was 15 to 20 minutes away. To transport him, an ambulance would be called. Because this was not a life-threatening situation, it might take them 15 to 20 minutes to arrive. Once there, the ambulance personnel would transfer him to a stretcher, strap him in, and secure his arm for the journey. His mother could travel with him in the ambulance, if he wished. At the ER, he would move to a waiting area where his mother would fill out the paperwork so he could be helped. Once the paperwork was complete, he would wait his turn to see a doctor, who would then contact the orthopedic surgeon and schedule the operating room to have his bone set. The specialist further explained that, at the MF, they would try to speed up this process for him by supplying the hospital (ER) with the pertinent information prior to his arrival. The patient was told that his wait in the ER could be anywhere from two to three hours or more, depending on how busy they were. After surgery, he would be in recovery then taken to his room for an overnight stay, or longer, depending on his condition. Upon release from the hospital, he would be referred to his doctor for follow-up care.
The second option, the patient was told, would be to have the bone safely set there at the MF. However, for that to occur, his anxiety and pain level would need to be lowered.
PNPR and Deep Breathing Lowers Anxiety and Pain
How, the patient asked, could he lower his anxiety and pain level? Was he going to get some pills or something else? The specialist told him that medication was not available, but he (the specialist) thought that he (the patient) could reduce or eliminate his anxiety and pain himself with the specialist’s help. The patient was surprised and said, “Do you think that I can do it?” The specialist said that he was not absolutely positive he (the patient) could, but he (the specialist) would help if he (the patient) was willing to try. Cautiously the patient asked, “What do I do?” “First,” said the specialist, “I want you to take a deep breath3,4 and then let it out slowly. This will help to relax you and allow you to become calmer.” After a few deep breaths, the patient started to become visibly calmer, so the specialist asked the patient if he could think of a fun or enjoyable time in his life. It could be with friends, family or by himself. It could be something very beautiful like a sunset or receiving a special gift. When asked if he had thought of a fun time, the patient said that he had.