Radiolab - Inside "Ouch!"

Episode Date: August 27, 2012

Pain is a fundamental part of life, and often a very lonely part. Doctors want to understand their patients' pain, and we all want to understand the suffering of our friends, relatives, or spouses. But pinning down another person's hurt is a slippery business. 

Wait, you're listening. Okay. All right. All right. You're listening to Radio Lab. Radio Lab. Shorts. From W. N. Y.

C. See? Yes. And NPR. All right, three, two, one. Hey, I'm Chad. I'm Robert Krollwich. You're cheery today.

I was cheery. This is Radio Lab. And this is our podcast version. Yes. And today on the podcast, stay. in that cheery frame of mind. Okay. Because we're going to talk about pain today. So here's the quandary. It is really hard to put words to pain. Like to describe to somebody, I have this pain in my back and it feels like an, like, ah, like, ah, it really hard. It's like, it's like it's really

difficult to describe to someone in a way that would let them feel it too. It's like one of these classic empathy barriers, right? That's true. But if you could quantify it, measure it, If I could know exactly numerically what you're going through, maybe that would help. Maybe we could be better friends. If you could, do you think you could? Is that what you're going to? We're going to try. See, our producer Tim Howard over the last few months has encountered three different people

who in different ways are trying to measure pain, share it. So we're going to do three episodes of pain... Calibration. Calibration. A triptych of pain. Calibration. Okay. Bring it on.

Here's Tim. Well, Hi. How are you doing? I got started with all this when I met this guy. Yeah, I'm Justin Schmidt. I'm a research biologist. But he's really a bug guy.

I like to try to get into the head of the stinging insect. He lives in Tucson, Arizona, and works in this one-story building on a residential street. Right now, we're in my laboratory at Southwestern Biological Institute. Could we just take a quick, like, glance around? Yeah, yeah, this is... I'd love to just, like, know what it is we're looking at. Underneath those cabinets are 48 drawers of insect specimens. So these are...

Oh, wow. He's got wasp. That's a poika, and it's a nocturnal wasp. That's terrifying this one here. Different kinds of weird... What is this guy? Hornets. That's actually a flightless grasshopper.

He's got a lot of ants. Wow, there's some little furry... Yeah, those are very... velvet ants. They're huge. If you pick up one of these things and get stung by, it's going to feel like, oh my goodness, that could kill a cow. Okay, so this all started for Justin back in the 70s when he was a grad student.

And I just thought for a lark, I took a seminar course in entomology. We had one entomologist in the whole university. This is a course in bug science? Yeah. This was in Georgia, and he was outside one day in the field, and he was trying to get a sample of... A harvester ant. Harvester ant. What does that look like? They're about a third of an inch long and they're bright red.

Pretty good sized ants actually. And he was trying to get one into a jar. And I got stung by one. And I kind of, oh, it's odd. It didn't really hurt it first. Okay, it sort of felt like somebody was using a dental syringe, a really fine needle, slowly injecting a little bit of water. It had this kind of crue.

kind of crystalline feeling. It wasn't an immediate pain. This was a delayed thing. And so then I thought, oh, okay. But after about a minute, it started real hurting. I said, oh, this really hurts. It was this really deep sort of visceral pain. Something was going in and tearing out your nerves

and your muscles and your tendon. What struck me was how dramatically different this was from anything that I'd experienced from a bumblebee, honeybee, sweatbee, yellow jacket, paper was. And once the pain subsided, he thought, man, I need to study that. Yeah. You know, he had all these kind of higher-level science questions about, you know, evolution of pain and insects and how different stinging insects develops. But the problem was, oh, okay. pain. What do we do about measuring pain? If he was really going to get to the bottom of why one insect was more or less painful than another, he couldn't do that with just words like more or less.

I need numbers. With numbers, he could do all kinds of research, not to mention it would make working with other bug scientists just a lot easier. And I started looking into this and found out, oh, this wasn't anything new. Nobody really knows how to measure pain. Because, you know, no two people feel pain the same way. Some people have higher pain tolerance than others. On the other hand, that harvester ant was objectively way more painful than anything he'd ever been stung by. Oh, yeah. So Justin realized what I need is a universal insect sting pain scale.

So Justin starts traveling all around the world, and he's, you know, every time he hears about a bug, especially a stinging bug, he goes looking for it. In order to be stung by it? Well, I don't like pain. So he says he's not trying to get stung, but it usually happens. And as far as he's concerned, that's a good thing. For example. I was petrified of this sineca, which I call the warrior wasp.

A seneca is this black wasp with this metallic sheen down in Central America. And they're known for this warning sound that they make with their nest. They have this big carton nest, carton being cut. kind of paper, kind of goes, woo- who-woo. Justin was there with another scientist, and they're tromping through the

jungle, and then they find a nest. Here we are this nest. And it starts to make that sound. Well, sure enough, we eventually got a kamikaze that came out and nailed me. Where did he sting you? Kind of on my forehead. And I just

sort of sat on the stump and said, ooh, this really hurts. It hurt like a yellow jacket or a hornet, but it was just a whole lot more. And it kept hurting for an hour. And so I, you know, recorded what the feeling was for this hour. But you're sitting there and a stomp or something in your forehead is throbbing, and you're taking notes?

Well, what else can you do? He talks about getting stung by something that makes him hurt so much that he just starts screaming in pain for like an hour and lying on the ground because that'll make the pain less, I guess. And my left hand's sitting here shaking. It's trembling. It's going up and down. And I said, oh, darn your hands, stop that.

And then with his other hand, he's taking notes about exactly how it feels. This left one's here, flapping away. And I'm, in any case. How many times has he been stung? He told me he's been sung by like 150 species and probably about a thousand times. What?

And he's used all those experiences to build up a scale. Which he could say is a five-point scale. zero one, two, three, and four. Zero being that's essentially trivial. And four being... Really hurts. But wait, how does he deal with the whole subjectivity thing?

Because, like, your four is going to be different than my four. He did something pretty clever, which is that he took that one sting that we pretty much all know and decided, I'm going to use that as... For reference. So... And I anchored it with the honeybee... which is... Ouch!

Which you can talk about with anybody. Anybody's been stung by a honeybee. Yeah. It also doesn't hurt too much and it doesn't hurt too little. So it's like a midpoint. Exactly. And a middle point in this case

was easier than a top or a bottom because I didn't know what the top or bottom where there's no way to know what the top or the bottom is. So a honeybee was that and so you give that a two. Two out of four. The prime meridian of pain. And every time he gets stung by a new bug, He'll ask himself.

Is it more than a honey bee, less than a honey bee? About the same as a honeybee. A whole lot more, a whole lot less. Then he gives that sting its own number. Dig this. 1.0. Sweatbee. Light.

Ephemeral. Almost fruity. 1.8. Bullhorn, acacia hand. A rare, piercing, elevated sort of pain. Someone has fired a staple into your cheek. 2.0 bald-faced hornet. Rich, hearty, slightly crunchy.

Similar to getting your hand mashed in a revolving door. Ow. Three. Red Harvest rand. bold and unrelenting. Somebody's using a drill to excavate your ingrown toenail. This is his pain scale? Justin calls this his tongue-in-cheek version.

That was more fun. But yeah, these are some of this things that he's measured. And what's the worst? What's the top of the scale? The bullet end. It sends excruciating waves of burning pain that are undiminished for 12 hours. And you get these pulsations.

You get this pain crescendo that goes to you. about wanting to scream and then it backs off a little bit and says, ah, you kind of give it a little bit of a sigh of relief. And then it ascends back up and it keeps doing this, these hills and valleys of ascending pain and then decrease. Even the decreasing to the lowest still hurts. So this scale works for him? I mean, he uses it to communicate with bug scientists? Yeah. Yeah.

Wow. Well, all right. That's kind of cool, but I got to be honest. I'm wanting more right now because I like the scale but I'm thinking actually beyond bugs to like let me just put my cards on the table like childbirth okay

like when we talk about like the gap okay I know but we talk about the gap between like two people feeling pain and being able to share a pain that's where the rubber meets the road well it's used in a lot of marriages as a constant you don't know you don't know what exactly Thank you, Robert.

Does Tamar use it the way Carla uses it? Well, I can't say that in a recording. No, not at all, really, never. I don't know. I don't know. I wouldn't cross my mind. Carla, who's a very sort of understating lady, when it comes to this subject, she'll be like, you have no idea. You don't even begin to know what you don't know about what we just went through. Well, that brings me to my second story.

Can I take it from the top? For this one, we go back a few years. So we're in 1948. Who is this lady? This is Paula Michaels. She's a professor of the history of medicine. I teach at the University of Iowa. And she told me this story that takes place in New York at New York Hospital in 1948.

Right. So there's James D. Hardy. There's Carl T. Javert. Hardy and Javert are doctors. And they're trying to test drugs. You know, what drugs are going to be useful to alleviate the pain of childbirth? And in this period, there's a whole range of things that are being used. What are some of the ones that they're using? Well, like morphine and scopolamine.

Demerol is a big thing. Nice. And heroin, which to me sounds completely crazy. They play around crack, too? They would have if they knew about it. The problem is they want to be able to test all of these drugs so that they can use them in a standard way. But they weren't actually sure how much pain women were really in.

I guess you kind of have to know that. in order to know how much drugs they'd give him. Yeah, they had no idea and it was a source of a lot of debate. Yes. One man, Grantley Dick Reed, a British physician, basically said straight out, it's in women's minds, not their bodies. What? Childbirth is a completely painless experience, entirely psychological in origin. Wow, that is an incredibly bold thing for a man to say. Yes, that's Hutzpah. Now, Hardy and Javere didn't take it that far, but they wanted to wanted to get past the whole messy psychological part of childbirth. And eliminate that woman's subjective experience of pain from the calculation of whether these drugs are effective or not.

And how are they going to do this? Well, their method is pretty crazy. They had this apparatus called a Dolorometer. It was this little wood box that had dials and knobs plugged into the wall and then was connected by a wire to another part. what they called the exposure unit. That was like a heat gun with an aperture that can shoot out heat. Then they got some volunteers. Some of them were nurses.

Some of them were the wives of obstetricians or other physicians. All very pregnant. And they told these women, this might not be very pleasant. But by participating, you're going to be making childbirth just so much better for every woman to follow. That's right. And the women were excited to help. And then when the woman went into labor...

Hardy and Javert would show up bedside with the dolometer, and they'd wait for the contraction to finish. And then between contractions... During that pause, they'd take the heat gun and they'd put it against the back of the woman's hand, and they'd say to her, all right, we want to know about that contraction. The one you just had. Yeah. We want to know how much it hurt. They'd say, is it more like A or more like B? And then the woman would respond. Guess B is closer?

Then they would say, is it more like B or more like C? C, maybe? That was a way of then saying, okay, well, that was a contraction of three doles. Doles. What's a dole? The dole is their unit of pain, their standard unit that they use for everybody. And so over the course of labor, after every contraction, they would repeat this process. Same drill.

Is it more like A or more like B? Again. A, B. And again. B or more like C. again. Over the course of her whole labor. So wait, on top of all the labor pains, they're just cranking this heat up and up? Yeah. Wow. In the case of one patient who insisted on going the distance, a pain intensity of ten and a half doles was measured. Hardinjavert called this

the ceiling. This is the most intense pain which can be experienced. Second degree burns were inflicted upon the hands of this patient by the four tests made at levels of higher than nine dolls. Second degree burns. Yeah. I mean, I like what these guys are trying to do, but wow, that is sadistic. It seems totally twisted. But it's in the name of science.

It's for a greater good. Okay. All right. So then the doctors, they took all of the data from all of the women, and they start going through it looking for patterns, looking for things in common. And then the most incredible part to me is that they converted all that information into a mathematical formula.

Doles of pain equals 10.5 minus 1.5 times contraction intervals in minutes. What? Well, so they're saying if you tell us the amount of time between the contractions at any point in her labor, we can tell you exactly how much pain the woman is in. No more mystery, there's no more wondering. Problem solved. The code is cracked. And what happens? Does this breakthrough sweep the medical establishment? I'm guessing it doesn't. Well, no. Other people could not achieve the same results that they achieved using the De La... I don't know why I can't DeLormometer. Using the delormator, they

were not able to achieve the same results. When other doctors tried to do it, that formula didn't seem to apply to the women that they looked at. Shocker. Obviously, there's a lot of problems with the entire approach that these guys had. No. Yeah, I mean, for starters, they're trying to compare pain in the abdomen to, you know, like a burning sensation on the arm. Yeah, I mean, that's like a translation problem.

Yeah, well, I mean, in my opinion, there's kind of a bigger translation issue happening, which is. In order to talk about a pain you're feeling, you need to be able to observe it and kind of stand apart from me. in your own head, if that makes sense. Sure. And when you hear women talk about the pain of childbirth... Hello, my name is Sarah. I'm in Sacramento, California.

We ask people to submit theirs through the Radio Lab app. And when you listen to these different accounts... My experience of childbirth pain was... It sounds like there's a certain point where everything shifts. And one woman said it was at about like seven centimeters dilated. And that's when you lose your mind.

And you can't think, you can't talk. Suddenly, the pain. pain becomes so great. So bad. There's no more reference point. I just remember. There's no more objective distance. Making these noises that were just unearthly.

And in these submissions, it's usually at this point in the story where the woman either just draws a blank. Wow. Or resorts to some crazy analogy. I felt like there was a freight train. bearing down on my vagina from inside my body, and that I could almost hear it building. Like, to dunk, to dunk, to dunk, to dunk, to dunk, to dunk. I felt like I was being dragged out to see.

That's when I actually heard a couple times. Waves. Waves of pain. And it was kind of like that for Paula, too. I turned very much inward in a way that made time feel like it stopped. I was drowning, drowning. In this lake of pain. And there was a horizon.

And when the contractions were intense, I would swim towards the horizon. This is Yula. I'm Yula Biss. I'm a nonfiction writer. And she's our third pain calibrator. And for me, Yula kind of gets the closest at finding a way to communicate pain. If I could say you have a relationship with pain, when did that, when did that? that start for you? Let's see, about almost 10 years ago. I think I was about 26. At the time,

Yula was a grad student in Iowa. And I just woke up one morning in the fall and I had a terrible pain in the side of my neck, upper back, side of my face. She had no idea what it was. It was a burning pain. With this nauseating tingling sensation. I've really never felt. I've really never felt anything else like it. And months passed, and it didn't go away, and it was making it very difficult for me to sleep. It started to interfere with my thinking, too. I couldn't concentrate. So one day she went to the hospital, and by this point she was a total mess.

So I was kind of teary and shaking, and I said, you need to give me something to help me with this. And so the doc said, all right, well, take a look at this thing up here on the wall. This is called the pain scale. It had the number is zero to ten. At one end, it said no pain. At the other end, it said the worst pain imaginable. And the doctor says to her, okay, what number is your pain? Yula starts to think about it.

The worst pain imaginable is kind of vague. Is this the worst pain you yourself can imagine? Or is it the worst pain imaginable on earth? Hmm. You know, this was around the time that I think a man had died being dragged behind a truck in Texas. And I remember sitting in the exam room thinking about that. And then I was trying to do some rudimentary mathematics. If being dragged behind a truck to your death is the worst pain imaginable,

what proportion of that do I feel? And I thought, you know, a third of that seemed pretty significant to me. So she says three, I guess. And the doc's like, all right, and he does some tests. He tries to figure out exactly what's going on. Can't really, but since she said three anyway, he's like, all right, well, you know, have some aspirin. Go home. And this happened a few times.

She wasn't getting any better. So at a certain point, she calls up her dad, who's also a doctor, and she starts complaining. I was telling him how frustrated I was that the doctors didn't seem to be taking this very seriously. And he said, well, when they ask you to rate your pain, what do you tell them? And I said, I usually say three. And he said, well, there's your problem. Her dad tells her, you should say eight. Even if you're not feeling it, that's what you've got to say.

And Yula thinks, you know, this is ridiculous. Why do we even have a pain scale if I'm not supposed to take the number seriously? And he said, in part, it's a tool that's meant to protect practitioners because it's emotionally difficult to have someone say to you, it feels like someone's jamming a red hot poker through my eyeball rather than I've got a nine. But then he made a suggestion, which I think is really clever. He suggested one scale where

that would measure what you're willing to do to get rid of your pain. What would you trade for pain relief? Would you give up your sense of sight for five years? years. Would you relinquish your ability to walk? Did you come up with any answers at that point? I did. They were disturbing answers. You know, when my father asked, would you accept a shorter lifespan? At that point in time, I thought, yeah, I would. By how many years? I was thinking I'd take 10 years off my life. Wow. For me, that was

basically the first time I felt like I understood her pain. But, you know, I was 26 and life seems really long when you're 26. Now I'm in a much different space. My pain is not nearly as bad as it was then. So now I'm not really in the bargaining mood anymore. I bet like how about a bad haircut? Would you take a really bad haircut? A mohawk. Huh. Okay. Yeah. Actually, I would. And these days, Yula is kind of pessimistic about the idea that we're ever going to really have a useful pain scale. At the end of the day, I'm not sure pain is a quantity that is measurable. Thinking that kind of bums are out.

Because part of me wanted to believe in the project of quantification. Why? I'm not sure. I think because not believing in it is a little bit lonelier. The idea that we cannot feel, cannot understand, and cannot imagine each other's pain is a really isolating thought. By the way, what was her pain from? Did she get a diagnosis? Well, her doctor tried a lot of stuff, actually. They did a brain scan. They checked for a spinal infection. And ultimately...

He said, you know, unfortunately... unfortunately, we don't know what causes this. We don't know how to treat it. We don't know if it will ever get better. But we do know it's real. And that was my final conversation with him. And he said, good luck out there. Thanks to producer Tim Howard, Justin Schmidt, Paula Michaels, and Yulabas.

I'm Chad Abumrod. I'm Robert Kulwitch. Thanks for listening. Hi, guys. I just called and I think I messed up. try it again. Okay? Okay. Hi, this is Studies. I am a radio lab listener in Jamaica Plain, Massachusetts, and here are the

credit. Radio Lab is supported in part by the National Science Foundation and by the Alfred P. Sloan Foundation, enhancing public understanding of science and technology in the modern world. More information about Sloan at www.floane.org. I think that one was better. Thanks, y'all. Bye.

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