• About seven weeks ago, I had a bike accident where I went flying over my handle bars, essentially diving into the street. I caught myself on my hands, protecting my head from hitting the street, but breaking both elbows in the process. I dislocated my left elbow — icing on the cake, I guess.

    As I was flying over the handle bars, I had just enough time to say those famous last words, “Oh shit!”

    Then, the pain.

    I was lying in the street on a busy street corner. I rolled over on my back, cradling my arms as best I could. People were asking if they should call 911, but I had no idea. I was pretty sure I had broken my arms, but what did that mean in terms of the care I would need?

    It hurt a lot. Then again, it wasn’t so much that I couldn’t think about anything else. I felt like I needed to get out of the street because I didn’t want to get run over, so I inched my way over to the curb and somehow got up on the curb, all the while protecting my arms on my stomach. At least, I think that’s what I did. I still couldn’t really think much into the future, like whether I needed an ambulance as people were asking me.

    All I could think about was what to do to protect my arms and keep them from hurting any more than necessary. Eventually, an ambulance did arrive. The EMTs wanted to cut off my jacket, but I must have refused, because they didn’t cut it off. It was brand new, and I didn’t want to ruin it. Turned out that in the ER, they managed to get it off without cutting it, so chalk one up for me. My T-shirt, a favorite, wasn’t so fortunate.

    Then ended up cutting it off, since there was no way I could bend my elbows or move my arms enough to get the T-shirt off. I later bought a replacement, although I still think twice before I wear it. I guess I’m not immune to superstition, although I can overcome it.

    “On a scale of zero to ten, what level is your pain?”

    The EMT asked me that. The ER doctors asked me that. Every nurse and every physician’s assistant and every occupational therapist on every visit for the last seven weeks has asked me that.

    How the hell do I know? I can’t calibrate that scale. I guess zero is no pain, but then, how do we define pain? Recently, I was told that itching is a form of pain. Where do you put itching on a scale of zero to ten?

    I tend to think of pain as acute, broken limb, excruciating, sudden, unexpected pain. That seems like it should be the worst, but I’ve had so many kinds of pain in my life, and they have so many different qualities, that it seems to me that “pain” is a very inadequate word. Not only do I not know where I stand on the zero to ten scale, because I’ve never experienced a pain that I would call a ten, but I don’t know how to compare all the different kinds of pain I’ve had.

    I’ve been depressed enough to come to believe that the only way to stop the pain would be to die. I’ve never wanted to die, but the prospect of having that kind of depression — it felt like there was a black hole inside a black hole inside my stomach sucking every decent feeling in the universe out of me — forever, made me almost decide that it would be worth ending my life just to not have to suffer like that for decades, which I was sure was the only other option, besides death. Absolutely positive.

    And even that pain — the worst I have ever felt — I would not rate a ten. That pain was so bad that if amputating both legs without anesthesia would have cured it, I would have made that bargain in a heartbeat! It was far worse than any physical pain, but it wasn’t a ten. Maybe a seven. Maybe. It was too drawn out and persistent and dulling to be a ten.

    But having two broken elbows — that seemed like only a six or seven or maybe just a five. I mean, by the time I got to the ER, it had settled down. There were moments when, if I didn’t move my arms, I felt reasonably comfortable. A three? A four? Even when I moved, and there was an acute, sudden flare-up of pain, it didn’t rise above a six, by then.

    It turned out one of the elbows was also dislocated, so they gave me Ketamine to distance me from the pain while they put the bones back in place. They called it a “reduction.” I would have called it a relocation, but I’m not a doctor.

    I remember hearing someone scream during the reduction. Later on, they told me that was me. The Ketamine seemed to put a distance between the me that feels and the me that understands what is going on. The feeling me was able to converse with the folks around me, and apparently I was quite a star. There was an audience of around seven student doctors and nurses and so on. Elbow reductions are somewhat rare, I found out. So they all wanted to see how it was done.

    As I was coming out from the influence of the Ketamine, I remember feeling like I was in a pink Matrix, with white lines extending to infinity. I heard myself conversing, but I didn’t understand what I was saying for about a second. Then, when I comprehended what the others and myself were saying, it made sense. It was really weird that I could carry on a sensible conversation — even make jokes — without being able to comprehend what I was saying until after I had said it. How does that work?

    It keeps the pain at bay. That’s how it works. The person who screamed in pain was me, but not a me I was connected to. Somehow, the part of me that comprehended pain and was really hurt by it wasn’t connected to the part of me that experienced the pain, and I’m grateful for that, although, as I said, if dislocating an elbow and getting it reduced would ban depression forever, I’d do it without Ketamine, any day.

    My pain settled down. I was constantly annoyed when I was asked what level it was, because it changes constantly, both in terms of intensity, but mostly in terms of quality.

    At night, I couldn’t sleep. My elbows couldn’t get comfortable, but during the day, moving them, the pain, though worse in intensity, was not nearly as bad as it was when I was trying to fall asleep. Falling asleep, not even moving, my elbows would ache and then suddenly experience shooting pains from nowhere.

    When they ask me my level of pain, I’m always awake. Do I mention what happens at night? Does anyone care? Why do they want to know how I rank my pain? Does that give anyone any useful information? They must think so. Then again, maybe they don’t. Maybe it’s just the insurance companies that make them ask the question and record the answer.

    If itching counts as pain, what about numbness? This is a big problem for me, now. The nerve in my left elbow needed to be put back in place during the surgery I had a few days after the accident. They had to put in metal plates and screw the bits of bone that had broken back together so they could grow back in the right place.

    My left two smallest fingers can move and do things, but they always feel like the blood has been cut off and they’ve “fallen asleep.” Sometimes, typing, I would even say they hurt. But it’s mild. A one? A two? Naw. The pain isn’t enough to stop me from doing anything, but it annoys the shit out of me.

    My elbows won’t straighten and I’ve got to work on range of motion. They’ve given me a device to force my elbows to straighten, and I’m supposed to ratchet it up to the point where it hurts, and then back off so it doesn’t hurt.

    Pain is a continuous scale, I’ve discovered. It’s like testing your ears, and the doctor raises the pitch until you can’t hear it any more, and then lowers the pitch until you can hear it. The point between hearing and not hearing doesn’t seem to stay the same, and pain is the same. Straightening my elbow until it hurts and then pulling back until it doesn’t hurt, and then straightening it a little more — the pain doesn’t stay in the same place. Plus it’s not acute pain. It’s more like an ache that slowly transforms into something more acute, but not really stabbing. Changing pain gradually is different than changing it suddenly.

    Pain comes in so many varieties, I’ve discovered: itching, aching, acute, sudden, depression, despair, stabbing, searing, heat and cold, and on and on. My pain scale goes from zero to seven. I’ve reserved eight, nine and ten for something I hope never to experience, but I imagine could be out there. It seems like there could be somethings worse. What if I were in a medieval torture machine that was stabbing into me in multiple places at once? What if I was being burned alive?

    Making patients rank pain on a scale of zero to ten seems so useless to me. I can’t imagine what that tells anyone. You could ask for so much more useful information. But they don’t.

    Pain is subjective. We all experience it on our own and we can never know what it is like to experience someone else’s pain. We can empathize and imagine, but never know for sure what another person’s pain feels like. For me, that means it is useless to compare pains. We can never know if our pain is worse or not as bad as someone else’s. Comparing pain, it seems to me, tends to make us either diminish it, if we don’t think we are worth much, or try to make a lot out of it, if we think we deserve to have more attention paid to us. Either way, that is more related to our sense of worth than to any objective measure of pain — a measure that doesn’t exist, anyway.

    Pain, it seems to me, has a huge social component, even though it is subjective. We feel it on our own, but we express our feelings about it in the context of relationships to others who either do or do not care about us. We use our pain to try to change our relationships with others — sometimes to diminish ourselves and sometimes to try to demand more from others, depending on our sense of entitlement or machismo or the mix of both.

    Perhaps pain is about understanding others. We end up using it to establish communication with others about where we fit, socially. How much do others care? How much do we want them to care? How much can we allow them to care? We don’t want to be seen to be whiners or to be asking for more than our share of care, and for many people, that means we diminish the pain we are willing to communicate, perhaps more than is helpful for our recovery. Yet, other people may exaggerate their pain, hoping to get more care than they think others might otherwise be willing to provide.

    So even though pain is subjective, it’s relevance is quite different depending on whether we are alone when we experience it or with others. When with others, we have to balance our need for help with the consequences that asking for help will have on our social standing in the long term. That causes people to diminish or exaggerate pain, depending on their social goals and experience.

    When we are alone, the social component of expression of pain doesn’t matter. The pain is just information for us, telling us what we can and cannot do. It is our body’s way of trying to keep us safe. Even then, we have to balance the need to protect our recovery against immediate needs for protecting ourselves from further injury. If we have a broken arm, it really doesn’t make sense to try to protect the arm if a tiger is attacking. We need to stop the tiger from killing us before we can worry about fixing the limb. If we’re dead, the broken arm won’t matter.

    Pain is something different depending on context. It has one purpose when we are alone, and another when we are in communication with others in social contexts. There are many kinds of pain, and our communication regarding pain has a lot of potentially different goals, depending on who we are talking to, and what kind of relationship we have with them.

    In the hospital, my broken elbows meant I couldn’t feed myself, or brush my teeth, or clothe or unclothe myself or even disrobe enough to pee or defecate. I needed help for all these things — help from strangers whose job it was to provide this assistance. The thing that bothered me the most, though, was something I never thought about before that.

    I wear glasses. My glasses slip down my nose all the time. I never knew this until I couldn’t do it for myself, but I must push my glasses up my nose hundreds of times a day. I have had the thrill of seeing two children come into this world. I have had the thrill of getting a dozen jobs in my life. I’ve performed in front of audiences. But I have never had a thrill as exciting as the day I finally got my ability to push my glasses back up my nose on my own, about a week after the accident.

    Here’s a song I made up to entertain myself while in the hospital that demonstrates the difficulties I had as a result of having two broken elbows.

    Nowadays, I get to “indulge” in voluntary pain in order to try to straighten my elbows more than I can make them do using my muscles. Right now, I am overdue, and need to go strap this on:

    Hello pain, here I come!

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