I have had two recent injections of local anaesthetic. The injections were similar but the accompanying verbals weren’t. In the first one, the injector said. “OK at the count of three I will put the needle in and it will sting a bit, 1,2,3 there you are…” It really stung! Some months earlier, another injector was about to put the needle in when she said “ouch” just before the needle went in. I didn’t feel a thing. It was as though she had my needle pain for me! I thought it was pretty cool.
Here is an interesting study – In two groups of 70 healthy women at term, prior to having a local anaesthetic before an epidural, “we are going to give you a local anaesthetic that will numb the area and you will be comfortable during the procedure” was compared to “ you are going to feel a big beesting – this is the worst part of the procedure”. In group 1 the median VAS scores were 3 (2-5) and in group 2 they were 5 (3-6). Highly significant differences (Varelmann et al (2010) Anesthesia & Analgesia 110: 868).
Is this just a bit of increased local discomfort that we shouldn’t worry about? It may be more than that. At least 10% of the population are trypanophobic i.e have a fear of needles. This may lead to further health problems, for example blood tests may be missed . There are many reasons for needle phobias but maybe language enhanced needle-pain neurotags may be one of them.
I must say I would feel odd saying to the next injector “can you say ouch before you inject!
I would love to hear your comments.
I wonder if this is better or worse than the injector that doesn’t let you know you are going to get an injection and just does it! The only one that I have had went roughly like this – I can’t compare to other LA injections. Aside from the informed consent considerations…………………
After listening to Mark Jensen talking about theta brain waves induced by rythmical music, I wonder what would happen if you sang “one, two three, needle going in, this is going to sting” with a bit of a lilt, a bit of laughter-like a nursery rhyme (maybe get some age regression too) a couple of times over; get the patient singing and laughing too?
Or what about, instead of “1,2,3” jab, *sting*, something like (slowly) “I’m going to count to three, and on three you might find that you are pleasantly surprised and delighted by just how comfortable, soft and safe you feel, 1..2…..three” – I’d probably jab you on “2” as well.
What a horrible (potentially) post hypnotic suggestion in that study “…big bee sting…..this is the *worst* part of the procedure…” If they weren’t trypanophobic before, they may very well after that!
I’m also thinking that there’s nothing like a bit of distraction “ouch!” to “momentarily disassemble a neurotag”.
Equally, saying something like “this is the worst part” would seem likely to add to the “credible evidence for threat or danger to self” for the woman undergoing the injection- maybe enough for that same self to decide to construct a 5/10 pain neurotag rather than a 3/10, or none at all?
Thanks David for this great little story- a brilliant reminder of even the seemingly simplest pain experience (injection) still being remarkably complex and emergent but also able to be modulated and made more comfortable with a bit of thought, empathy and careful use of language.
(Is trepanophobia the fear of having holes drilled/scraped in ones skull perhaps??)
“Ouch” as she injects. That’s some good utilization.
When Milton Erickson’s young son fell down the stairs, this is how he handled it:
” No effort was made to pick him up. Instead, as he paused for breath for fresh screaming, he was told quickly, simply, sympathetically and emphatically, ‘That hurts awful, Robert. That hurts terrible.”
“Right then, without any doubt my son knew that I knew what I was talking about. He could agree with me and he knew I was agreeing with him completely. Therefore he could listen respectfully to me, because I had demonstrated that I understood the situation fully”.
So in the clinic, just by acknowledging verbally the pain and suffering, great headway can be made in a very short space of time: Add some mirroring and *boom*, the need for physical treatment has all but vanished. I think it’s quite true to say that a patient is someone who is looking for surrogate parent to rub the sore spot and just be present. I don’t say this in a derogatory way; I’ve noticed I respond favourably to this approach as well.
There’s one point where I would differ from Erickson and that is I would not use such words sympathetically. A sympathetic tone is absolutely NOT the way to go. If you’re fully present, sympathy is seen as not just unnecessary but counterproductive.
This all resonates well with me. Throw in some of Mark Jensen’s motivational interviewing and you potentially have some powerful tools. Perhaps using open ended questions in these sorts of situations can save you and the patient a lot of grief. E.g. Simply asking, “What do you think of injections?” , this may open the patient up a bit more and reveal potential neurotags. I’ll elaborate with a couple of personal examples. I have realised that whenever I get a blood test/injection I close my eyes as they do it. I theorise from this that I am removing the visual sensory input, which must be strong in me. Interestingly it seems to freak the person out who is taking the blood, they often say “are you okay !!”, I just reply I’m fine, it’s just what I do. Now, I will try to apply all these factors to a very specific example. Last year I had viral meningitis. While still trying to get a diagnosis in emergency it was decided that they would do a lumbar puncture on me (I had never had one before). As the nurse was wheeling me off for this she said “Oh no, you poor thing, you need a lumbar puncture, they’re awful!”, you can imagine what this did to my already stressed out nervous system. Anyway, I had the lumbar puncture and it was absolutely fine, I’ve had dry needling done to me before that felt way worse. Reflecting on this , as many would know you get a lumbar puncture lying on your side facing “away” from the procedure. I.e. I didn’t see what was happening. So, in my case the visual stimulus was removed (by nature of the procedure, not by design). My past experience tells me visual stimulus is strong for me, so maybe by accident this outweighed the negative neurotag the nurse provided on the way to the lumbar puncture?? Even the word “puncture” invokes negative thoughts. Maybe it could be called a “CSF Appraisal”?, sounds a bit more positive and less aggressive.
All this comes back to what the NOI group explain so eloquently. Assess the ” person as a whole” ( body, thoughts,fears etc). Then educate (only as much as needed) , re conceptualise (where needed and able),encourage and enable, then empowerment will follow.
Does this sound reasonable?
Dr Elvira Lang has written a brilliant book “patient sedation without medication.” It is revolutionary for acute care, I think. It speaks to exactly your post–the power of words, or communication, to alter pain. She now teaches this throughout the States, and some enlightened parts of Canada. She calls it ‘comfort talk.’
It is being adopted, in great part, because the proof is, as they say, in the “pudding”—-it saves money. Her research is clear–being aware of language and its power can improve patient care. I highly recommend her book, or any of her extensive research.
Her courses are superlative for the clinician also.
Many thanks – Reading it now
Or just get the patient to sing “Three blind mice”. Derren is masterful.
Thanks Cam and Tim – and Nigel – that sounds SO reasonable.
I uust want to add that “Lumbar puncture” is a horrible metaphor, so embedded we forget it is a metaphor. – it’s as though all the air and goodness goes quickly out of the nervous system. I do like “CSF appraisal” though!
The term CSF appraisal is lovely and gentle. The term lumbar puncture does conjure up such threatening images. Formerly, of course, it was known as a “spinal tap” until the self-titled Mockumentary made it obsolete. Perhaps they should have held onto it considering how funny “This is Spinal Tap” was! On another note a lovely doctor I know always had queues for his blood taking skills. When colleagues had needle stick injuries he was called upon to do the honours. He tapped around the area to desensitize it before inserting the needle and said in fairly dulcet tones “you may feel some pressure”. Perhaps it was his tapping of the area that made it less painful or maybe his dulcet tones that made him so popular or maybe indeed a combination of both. Either way the procedure was invariably reported as painless!
Ah – dulcet tones! Spending last weekend with Mark Jensen, Lorimer and some introductory hypnosis makes me think that if the brain was in theta rhythm, the needle would be far more acceptable. I am working on my dulcets!
I often think of the warning recommended before a cervical manipulation, around the idea that “this could kill you.”
Hi David, Is there a link between tone of voice and an ability to create Theta waves in a patient. Is that why some voices are more relaxing to listen to. It seems as if some accents are more appealing in general than others (Southern accents in the US for example?). I wonder if accents are just a variation of tone and therefore some are more effective in reducing stress in patients than others?
Absolutely – I think a key thing I learnt from the Mark Jensen workshop was that we use hypnosis all the time. The times when the clinical encounter really works may well be when we are in theta rhythms. I am reviewing this literature and will post a summary here soon.
Are we saying that hypnosis causes theta waves?
there is some evidence for that
What a wonderful post, thank you……our tone of voice, our choice of words and our delivery are pivotal for a positive outcome……..the art of the trickster !!!!!