I presented a case to my senior registrar as I was a bit stuck as to what to do next.
A 41 year old Italian lady had presented with abdominal pain. ‘Dolore’ she screamed anytime I even got close to palpating her belly.
She’d been in Australia 10 years but didn’t speak a word of English – I’d obtained the history from her husband. It didn’t really sound like anything in particular and when I was able to distract her, her belly was completely soft with no significant findings. Her observations were normal. Her urine and blood tests were all normal.
The Senior Reg paused for a second after my presentation before declaring:
‘She clearly has SEPSIS.’
What?!! I’d previously thought this Registrar was a bit of a whizz. Thankfully he further elucidated:
Southern European Pain and Suffering Intolerance Syndrome. (SEPSIS)
‘That’s so non-PC‘ , I laughed, but on further reflection and after much more experience it is an undeniable truth to state that there are major cultural differences in how we as human beings deal with, and express pain. Being of stoic Ulster-Scots stock I have learned over the years that if a farmer presents to an Emergency department with a sore toe he should immediately be moved to the resuscitation area as he is about to die. Conversely if someone presents with SEPSIS, their mortality is almost zero.
This is a topic that has been little researched – perhaps it’s not something that sits comfortably with us in an era of political correctness. It does seem OK, however to research whether men or women have a higher pain threshold (the answer is Men!).
One paper I found from 1983 stated
‘American Jewish and Italian parents have been noted to be especially indulgent and attentive to their children regarding pain, perhaps thereby encouraging sensitivity to pain. Other cultures reward stoicism or punish complaining children, resulting in adults who may actually feel less pain. But the interaction between the learning and genetics of pain sensitivity has still to be delineated.’
This is from the pre-political correctness era and probably could have been phrased less offensively. Another paper questioned 4000 nurses from 13 nationalities about patients suffering with some revealing insights:
- Nurses generally see patients of lower socioeconomic status as suffering more than patients of higher socioeconomic status.
- Nurses see Jewish and Hispanic patients as suffering most, Asian and Anglo-Saxon/Germanic patients as suffering the least and other ethnic groups falling between.
- Nurses of northern European background inferred the least painful suffering in patients. Nurses of African and south and east European backgrounds inferred relatively high patient suffering (each group may be projecting its own experience of pain).
Pain is clearly an immensely complex amalgam of noxious stimuli, psychological and cultural influences – with the cultural influences equally affecting the caregiver and the sufferer.
How an Emergency physician reacts to a patient’s pain is part of the art of medicine and will be a direct result of a multitude of factors including their professional experience, culture, current mental state and personal experience of pain.
My advice to Doctors just starting out is to be generous with your opiates. Adopt the mindset that you’d rather give a drug-seeker morphine than deprive someone in pain one of the few drugs in our Emergency department armamentarium that actually does something.
- Hartog J, Hartog EA. Cultural aspects of health and illness behavior in hospitals. West J Med. 1983 Dec;139(6):910-6. PMID: 6666109 (Free full text)
- Koltyn KF, Focht BC, Ancker JM, Pasley J. Experimentally induced pain perception in men and women in the morning and evening. Int J Neurosci. 1999;98(1-2):1-11. PMID: 10395360
- Komiyama O, Wang K, Svensson P, Arendt-Nielsen L, De Laat A. Gender difference in masseteric exteroceptive suppression period and pain perception. Clin Neurophysiol. 2005 Nov;116(11):2599-605. Epub 2005 Oct 10. PMID: 16221570
- Chesterton LS, Barlas P, Foster NE, Baxter GD, Wright CC.Gender differences in pressure pain threshold in healthy humans. Pain. 2003 Feb;101(3):259-66.PMID: 12583868
Know any variants of SEPSIS? Leave a comment below! So far there is Unt Heer Syndrome, Begum and the ‘Aye, Aye, Ayes’.