The Patient Was…

The patient was a 70-year-old  male with severe atherosclerotic cardiovascular disease, meaning narrowing and obstruction of blood vessels of the heart and other parts of the circulatory system that provides blood supply to all the organs and tissues of the body.

His coronary arteries, those supplying his heart muscle with oxygen-rich blood, were especially diseased and, as a result, he suffered from repeated episodes of angina pectoris, chest pains due to inadequate blood flow to areas of his heart.

He was on maximum doses of various medications, all designed to improve the balance between the blood his heart needed and the available supply, and thus relieve the symptoms of angina pectoris. He had also undergone an unsuccessful surgical attempt to revascularize or provide new blood supply to his heart.

When an episode of chest pain became very severe and persisted for a long time, he would be admitted to the hospital and given morphine, a powerful opiate drug, to relieve the pain. Tests to rule out an actual heart attack would be done and if the test results came back normal, he would be discharged from the hospital.

One day, when I was in my office, I received an urgent call from the hospital. The patient had presented himself to the emergency department complaining of  severe and persistent chest pain. He was admitted to the hospital and, as per usual, given morphine. But unlike prior instances of similar presentation, the morphine did not relieve his pain.

The hospital staff at the bedside called for an anesthesia consultation, hoping that the anesthesiologist could either suggest another pain-relieving medication or even agree to put the patient to sleep, as if for an operation, to stop the pain.

The anesthesia specialist declined to offer further medication or to put the patient to sleep. Since powerful opioid drugs can severely reduce breathing, the doctor said that further medication after all the morphine that had been given might cause complete respiratory arrest, meaning the patient would stop breathing altogether.

Further, he said that putting him to sleep was too risky because he might not be able to reawaken him because of the patient’s age, frailty, and the amount of medication he had already received.

Since I was the patient’s physician of record, I was called to the bedside. My office was only a short distance from the hospital, but I used those few minutes to try to formulate a strategy. Should I give the patient more morphine, and risk stopping his breathing? Should I try to persuade the anesthesiologist to put him to sleep, thereby shifting the responsibility to the other physician?

When I arrived at the patient’s bedside, I still hadn’t decided what to do. His condition was worse than I had imagined. He was clutching his chest, moaning, and literally writhing in pain. The interns, residents, and nurses were standing around the patient’s bed, all of them clearly distressed by what they were witnessing. And they properly looked to me for a decision on how to proceed.

I had to do something. And more medicine or deep anesthesia were not viable options.

Not too long before this encounter, I had become interested in hypnosis as a means of helping people to stop smoking. Smoking is a prime risk factor for developing cardiovascular disease and none of the more traditional methods of smoking cessation seemed very effective. I had learned only one method of inducing hypnosis and had used it on only a few occasions. In each instance, the patients were alert and able to focus on what I was saying and to follow instructions. My success rate was pretty good.

Never had I seen or even heard of trying to hypnotize someone in the agitated and suffering state of this man. But it seemed to be the only safe thing to try at the moment. When I explained to the staff at the bedside what I was going to do, nobody said anything, but they looked at me in incredulity. In their position, I would have done the same.

I had known and cared for this patient and members of his family for a long time. He knew me well and I knew that he trusted me. I touched him and told him I was there, and he looked up at me with pleading eyes for help.

I told him that I was going to put him in a state of deep relaxation which would reduce his pain and allow him to fall into a restful sleep. I actually had no idea what I was doing.

The technique I had learned to induce a state of hypnosis was known to me at the time as eye roll and arm levitation. It involved specific motions of the eyes and coordinated breathing, then producing by words a general sensation of floating and lightness and numbness of one arm.  If the patient’s arm floated up as if drawn by a string or a balloon, they were supposedly in a state of intense focus on what they were told.

I didn’t know if this patient, in severe pain and heavily medicated, could even focus on the instructions I was giving, and be able to follow them. But he could and did. I had focused on his left arm which was now elevated. Although he had stopped writhing, he was still shaking and sweating and grimacing in apparent pain.

I was still winging it, and I didn’t know what to tell him. I was pretty sure that if I told him his pain was gone, the intensity of it would override my suggestion and the whole process would fail. A hypnotized patient, I had been told, cannot be induced to do something that goes strongly against their core beliefs, and I thought that the same principle might mean that the reality of his pain could not be eliminated by just saying so.

I thought that I could perhaps take advantage of his left arm that was still in the air and very numb. I told him that he could slowly lower his arm to his chest, and that the numbness in his arm would flow out of his arm, through his fingers, and onto his chest. I didn’t dare suggest that the pain would disappear, but I said that the pain would be “surrounded by an envelope of numbness.” He would still be aware of the pain, but the numbness surrounding it would make it tolerable and he could fall into a deep sleep.

Eureka!

His left arm slowly descended until it rested on his chest. He began to breathe more easily. His grimace of pain subsided, his face and body relaxed, and he drifted into what appeared to be a restful state.

I casually turned to face the assembled professional staff, and acted as if this was an everyday occurrence. To a person, they were dumbstruck, mesmerized by what they had witnessed. They had never seen or done anything like it.

Then again, neither had I.