Pain Transference


It took a while, but I now have five things on my list of rantable offenses occurring in the emergency department.

To recap …

Don’t call it the “emergency room” or the “ER” to my face, in the comments, or anywhere else. Period. It is the emergency department. “ER” is a TV show that was canceled. We don’t need to dredge up old drama. I’ll politely correct you once, then I’ll get DeNiro on you the second time. And we’re emergency physicians. We’re not “ER docs”.

If you use a cell phone while I’m examining you, talking to you, or treating you, that’s like spraying me with pepper spray.

Baby talk will probably cause me to have little twitching episodes. If I hear it, I might say something like “Hey, I speak ‘Fudd’ too” and talk back to you in the same manner. Don’t be offended.

If you come requesting a ZeePack for a “low grade fever” of 99.1 degrees you’re going to be disappointed. Look up diurnal temperature variations. It isn’t a fever.

Then there’s pain transference.

Wait. What is pain transference, you ask? Let me describe a typical experience in detail for you.

Consider a patient with a complaint of pain who comes to the emergency department accompanied by another person. The patient dons a gown and the accompanying person sits in a chair next to the stretcher.

Your thorough exam leads you to the area of the body in which the patient is having pain. You press around gently on the area … not even on the area where the patient is reporting to have pain … and then it happens. You hear a “reverse hiss” from across the bed.

Imagine making a hissing sound with your mouth. Now imagine sucking air in through your clenched teeth instead of blowing air out. The “reverse hiss” is the first sign that pain transference has occurred.

If you’ve not had this happen before, you think to yourself “what was that”?
You look up and the other person in the room invariably has a frightened look on her face.
You look at the patient.
The patient looks back at you and shrugs his shoulders.
You lightly touch near the painful area again. The patient doesn’t flinch, but you hear another reverse hiss from across the bed.
You look across the bed out of the corner of your eye. Now the person across the bed has her mouth open and is tensing those muscles that make all the skin on the neck stick out. In severe cases of pain transference, the other person in the room will even yell at you because you’re “hurting” the patient.
You look back at the patient.
“Does that hurt?”
“Ummm. I guess …”
You gently press around a little more and you hear a series of short reverse hisses. You see if you can get the person across the bed to signal “SOS” in reverse hiss Morse Code. “S … O … U” SOU? No no no. The last hiss was supposed to be short, not long. Aaahhh forget this. Didn’t work.

But to cinch the diagnosis of pain transference, you have to perform a confirmatory maneuver:
You have to lift up the sheet so that the person across the bed cannot see where or when you are touching the patient. This act of defiance interrupts the visuo-spacial pain continuum, causing immediate anger in the person across the bed, ceasing any additional reverse hissing, but also causing the patient to experience much worse pain in the same spot that wasn’t hurting only a few seconds before.
“Oooooowwwww” moans the patient.
“Why are you trying to hurt him?” Yells the advocate.
“But I just touched there a second ago and it didn’t hurt at all.”

Doesn’t matter where you touch. Doesn’t matter how hard you touch. You have now become a victim of pain transference. Studies clearly show that there is now a 24% chance of a call to an administrator and a 97% chance of Press Ganey badness.

You should have excused yourself from the room at the first “reverse hiss.”


  1. On the temperature issue: I don’t think I’ve ever demanded antibiotics for anything. But please listen when I tell you that my normal temperature is between 97.0 and 98.0.

    If I’ve gotten up above 99, then there’s something going wrong. If I’ve turned up in the emergency department, it means I think something is REALLY wrong.

      • MamaOnABudget on

        Well, good for you. I hope you actually take the time to listen to your patients better than you listened to “V” above.

        I can show you YEARS of temperature charting that show my average daily temperature is about 96.8-97*F. A 100.4* temp in someone with the AVERAGE body temp of 98.6 is only 1.8* higher than their normal. On me, that’s a 3.4* difference. I’m not one to jump on to fever reducers – I prefer to let my body fight off whatever is going on. But if someone like me comes in with a 99* temp, it isn’t the .4* shift doctors like to make fun of – it’s a 2* difference, which is already over the temp threshold you mocked V about in “medical land.”

      • Since a fever is not that big a deal, medically speaking, outside of the early infant period, in most cases I don’t really care whether you technically/philosophically/really have a fever. It is but one data point, and not the most important one in most cases.

  2. Funny post, thanks. I believe it’s “clinch,” not “cinch.” Clinch actually has a really fun history relating to showing horses. 🙂

  3. Eric Atkinson on

    Well if you could get a least fifty percent of ER workers to use the term emergency department you might have a case, otherwise its just semantics.
    Have your pet peeves if you want, but in this country common usage is ER.
    Hell, most of the medical bloggers use the term ER.

  4. MamaOnABudget on

    I’m gonna go with Eric here. I try my best to say “ED” when in this blog, but when you are given directions to enter the hospital through the ER to get to your destination, the hospital sign says ER and Emergency Room, and you’re told that an ER Doc will see you shortly… It’s a divided world.

  5. Yes, I see this often. Usually with either kids or old people as the patient and the anxious family member can’t control themselves.

    I don’t mind if people call us ER docs. Many lay people think that “Emergency Medicine” is what paramedics and EMS do.

  6. I had a patient tell me the other day that her temperature ran “high”. First time in 15 years anyone ever told me that. I actually almost busted up laughing because I was so expecting them to say “low”.

    When dealing with a “pain transference” patient, I always ask them to push on where it hurts. Invariably, they mash on their abdomen pressing the umbilicus to the spine while laughing and smiling. Then I gently touch them with pressure barely enough to dimple the skin – and they scream out…..and I remark “wow, why didn’t you scream when you punched yourself in the gut 5 seconds ago”.

  7. MamaOnABudget on

    Have none of you doctors replying ever heard of thyroid disorders? I know – it’s only something fat people complain about as an excuse to why they don’t put in the effort to lose weight. Or could it also be that a known symptom of underactive thyroid is lower than average body temperature and overactive thyroid is higher than average body temperature? I’m sure they aren’t the only possible causes of not having the AVERAGE (in other words – some people will be higher, some will be lower) body temperature. Maybe actually considering real medical possibilities would be a start instead of mocking patients.

    • I am not sure that hypothyroidism is a disease that tyically requires evaluation and treatment in the Emergency Department.
      In my outpatient clinic(and occasionally in the inpatient world) I do check thyroids fairly often for a whole host of reasons.
      But once again, whether or not you have a fever and whether or not your basal body temp of 97.6 changes your management in the ED is an entirely different question.

    • There is no known medical indication for anyone to chart their temperatures for YEARS. The only exception s if you are using the BBT method of unreliable contraception.
      Your temperature variation history is unlikey to help any doctor who will see you in the future to figure out anything of value to YOU. You’ll be just dismissed as crazy (rightfully). Just being honest.

  8. Why are we discussing fever so much. We all treat infections with antibiotics in persons without a fever. Similarly we frequently don’t prescribe antibiotics to runny noses with a documented fever. Can’t I just admit that I don’t care if you have a fever or not. In fact unless you are altered just skip that ‘vital’ sign because there is nothing vital about it.

  9. As a lay person, I am completely perplexed by this pain transference phenomenon.

    Is the non-patient just really anxious? Is somebody faking it? What in the heck causes that?

  10. Dr. Franklin on

    I’ve found that people focus too much on the “room” part of emergency room, and not the “emergency” part. I mean…yes…you’re right….there is a certain “room” quality to it, I guess…walls, floor, ceiling, BUT….the qualifying part of the statement is “emergency” room. Would you take your kid to the “maim and torture” room at 3AM just because he has a fever? It’s a room, too. Why not? How about even just the “Pie in the face” room? “kicked in the groin” room? Heck, I’ll even go one further…”free toys and cupcakes” room? Probably not…peculiar that of all the unnecessary rooms you wouldn’t go to at 3AM when not needed, the “emergency” room seems to do just fine.

  11. Electric Machete on

    Anyone who tells me that they have charted their body temperature on a daily basis for “YEARS” will be discharged immediately regardless of their complaint.

  12. Well WC – you …many moons ago now …put the fear of God in me about referring to the ED as an ER in this blog …or in any sentence in which I use your name. I actually have called it both …prior to your blog …although ER was more frequent. What’s wrong with Doc tho? ED Doc? I wouldn’t call you Doc ..”Hey Doc!” Although, my former dentist …likes to be called Doc. I do write Doc when blogging sometimes just because shorter.

    Anyway …just for you (Oh and try to ignore the fact that my cell phone ring tone is now blaring loudly -Canon’s Pachelbel in D major) and just imagine that I am now talking to you in the cutest baby talk you ever did hear …”Hi Doc WhiteCoat …I hope your next shift in the emergency Room is everything you want it to be.” Yes I used all regular spelling, but trust me the baby talk with my lips forming every word so preciously …it was all in the delivery …baby talk all the way. 😉

    The image of you twitching and pepper sprayed cracks me up. I always loved the chief inspector Dreyfus in the Pink Panther movies when he twitched around Inspector Clouseau or at just the thought of him. 🙂

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