Dirty Pain is Voluntary Suffering

Thirteen years ago, I did the biggest thyroid case of my life.

The patient was about thirty. He had a massive ten-centimeter thyroid cancer, bilateral neck mets, and severe untreated obstructive sleep apnea. His mouth was tiny. His epiglottis looked like that of a laryngomalacia baby’s. His arytenoids were floppy and ball-valving. He sounded like Darth Vader just sitting quietly.

You could not have accessed his trachea if you wanted to.

The anesthesiologist and I decided on an awake nasotracheal intubation under ketamine. You get one shot at those. The anesthesiologist delivered the medications while I intubated.

It went in on the first pass.

Then I operated for ten hours.

A surgery resident graciously came in to help me with the second side of the neck. We finished late into the night. At the end of the case, I sutured in a number eight Shiley tracheostomy tube. Then I accompanied the patient to PACU and called my husband.

I was a new mother at the time. I drove home exhausted, thinking only about kissing my sleeping baby's cheeks.

I had barely walked through the door of our condo when the phone rang.

A PACU nurse's frantic voice telling me the trach had dislodged.

I flew back to the hospital. A surgery resident had placed an endotracheal tube to temporize the situation. I exchanged it for a proximal XL tube, and the patient ultimately did fine.

The following week, the case was presented at M&M.

I was sitting in the third or fourth row of the auditorium when the chief of surgery turned around and looked directly at me.

“Why did you decide to place a regular eight Shiley trach in that size of a patient?”

What I heard was:

What the fuck is wrong with you? Are you stupid or something?

My face turned beet red. I froze, unable to find my voice.

It would be years before I understood what had happened in that moment.

The question the chief of surgery asked me was one thing.

The suffering I created based on how I interpreted that question was another.

That distinction is what I now know as clean pain and dirty pain.

Clean pain is the emotion that fits the circumstance.

A patient dies and you feel grief and sadness.

A patient has a complication and you feel guilt and disappointment.

Someone you trusted betrays you and you feel hurt.

That’s aligned pain. It belongs to the moment.

Dirty pain is what happens when we take the pain and add a story to it.

A complication becomes:

I hurt someone.

Which becomes:

I'm not good enough.

Which becomes:

I'm a terrible surgeon.

Which becomes:

Maybe I shouldn't be doing this.

The event was a complication, but the suffering became an identity crisis.

That's dirty pain.

The most fascinating part is this:

Dirty pain is voluntary suffering.

Not because we consciously choose it.

Most of us don't wake up and decide, Today I'd like to turn this uncomfortable experience into evidence that I am fundamentally defective.

It happens automatically.

The brain offers a thought. We believe it. Then it offers another one. We believe that one, too. Pretty soon we're suffering not because of what happened, but because of what we decided what happened means about us.

This is especially common in surgery.

M&M is practically engineered for it.

The retrospectoscope gives everyone perfect vision. The peanut gallery has answers. Monday-morning quarterbacks explain what they would have done. And sometimes, in some institutions, the entire exercise becomes a shame-and-blame ritual disguised as education.

But sometimes the person standing at the podium isn't actually shaming you.

Sometimes you're already carrying enough shame that almost anything is salt on an open wound.

That was me.

I was a traumatized young attending, perceiving the world through wounds that were still festering. I didn't have a solid enough sense of who I was to hear a question about trach size as simply a question about trach size.

If I had been able to recognize dirty pain in that moment, I could have thought:

Oh. This hurts. And I'm making it mean something about me.

Then I could have answered the question.

“That's a fair point. I should have put in an XL. That's a mistake I made, and I'll learn from it.”

That would have been clean pain.

The embarrassment still would have been real.

The learning still would have been real.

But I wouldn't have needed to make myself the villain in the story.

This is where we have more control than we think.

It may be true that we have very little control over what happens to us. But we do have influence.

We don't control what our boss says, or whether a patient complains, a case gets complicated, or someone misunderstands us.

But we do have influence over what happens next.

And yet, when something goes wrong, most of us skip straight to action.

What should I do?

What should I say?

Should I call someone?

Should I defend myself?

Should I apologize?

Should I quit?

We crowdsource strategy before we've even figured out what we're feeling.

The better question is:

How do I want to think and feel about this?

Because if you're acting from unprocessed pain, you will take new actions from old beliefs.

You'll defend yourself because you feel threatened.

You'll over-explain because you feel ashamed.

You'll blame anesthesia because you're terrified.

You'll worry about a lawsuit that hasn't happened because uncertainty feels unbearable.

You'll say yes when you want to say no because disappointing someone feels like rejection.

And then you'll wonder why the same patterns keep following you.

The work isn't to eliminate pain.

Pain is part of being alive.

The work is to stop adding unnecessary suffering to it.

A lot of emotions we feel will leave if we give them space—if we observe them, name them, and take them with us every where we go.

We keep painful emotions alive by arguing with them, resisting them, avoiding them or building elaborate stories around them.

The question that helps me interrupt that process is simple:

So what?

Not in a dismissive way.

Not so what, get over it.

More like:

Okay. That happened. So what?

A patient had a complication.

So what?

Someone criticized me.

So what?

Someone doesn't like me.

So what?

I made a mistake.

So what?

What am I going to make this mean?

Because there is always an opportunity to turn an event into an indictment of yourself.

And there is always another option.

The next time something lands in your chest, ask yourself three questions:

Does this emotion fit what actually happened?

Do I like the thoughts I'm having about it?

What am I making this mean about me?

If the guilt fits, feel the guilt.

If the disappointment fits, feel the disappointment.

If the grief fits, grieve.

That's clean pain. Let it move through you. It will teach you something.

But if you've arrived at I'm not good enough, or there's something wrong with me, or I should have known better, or this proves I'm a terrible surgeon…

pause.

That is the story.

Not the circumstance.

And the story is optional.