Clinical hypnosis: my first attempt

He walked in without an appointment and asked the receptionist for a ‘subscription for penicillin.’ Judy buzzed me, saying in the special quiet tone she used for urgent matters, that I needed to come to the desk - now. He was an impressive sight, big enough to have to stoop to talk to Judy through the window and wide enough to completely block the view of the waiting room behind him. He was wearing greasy coveralls and a cotton sweat shirt, probably the source of the pungent smell of machine shop that filled the room, with his right sleeve rolled up revealing a blood soaked and dirty makeshift dressing on his forearm. 

 

Ginny and I walked him back to our procedure room, where she sat him down on the exam table and began taking and recording vital signs, while I asked him what had happened and how we could help. He had been doing maintenance on some of his farm machinery (explaining the grease and smell of gasoline and oil) and had gotten his forearm caught between a housing and its blade, and in the process of extricating his arm ‘I chewed her up pretty good.’ I suggested we take a look and unwrapped his blood and oil soaked dressing to find an irregular 4 inch long gash down to fascia. The wound edges were indeed ‘chewed up’ and the wound itself had pieces of rust, grass and other debris throughout. I told him his wound needed to be cleaned up and stitched and suggested that we make arrangements to have this done in the ED (a short walk across the parking lot) by one of the general surgeons. He insisted in a voice that I learned later carried through the closed door, down the hall and around the corner into the waiting room, that ‘I don’t need no damn stitches’ and repeated his request for penicillin. In response to some prodding, he confessed to a massive fear of needles and continued to demand antibiotics to prevent infection.

He was big enough - and motivated enough - that it seemed unwise to argue. I suggested that at least he should let me clean it up by rinsing it out with sterile saline and put a proper dressing on it ‘to make it easier for the antibiotics to prevent infection’ and he said ‘Sure, doc. Jest no needles.’ I warned him that if I didn’t numb it up, cleaning it out properly would be pretty painful, and he assured me he could take it. ‘I don’t care. Pain don’t bother me none. Jest needles.’

We made him as comfortable as we could on a procedure room table not designed for someone his size, Ginny got out several bags of saline and some tubing, a catch basin, and chux, and I gloved up and began irrigating. He winced a bit, clenched his jaw and closed his eyes but otherwise lay still and allowed me to work. Making conversation and trying to distract (and stay on the good side of) this mountain of a man, I told him that the saline was pretty cold and would ache as we started, but would start to numb up the cut as I worked and the pain would begin to go away. As I said this, he relaxed noticeably, unclenching his jaw and letting his eyes partly close. Watching him relax in response to my suggestion, I remembered...

My first experience with hypnosis in a clinical setting (as opposed to bad movies) had been as a desperate dental patient in medical school. During residency, I had watched a faculty member use it effectively for minor office procedures, labor, smoking cessation, and treatment of some anxiety related issues, and several years after residency, I had taken a formal course, but I had come back too uncertain of my abilities and insecure to suggest it to patients, fearful that they would see it as unscientific quackery and mindful that insurance rarely covered it. As a result, four years had now gone by, and I hadn’t used it. I rarely even considered it. And now I was watching it work!

Induction of a hypnotic state, sometimes called a trance, is absurdly easy in a willing and motivated patient. The skill lies in knowing how to use relaxation, directed and misdirected, focus and suggestion for clinical goals. My suggestions to him were that the saline was colder and colder and his cut was number and number, and that as he felt the saline run in and out it washed both the dirt and the pain away, and he would be able to relax, be comfortable, safe, fully in control, focusing on my words, deeper relaxed, more and more numb... His eyes closed and his breathing slowed down. I pantomimed to my nurse to get a laceration kit from the closet, which she did, setting it up on the procedure tray with furrowed brow. Tentatively at first, I began probing at the wound, picking out some of the adherent debris. He remained relaxed with eyes closed. I explored the wound a bit more aggressively and snipped out some of the subcutaneous fat. Still no response. Emboldened, I picked up the toothed forceps and a pair of tissue scissors and began gently trimming the irregular skin edges to removed damaged tissue that would heal poorly and increase the risk of infection.  

“Hey doc.” He said. “You doin’ what I think ye’r doin?” I froze.

“I don’t know, Wes. I’m just numbing up and cleaning up here. What do you think I’m doing?”

“Ye’r cuttin’ bits of me off, like, snipping. Friggn’ weird, doc. I can feel it, but it don’ hurt. Like it isn’t real, mebbe, or like it ain’t my arm. Why am I lettin’ you cut me?”

“You’re really relaxed, Wes. Deeply relaxed,  calm, and comfortable, I don’t think your arm really wants to hurt right now.”

“I guess.”

More pantomime with the nurse, a suture set and sutures are procured, 5 interrupted deep absorbable sutures and 8 4-0 Ethilon in the skin close the wound, neat and dry. The stitches are followed by a tetanus shot.

As I’m getting ready to put the dressing on, backing him out of his hypnotic trance state (staying relaxed and comfortable, you’re feeling more and more normal, a bit more alert, almost ready to open your eyes, feeling refreshed...) and he looks down at his arm.

“Damn. Doc. How the frig’ did ya do that?”

“Does it matter, Wes? You seemed ok while I was working, I didn’t hurt you much, did I?”

“Shit, no. Just weird, is all. Ya didn’t try to hypmatize me, didja? ‘Cause I can’t be put under. They tried once, back in Nam (I would later learn more about this and his fear of needles) but it didn’t work. They told me I’m immune.”

“No, Wes. I didn’t try to hypnotize you. I just helped you relax while I worked. You took care of stopping the pain.”

He left with a prescription for 5 days of antibiotics, and instructions in twice daily dressing changes and signs of infection. He returned in 10 days to have the stitches out in the same grease and gas soaked clothing, which I suspect had never seen the inside of a washing machine. The wound looked great, and he let me take the stitches out without protest. And I stopped avoiding the subject of clinical hypnosis with patients. 


 

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