7.David King — Direct (Part 2)

DAVID KING: So pain is a sensory manifestation, all right? It's something that you feel. And there's a variety of ways pain is generated in your body. The one most people are familiar with is what's called somatic pain. So that is, for example, the pain from a paper cut, right? That type of pain is sharp, it's localizable, meaning if you close your eyes and someone cuts your finger, you know that you cut your finger. And that's probably the most familiar type of pain. And patients who experience some type of trauma, particularly to their skin and soft tissues, experience that kind of pain. There are -- but there are other types of pain receptors in your body that are not what's called somatic pain; it's called visceral pain. And these are entirely different types of pain receptors that are on the inside largely, the inside of your body. And that produces a very different kind of pain that is not well localized and is, in some cases, much more challenging to treat. The biggest example -- well, the somatic pain is easy. That's like a cut on your skin. Everyone can wrap their mind about that. Probably the -- a classic example of visceral pain is the pain you get, for example, from a kidney stone or having gallstones, gallbladder disease. So it's an excruciating pain that you can't describe well. People don't know how to put it into words. It's deep. It's not in one spot; it's always in an area and it's evolving. So those are two very different types of pain and they're, in some instances, treated differently. And then, of course, it becomes problematic if you have both types of pain because then you have to treat both of those sometimes the same way but sometimes differently.

DAVID KING: Generally speaking, visceral pain is much more challenging to control. It connects to a part of your brain that's more primal, deeper brain function. And the drugs or medicines, especially in the acute phase -- acute meaning right after injury or at the time of injury -- usually we treat those with a variety of medicines. And, unfortunately, generally speaking, those medicines can control visceral pain fairly well, but like everything else, it's -- there's a risk-benefit profile. So generally what we say is we try never to take your pain away. We can't -- well, we can't take your pain away because doing so would require giving so much medication that you would be unconscious and, of course, if you take that to its logical end point, you give so much pain medication that you would die, so naturally that's not a desirable outcome. So what we try to counsel patients who have terrible visceral pain is that we want to make it tolerable or manageable. And the goal should never be to take pain away; it should be to make it tolerable and manageable because the side effects of making it go away are wildly unacceptable.

DAVID KING: Yes, ma'am, I have.

DAVID KING: So I can -- based on the anatomic injuries, I can say with an extraordinarily high degree of medical certainty that he did not die instantaneously. As I mentioned earlier, this is a spectrum. Martin died from blood loss, yes, and he died from rapid blood loss, yes, but that is not instantaneous. It is still along the gray scale of blood loss. And whether -- yes. So the answer is yes, with a high degree of certainty I can state his injuries are not consistent with dying instantaneously.

DAVID KING: Yes, without question. His injury pattern, particularly the abdominal injury, would have engaged both types of pain pathways. So somatic pain from the skin and soft-tissue injuries, so the abdominal wall being disrupted and so on, and the visceral pain which is, as I said, a much more primal, very disturbing kind of pain from the disruption of the internal organs, which is where those visceral pain receptors lie.

DAVID KING: So the receptors are very different. And the types of receptors that are on the -- they're called visceral because they're on the viscera. "Viscera" is just a catch-all term that means everything that's within your abdomen, your intestines and spleen and liver and so on. Those receptors are generally not responsive to, for example, cutting. So if you cut your skin, you will hurt and flinch. If you happen to be awake and someone cuts your bowel or liver, for example, it actually generally doesn't hurt. What does hurt, though, is stretch and distention and twisting. So this is the reason why kidney stones hurt so much. The stone is stuck in the ureter. It causes the ureter to stretch, and those stretch receptors are interpreted by your brain as being incredibly painful. The same is true for a gallbladder or if you have a bowel obstruction and so on. So it's really stretch, twist and distention that activate those visceral type pain receptors. In Martin's case, there was disruption of his viscera, so of his liver and spleen and intestines, in such a way that the intestines were pulled and twisted, and as we say, on tension, creating stretch that would have, with any degree of certainty, caused visceral-type pain.

DAVID KING: So yes, and here's why: So the way -- one of the primary ways to render yourself safe from an explosion is to create distance from it, right? So naturally, the farther away you are from an explosion, the safer you are. If you're talking about a set of circumstances where you cannot create distance, right -- so, for example, the explosion is by surprise -- if you can imagine you're 20 feet tall for a moment -- suppose you're 20 feet tall and an explosion goes off at your feet, that explosion would likely injure your legs or your lower legs. It might injure your thighs, for example, but because you're so tall, your torso might be entirely unaffected and you might only have lower leg injuries. On the other hand, imagine for a moment you're only 3-feet tall, exposed to that same explosion at your feet. Well, if the blast created from that explosion is 3-feet wide, suddenly you're exposed to risk of injury not just to your legs which are right next to it, but because you're shorter, suddenly your torso, abdomen, lungs, trachea, brain and so on, are all exposed within that intense confined -- or perhaps not confined, but within that blast radius. So this gets to the principle of distance away from an explosion. What that means is for someone who is shorter, it puts their vital organs closer to the blast than someone who is taller. So for Martin to be standing very close to that blast puts him at much greater risk of lethal injury than somebody who was taller.

DAVID KING: Yes, it does. So if the diameter of the aorta is an inch, for example, in an adult, and a fragment flies through it, and that fragment is half an inch -- so it makes a half-inch hole in your 1-inch aorta -- you'll lose blood at a certain rate, right, whatever the rate is, through that hole. On the other hand, if your aorta is only half an inch in diameter and a half-inch fragment flies through it, suddenly the entire thing is disrupted, or more so than it would be if it was an inch in diameter, so the rate of blood loss, or the ratio of blood loss is much higher because the aorta is smaller. So, again, for a smaller person with the same injury pattern, it puts them at particularly higher risk for injury, blood loss and death.