Pain control and cultural norms and expectations after closed femoral shaft fractures.

The purpose of this observation-cohort survey study was to compare the analgesia given and satisfaction with analgesia after a uniform orthopedic injury and operation in culturally disparate settings. Twenty-five patients with isolated closed femoral shaft fractures treated with intramedullary rod fixation within 1 week of injury were retrospectively evaluated at two urban hospitals in the United States. They were compared with a matched group from three urban hospitals in Vietnam (two in Hanoi and one in Ho Chi Minh City [Saigon]). Ages and sex did not differ significantly between the two groups. The mean weight of the Vietnamese group was significantly less than that of the US group (58 vs. 81 kg). During the 14 days following injury, the Vietnamese and American groups were given a mean of 0.9 mg/kg per day versus 30.2 mg/kg per day of morphine equivalent units, respectively. Two (8%) of the Vietnamese group felt their pain control had been inadequate, versus 20 (80%) of the US group. Similarly, 2 (8%) of the US group and 7 (28%) of the Vietnamese group felt they had received "too much" pain medication. Mean heart rates during the first 5 days after surgery were not significantly different in the two groups. Only 4% of the US group felt they had had an accurate impression of how much a femur fracture would hurt prior to the injury, whereas 76% of Vietnamese patients responded that they imagined such an injury would be approximately as painful as it was. Results were similar for preconceptions of pain as a result of surgery and during the postoperative period. More than 50% of patients from the US group felt there must be some explanation other than the femur fracture to explain the severity of their pain, such as infection, missed injury, hardware failure, or inappropriate medical care. Despite much higher administration of narcotic analgesia, American patients with femoral shaft fractures were much more dissatisfied with their analgesic results. In assessing the recommended dosing for "adequate analgesia" and "analgesic requirements," determinations may depend less upon tissue injury than upon cultural norms and patient expectations.