**2.4 Case: perioperative injuries**

Appearance of additional pain signals during treatment for other conditions mainly orthopedic operations - can be illustrated by five cases: two affected lower limbs, two affected upper limbs, and one affected a shoulder. The patients all reported severe pain and difficulty moving the affected limbs. In all cases their reports of abnormal pain were interpreted as normal pain. The patients were prescribed physical rehabilitation which brought no positive results. CRPS was not recognized until limb deformation was visible or bone loss was detected with radiographic imaging.

All this evidence suggests that there are major blind spots in diagnostic procedures where chronic pain is a factor, often preventing new disease entities from being discovered and treated. To rectify this situation, new procedures are required to complement existing procedures in situations which, currently, leave medical practitioners exposed to improvisation.

The following case illustrates issues caused by insufficient diagnostic procedures: girl, 15, was diagnosed with antero-inferior subluxation of the glenohumeral (shoulder) joint with muscle weakness of the shoulder girdle. The various treatments prescribed, such as Kirschner wire fixation, all followed existing procedures but, irrespective of the method used, the shoulder always slipped. In effect, the patient was discharged from several hospitals without positive prognosis. Doctors failed to act on the patient's reports of pain, treating it as natural and necessary under the circumstances. Over the next 120 days, the patient underwent various attempts to set the shoulder, leading to brachial plexus paralysis and gradual loss of functionality in the arm and the hand. The arm became hypersensitive and changed color. CRPS wasn't diagnosed until the detection of bone loss. Symptomatic treatment at a pain management clinic and arthrodesis improved the patient's comfort and returned relative independence to her.

Although medicine, as a study of humans and nature, appears to be closer to the humanities, its history shows it has more in common with the sciences. Physicians frequently see the human body as a mechanism. A rather complicated mechanism, but nevertheless one which allows us to specify procedures for pairing symptoms with treatments. The body is so complex that it could work if 99% of its components malfunction and, conversely, die with just 1% damage. Cause-and-effect medicine appears increasingly helpless when our cognitive apparatus identifies

new disease entities. It seems reasonable to suggest refinements to existing medical procedures. There should be a procedure for when there are no more procedures. Let us use another example, of a girl aged 15 diagnosed with antero-inferior subluxation of the glenohumeral (shoulder) joint with muscle weakness of the shoulder girdle. The various treatments prescribed, such as Kirschner wire fixation, all followed existing procedures but, irrespective of the method used, the shoulder always slipped. In effect, the patient was discharged from several hospitals without positive prognosis. Doctors failed to act on the patient's reports of pain, treating it as normal under the circumstances, because procedures which they followed did not anticipate the particular symptoms which occurred. They failed to reach beyond standard procedures to investigate the patient's condition and offer solutions; a state of affairs unfortunately common in an underfunded national health service.
