Surprisingly painful moments

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Why does something as small as a paper cut hurt so much? Gabriel Neal, MD, clinical assistant professor at the Texas A&M College of Medicine, explains why superficial afflictions can cause so much pain.

Episode Transcript

Mary Leigh Meyer: Welcome to Sounds Like Health. This is Mary Leigh Meyer.

Sam Craft: I’m your co-host Sam Craft.

Mary Leigh Meyer: And we are here with Dr. Gabriel Neal. He’s here with us from the Texas A&M College of Medicine. Thanks for joining us today.

Gabriel Neal: Thank you, it’s a pleasure to be here.

Mary Leigh Meyer: Perfect. So, we are going to be talking about superficial injuries.

Sam Craft: Like paper cuts, small burns? Like, “ow, I burned my hand on the coffee cup”. That kind of stuff?

Mary Leigh Meyer: Yeah. Just like those baby little injuries that bother us so much.

Sam Craft: Paper cuts.

Mary Leigh Meyer: And so, we’re calling you Gabe now?

Gabriel Neal: That’s right, you can call me Gabe.

Mary Leigh Meyer: That’s what I hesitated on.

Sam Craft: Dr. Gabe or just?

Mary Leigh Meyer: Doctor.

Gabriel Neal: Outside of the exam room, I would prefer to be just Gabe.

Mary Leigh Meyer: So, we’re here with Gabe and he has become quite the expert on paper cuts.

Gabriel Neal: You write one article on something and you’re the expert.

Mary Leigh Meyer: So, why do paper cuts like that hurt so badly? Why is it just a catastrophe when you get one?

Gabriel Neal: I think there are a number of reasons why paper cuts are the catastrophe that we think of them as. And the first is that they’re usually unexpected. No one intentionally goes and gives themselves a paper cut.

Sam Craft: You’re just folding a letter and all of a sudden slice and it’s like oh, my hands, I just cut my finger off.

Gabriel Neal: Yeah, we’re doing something really easy and something that we’ve mastered, licking an envelope, folding a piece of paper, and it’s usually something kind of even personal like we’re writing that letter to a family member thanking them for that cool thing they did for us and we’re happy and then boom, right, a paper cut happens.

Sam Craft: You’ve blood stained it now.

Gabriel Neal: That’s right. It’s definitely more personal when your blood is on the envelope, at least I think so. However, it may be off-putting to Aunt Sally too. We’re having a good moment and then a paper cut happens and there’s this immediate recognition of injury and we’re kind of pleading with ourselves for a moment to think maybe this didn’t happen, but it did. It hurts and then, throughout the day of course, it continues because these paper cuts happen on an area of our body that’s usually in use a lot like our lips or our fingers. And so, we’re constantly reminded of this injury for the next day or two while it’s healing. And even though it’s this small injury that can easily reapproximate and heal, because of where it’s at, it’s gonna reopen because it’s an active part of our body.

Then there’s kind of this shame…there’s this psychological aspect to the fact that I was doing something easy and that I know how to do that I really mastered. And yet, while I’m doing that, I injured myself. And so there’s a variety of emotions that I think we experience. We get angry at ourselves for doing it and we’re kind of ashamed, like who wants to complain to their colleagues, “guess what I just did?” You’d love to commensurate a little with somebody but you don’t really want to admit “ah I cut myself accidentally folding a piece of paper”. And so, there’s kind of maybe even a shame aspect that we don’t like about it, makes it worse. I think shame makes anything worse. And then there’s this fear, anxiety perhaps that, am I gonna do this again like later today when I’m folding that next stack of envelopes? So, all that together makes paper cuts, I think kind of fun to talk about and a little bit unique.

Sam Craft: I’ve never thought about that in depth of a paper cut before of like shaming myself into a wound. I’ve just never thought that in depth about “oh it’s a little cut,” but when you say all that you just did, it really kind of comes back to you and it’s like how could you do that?

Gabriel Neal: Yeah, well compared to an injury that you can’t wait to tell your family about, right, or your friends or your work injuries. You’re driving your car and a deer runs into you and you smack your head, that’s a good story. Everyone’s gonna be like we’re so happy you’re still alive and you’re so tough. A paper cut…everyone’s gonna be like, “suck it up! Get to work! We don’t want to hear about it!”

Mary Leigh Meyer: Yeah, even, I feel like when I get a paper cut, even I’m like, “okay, I’m being a baby, it doesn’t hurt that badly.”

Sam Craft: It stings though really bad. It’s the littlest thing.

Mary Leigh Meyer: And why does it hurt that badly?

Gabriel Neal: Right. So, the sort of historical answer to this was well, there’s a lot more nerves in your finger, in your lips or wherever these happen and so they hurt more. And as I dug into this and looked at articles going back into the ’50s with punch biopsies and putting slides of skin under a microscope and counting the number of pain fibers in the skin at different points of the body, you do see that the body’s ability to tell how close one point is to another on the body does get better as we get out to our fingers and toes. And so, there is excellent discrimination of pain and heat and cold and injury in our fingers and hands and feet and lips. And that’s all true but that’s not really the whole story.

The reality is that the brain also commits a lot more real estate to interpreting what it’s getting from the periphery as well. I think that’s the cool scientific side of this is that we all know that we can discriminate better at our fingertips, but what we may not realize is that there’s a whole lot of hardware and ram and brainpower built into deciphering and putting that pain on display and analyzing it in our mind. And I think that’s the real amplification is just our brain treats the pain that’s coming from those parts of our body with a lot more high definition than it does from other parts and it’s not just because of the number of nerve fibers. So, that’s the fun part is it actually is in the mind that this amplification is occurring, and it’s very, very high definition.

Sam Craft: That’s interesting. I never knew your brain would delegate more pain to certain parts of your body than other parts of your body.

Gabriel Neal: Right. And so that was the fun part of what I’ve written about is that there’s more to the story than just the number of nerve fibers, it’s the brain part.

Mary Leigh Meyer: Yeah, and that’s probably why sometimes I’ll wake up the next morning with a bruise and I have no idea where it came from, but I would know immediately when I get a paper cut.

Gabriel Neal: Right. And I think it’s worth pointing out that there’s a lot of different types of nerve fibers and we don’t have to go into that ’cause it’s not that exciting, but there are different pain fibers for sensing temperature and pressure and even different kinds of pain. And so, there’s that first instant feeling of pain and that’s one type of nerve fiber. But then there’s other types of nerve fibers that don’t fire quite as soon—it takes them like less than immediately to fire, but they fire longer. And they’re kind of responsible for that throbbing achiness that we get with those paper cuts for hours and hours after they occur.

Sam Craft: They’re so awful.

Gabriel Neal: Yeah.

Mary Leigh Meyer: So, this might be a silly question, but when do you need to do anything about a paper cut? If it’s bleeding, do I need to reach for my antibiotic ointment, or do I need to call my doctor?

Sam Craft: Do you find super glue to glue it back together?

Mary Leigh Meyer: Yeah, is my world ending if I get this paper cut?

Gabriel Neal: Yeah, I dare you to call your doctor about this and say, “I need to see my doctor about this paper cut I have”. Just see what their response is. Most paper cuts do not require a health professional. I think patients who are on blood thinners, which is a lot more common now, might have a paper cut that bleeds significantly. I still don’t think they necessarily have to see a doctor but obviously those kinds of patients might take that question a little more seriously, especially if the bleeding doesn’t stop quickly. So, most paper cuts are superficial enough to where if they bleed at all, they will quickly stop under normal circumstances. And I think that putting a bandage on it makes a lot of sense if it’s bleeding. It also offers some protection from reinjury. If you bump that part of your finger again with a paper cut, it’s gonna hurt and that bandage can just cushion it and that can speed up the healing process. So, I would say feel free, put a bandage on it.

Antibiotic ointment’s never a bad idea. I would also think that most paper cuts wouldn’t require that. My big advice for any wound though is keep it clean and keep it dry. And so, if you get a paper cut, wash your hands. That’s gonna help get any of those bacteria, those bad bacteria that live on our skin—we have good bacteria too just for the record—but the bad bacteria like we’ve heard about streptococcus and staphylococcus that they can get into a wound, even a superficial one.

And if you have diabetes or some other disease that puts your immune system in a little bit compromised state, then it’s really imperative that you wash that part of the body that has the injury. So, wash it with soap and water and keep it dry. And that really wards away nearly any development of infection that might occur with a paper cut or some superficial cut injury. But if you do get a paper cut and you notice that over the course of the day or the next day that the redness is getting worse, if there’s surrounding redness, progressively worsening pain, that would worry me that there is developing a skin infection at that point. There’s more than just a cut then, the bacteria’s found a foothold and it could cause problems. In that case, I think calling your doctor makes a lot of sense.

Mary Leigh Meyer: That’s crazy how something so small can–

Sam Craft: Losing your finger or your hand. You get staph and it’s very possible, it’s terrifying.

Mary Leigh Meyer: So, what’s another type of superficial injury? Maybe sunburn.

Sam Craft: Oh, rug burn! Let’s do rug burn.

Mary Leigh Meyer: Ooh, those are painful.

Sam Craft: Rug burn, surface burn.

Gabriel Neal: Right on. Well I think, thankfully we don’t see the carpet basketball and volleyball courts that I saw when I was in high school back in the ’80s and ’90s. I can remember a lot of horrible rug burns playing in these high school gyms that had carpet flooring. And I’m relieved frankly that those don’t exist really anymore.

Mary Leigh Meyer: I don’t think I realized gyms had carpet flooring.

Gabriel Neal: It was a real thing and when you dove for a ball, you just knew I’m gonna regret this.

Sam Craft: It was like the floor literally is lava like the old game you played when you were a kid, that’s literally what it was.

Mary Leigh Meyer: Even on the hardwood basketball courts, you can still get a–

Sam Craft: There’s a little give but you can still get bruised up or burned.

Mary Leigh Meyer: Lose some skin.

Gabriel Neal: There was nothing like a carpet gymnasium to just skin you alive.

Mary Leigh Meyer: Oh, and I bet that just held infections and held–

Gabriel Neal: Yeah it was a terrible idea. I don’t know how it caught on. I wasn’t there when that happened but I just suffered from that legacy decision. So, carpet burns are similar in depth to a paper cut and so they’re very similar. The downside to a rug burn or any kind of traction, friction-based injury to the skin is that it’s gonna expose a lot greater surface area of our deeper skin tissue than a paper cut is. And so those are far more ripe for infection than I think a paper cut is. The good news on them though is that they’re exposed to the air. You’re not injuring the tissue and then having it recovered by another layer of tissue. And so that, in a sense, protects it in a lot of ways from infection. It’s very easy to keep a rug burn clean and dry. Same trick, you wash it, you dry it, and I think with those kinds of wounds using an antibiotic ointment, at least for the first day or two, makes a lot of sense and covering it with a bandage to keep your clothes clean, number one, but number two, to protect it from getting dirty again makes a lot of sense. So, on rug burns, they’re gonna hurt for all the same reasons that we just talked about with paper cuts but the care of a rug burn usually is a little more because they’re just bigger and there’s a larger surface area involved.

Sam Craft: They’re always more tender too I feel like ’cause there’s a bigger area.

Gabriel Neal: Yeah.

Mary Leigh Meyer: And they’re normally on a knee or some part of the body that you bend. So, what, how do you take care of them if it takes longer than a few days? Sometimes they can feel like they can last forever.

Gabriel Neal: I literally nursed a knee scrape for like two months during soccer season back in 2017. I would re-scrape it during every weekly soccer game, and so I would come home and my kids would comment, “dad, you’re knee’s bleeding again”. I was like “yep, it’s bleeding again. This is part of playing soccer.” So, it didn’t heal until the end of the season, but I kept it clean and dry. I covered it with a bandage and kept it covered. I gave it the time that it needed to heal. You can’t really speed that up.

Mary Leigh Meyer: So, let’s talk about a different kind of burn. How about sunburns? I feel like I’m always a little bit pink surprisingly.

Sam Craft: You’re pretty fair skinned. I bet you burn pretty well.

Mary Leigh Meyer: I could be walking to my car and will come back pink.

Gabriel Neal: You burn under the full moon.

Mary Leigh Meyer: I do. You would be, you’re joking but–

Gabriel Neal: It could happen if you’re out there long enough.

Mary Leigh Meyer: So, what do we do about that?

Gabriel Neal: Well, first avoid it, that’s the main thing. They’re a little more dangerous than the typical other burn because what’s really happening with a sunburn is you’ve got ultraviolet light coming from the sun that is damaging the bonds of our DNA and that disruption of these AT and GNC bonds in our DNA result in miscodes and ultimately lead to skin cancer over time. And so particularly before the age of 24, we know that sunburns really put people at risk for skin cancer later in life. So, I’m a big advocate for making sure that kids get sunblock on because that’s really protecting them. Of course, as an adult, we still need to protect ourselves from that. I’m not saying that you don’t need sunblock when you’re 27.

Sam Craft: Well no, that’s a good point. When you say 24, why is 24 the age? ‘Cause I feel like you’re always in the sun. So is it just as you get older your sun gets more conditioned to–

Gabriel Neal: No. It’s a matter of the skin cells replicating over and over and over again and when you get that DNA damage early in life, there’s enough time for those mistakes and miscodes in the DNA to get replicated often enough to where you end up with a cell that doesn’t know how to die. And when a cell doesn’t know how to die, which is genetically coded into it, it becomes a cancer and that’s the problem is that all of our cells in our body need to know when they’re supposed to die and die at the right time in the right way. And when they don’t, it’s really bad for the rest of our body.

So, sunburns need to be prevented first. But if you get one, I think the key thing is get out of the sun. When you notice and you’re out on the beach and you realize, “I think I’m turning pink.” First thing, get out of the sun. Second is take an anti-inflammatory like ibuprofen. It’s not so much thermal injury to our skin that’s occurring with a sunburn as it is that DNA injury that’s occurring. Our skin recognizes that pretty fast and that’s what’s generating this inflammatory response. So anyway, get out of the sun, take an anti-inflammatory because there’s all this inflammation present in the skin at that point and apply cool cloths. Don’t put ice directly on your skin—that’s not advisable—but a cool, cool cloth to areas of the body to cool it down. It’s gonna be very warm and you can reduce swelling and pain and the symptoms of the sunburn in a way if you didn’t take an anti-inflammatory or didn’t put a cold on it, it would take longer to heal.

So that’s my initial advice and then sometimes we get a first degree burn, which is just where the skin turns red and then it eventually goes away. A second-degree burn is when you’re getting blister formation and those usually pop up in a matter of hours to days after the sunburn. And those, we don’t recommend that you rupture. Leave those blisters alone. Just cover them and try to protect them. If it does rupture, which they often do, then treat it like the rug burn really. It’s a superficial abrasion at that point and it needs to be protected from infection. Keep it clean, keep it dry, keep it covered again. And so that’s what you do. And of course, those second-degree burns can become infected. Like I said earlier, if there’s increasing redness, increasing pain and it’s not just progressively getting better, then that’s the time to see your doctor.

And I would say that if you have a second degree burn that just covers a large portion of your body, if you’re out there and your whole back maybe your front and your legs and your arms and everything has a big bad burn on it, then that would be a time to go see your doctor. You’re probably gonna get very dehydrated. And that’s the other real risk with sunburns is that they promote dehydration because our skin, when it’s healthy and normal, helps preserve our hydration status. And when it’s injured, we lose water out of our body really rapidly. And then we can’t see or even know it’s happening until we’re like wow, I’m really thirsty or I’m feeling light headed or I pass out and then we go to the hospital and you need IV fluids. So those are the times to see the doctor with a sunburn.

Sam Craft: Can you go to a third-degree sunburn?

Gabriel Neal: I suppose but–

Sam Craft: What would be considered a third degree burn?

Gabriel Neal: A third degree burn is when you’re all the way through the dermis into the subcutaneous tissue into the fat tissue below our skin. I don’t think I’ve ever seen a sunburn ever progress to that level. I’m not saying it can’t happen but this is the kind of burn it takes a very high temperature like you put your hand in a fire or you touch the inside of an oven or the leg on the muffler of a motorcycle. These common injuries where you’re touching something that’s incredibly hot that can burn all the way through the skin, through the sub-skin structure into even the muscle, into the nerves, into veins and arteries. It can get really messy with a third degree burn. And that immediately requires emergency care.

Sam Craft: Sunburn’s just surface level?

Gabriel Neal: Yeah sunburns are first- and second-degree burns.

Mary Leigh Meyer: I don’t think I realized the connection between dehydration and sunburns, but it’s so true. Do lotions work or is that just a superficial, temporary relief versus drinking water?

Sam Craft: Aloe vera really cools off my skin.

Gabriel Neal: Yeah, aloe vera’s great and it will hydrate the skin but when you get a sunburn. You just need to aggressively drink fluids, even just sip on that water even more than you would otherwise. If you’re in Cancun and you get a sunburn, the temptation’s gonna be, “I’m thirsty, I’ll have another margarita.” Alcohol is also a driver for dehydration. So, make sure that you’re getting extra water, not just alcohol.

Sam Craft: Well that’s a good point, a lot of people go to the lake, they go out to the pool and they drink, they consume a lot of alcohol. Is that actually affecting you more getting sunburnt?

Gabriel Neal: Yeah, I’m not certain that there’s a connection between being dehydrated and then getting a sunburn. I would just say there is absolutely a connection on getting a sunburn and getting dehydrated. And so, it’s a bad thing to be dehydrated already because of alcohol and then get a bad sunburn. It’s a double whammy. That can land you in the hospital getting IV fluids.

Mary Leigh Meyer: And what are the different SPFs? ‘Cause I heard a rumor that you can only go up so high in SPF or it’s the same effect?

Sam Craft: It’s like 50 or 20, I never know which one to buy. I just buy the highest number.

Gabriel Neal: Yeah, there’s the natural temptation right to just buy that SPF 100. Why not?

Sam Craft: It’s the most powerful, it’s supposed to protect me the most.

Gabriel Neal: Bigger is better, right? When you look at the literature on protection from the ultraviolet A and B radiation, you want to get a sunblock that is for both. So, against UVA and B, that’s really important. There are sunblocks out there that are just A I think. So, make sure it’s for both, number one.

Number two is that really anything above SPF 50 is not adding much protection. In theory, above that is a better block but it’s kind of more than necessary to prevent. More than the strength…so definitely go for above 25 or 30. Aim for the 40’s, the 50’s for really good protection. That’s my advice to patients.

But where we usually miss it is not in buying the right sunscreen. It’s that we go out all day somewhere in the sun, then we apply that sunscreen in the morning and we don’t reapply a few hours later. If you look at the bottle, they’ll say apply after one hour, apply after two hours. Apply every hour. That’s where people make the mistake. They think they’re protected all day and they’re not. Even if the bottle says apply ever four hours, just ignore that and reapply at least every hour, certainly every two because it wears off, it just does.

Mary Leigh Meyer: Or I feel like I’ll apply and then immediately get in the water.

Sam Craft: Washes it off after like–

Gabriel Neal: Yeah, you know, I haven’t seen the research to support the idea that you have to leave it on for like 10 or 15 minutes. I still do that even with my own kids, because again, I don’t want them to get sunburned. But as far as I know, they don’t need to be activated by some certain amount of time. So, I kind of just logically looking at it imagine that it’s probably effective the moment you put it on, but I think giving it 10 to 15 minutes to really soak in and find its spot is a good idea.

Sam Craft: Parenting rules 101, like that.

Mary Leigh Meyer: Well I think that’s all the time we have today. We spoke about the different kind of burns, sunburn, rug burn, carpet burn. We talked about paper cuts. I hope everyone learned a little bit of something.

Sam Craft: I did. I’d never heard sunscreen and sunburns described at a DNA level. I thought that was really interesting.

Gabriel Neal: Yeah.

Mary Leigh Meyer: And these are such minor things that we can get every day that cause so much pain and agony. It’s kind of silly but it’s not.

Gabriel Neal: It’s part of the human experience. I mean if some alien life form showed up and said, “tell us what it’s like to be human.” Suffering would be one of those core elements of our humanity, and this is all part of that spectrum of the human condition. Paper cuts happen to rich people, poor people, all over the world. Burns happen. There’s this universality.

Sam Craft: Ooh, that’s a good word.

Gabriel Neal: I’m not sure that’s real but there’s a universalness to superficial injuries and self-inflicted injuries that I think help define what it means to be human.

Mary Leigh Meyer: Okay well thanks for joining us today Gabe.

Gabriel Neal: Thank you, it’s been a pleasure.

Sam Craft: Yes, great time.

Mary Leigh Meyer: This has been Sounds Like Health, thank you for listening.