Thoughts on chronic pain, modern medicine, alternative medicine, acupuncture, surgery, and anti-depressants

I started Lexapro a week ago. My primary care doc gave me a sample back in March, but I hate taking that kind of thing except as a last resort. On Tuesday, I thought that, well, it’s last resort time, so I looked Lexapro up on the net and learned that it’s for depression and anxiety in the worse-off of the worst-off. I’m not altogether catatonic, but close enough.

I can feel it raising that old familiar floor beneath my emotions that desipramine, Prozac, Wellbutrin, and Zoloft erected, only maybe higher and stronger. “And, lo, the Lord, Lowell’s God, looked upon that floor and saw that it was very good, and he sayeth unto Lowell, ‘Lo, Lowell, this floor, it is very good, but let us maketh it better by raising it higher, even until it is above thy head,’ and Lowell answereth the Lord, Lowell’s God, by saying, ‘Lo, Lord, the same floor cannot be both beneath my feet where it will doeth me good and above my head where it won’t, and the Lord, Lowell’s God, answereth back unto Lowell, ‘Lo, Lowell, all things are possible for the Lord, Lowell’s God,’ to which Lowell sayeth, ‘Oh.’ And the floor was raiseth, and Lowell fell out from under it.”

For most of my life, I had but one doc whom I rarely saw. This year, I’ve had one sleep specialist, three surgeons, two anesthesiologists, countless radiologists, two neurologists, one dermatologist, and one primary care physician. Today, I added a hand specialist (to help break down scar tissue from my carpal tunnel surgery) and an acupuncturist (for my back and shoulders) to my entourage of nurses, aides, phlebotomists, x-ray techs, massage therapists, physical therapists, and lab techs. One of the dominant labels that I now place upon myself is that of patient.

Medical doctors, are, by and large, less than pleasant people. They’re harried, impatient, unreachable except during paid visits, think of me as an assemblage of parts, don’t recognize me when they see me, and have offices that are brown and gray with nothing of solace or beauty except maybe a single print that looks to have been added as an afterthought.

My primary care doctor is somewhat the exception. His office is the worst of all, but he encourages me to talk about any and everything, and he listens good. He is also my only doctor who is not young enough to be my child. In fact, he is my exact age—fifty-nine. He’s a little more wrinkled than I, perhaps, and a lot more stooped. He also shuffles when he walks and has a tremor. You might say that he looks like hell. You might say that he looks like he should be my patient rather than I his, but maybe I flatter myself. In any event, I leave his office with the suspicion that I am better off with my problems than I would be with his.

Alternative practitioners are the opposite of regular doctors. Maybe it’s because they lack the scientific cachet, or maybe it’s because their patients are mostly people who are disenchanted with regular doctors, or maybe it’s just that they all happen to be supremely sensitive spiritual types. Whatever the reason, they are given to hemp clothing and to decorating their offices with Buddhas, waterfalls, potted plants, pastel paints, and rice paper prints—with meditative music in the background.

I go away from doctors’ offices disappointed that my “healer” had no interest in me except for a single joint or organ. When the acupuncturist I saw today tried to draw me out by saying, “You must be really frustrated by all this pain,” I immediately lowered the drawbridge and sent the archers to the castle walls. “What the the hell are you trying to do here?! I thought. “I’ve only known you for fifteen minutes. I’m not going to open up to you.” A while later he said he needed to leave the room for a moment, and I wondered, “Why are you leaving the room? Am I that hard to deal with? Don’t you like me?” It’s not that I’m impossible to please (no, not I), just that I’m ambivalent.

The acupuncturist is my last hope before surgery, so I read all I could about him and about acupuncture in general before I saw him. Almost every scientific study concludes: “Couldn’t come to a firm conclusion. More research needed.” Great. So, I questioned today’s acupuncturist as closely as I could without being obnoxious, and I couldn’t be sure, but I thought that maybe he didn’t like it. The truth is that nobody likes to be challenged. Even if they say they do, they don’t. Even if I try to be really, really tactful, they don’t.

He stuck needles into my lower arms, abdomen and feet. The pain in my right shoulder went from a two to a six (eight being about what it would take to bring tears). He noticed my discomfort, and put a pillow under my upper arm. “Does that help?” “Yes, I feel better now.” “Are you sure?” “Well, maybe you could lower it a little.” He did, and then stood looking at me in earnest silence. Next he put a pillow under my shoulder. “That’s even better,” I said. Then he put a second pillow under my head. “That’s better than when I came in!” I exuded. Night after night, I toss and turn in pain, yet it never occurred to me to use an extra pillow.

I hadn’t paid for moxibustion, but he did moxibustion. I hadn’t paid for magnets, but he put one on my neck and one on my right shoulder. Then he left me while these things did their magic, His potted ficus looked down upon me sympathetically, as if it too were a healer. But will magnets and needles and burning mugwort help? I divide treatments into things that make sense and will probably work, things that don’t make sense but might work anyway, and things that seem too stupid to even consider; and I’m open to the first two categories. Nothing Tom did seemed stupid.

The thing about medical doctors that bothers me most is that they are a lot more interested in treating symptoms than treating causes. In fact, they are often completely uninterested in causes. Maybe this is because they are expected to see several patients per hour. Or maybe it’s because symptoms are obvious, quantifiable, and approachable. Until three years ago, I was in pretty good shape. Then I had knee debridement so that I could hike twelve miles over steep terrain without a knee ache. Thanks to that very simple and very routine surgery, I can no longer walk more than a few blocks without pain, and I’ve gone downhill like a pig on a greased slide. If I were a doctor, I would be curious about that, but even my primary doc just kind of throws up his hands and grabs for his prescription pad. “Depressed about your declining health? How about a nice sample of Lexapro? It’ll do you good. Besides, Forest Pharmaceuticals often buys lunch for my staff and me—not that I would let it influence me any.”

Just as carpenters see every problem as requiring a hammer, surgeons call for a scalpel, so if you don’t want surgery, don’t go to a surgeon. That shoulder surgery (subacromial decompression, which translates into “take the pressure off the area beneath a bone called the acromium”) I cancelled two weeks ago has a four-month recovery period. In other words, the surgeon would injure me so severely that I would need four months, not to recover from the ailment, but from the treatment. Does that sound like anything YOU would jump into? Sure it’s a simple surgery (for the doctor), and sure it’s routine, but then my knee surgery was even more simple and more routine; and because of how IT turned out, I never lose sight of the fact that, if the worst happens, it’s not the doctor who will be screwed. What’s more, the doctor might not even care. Mine certainly didn’t want to be reminded of his failure.

Maybe my primary doctor is right about the brain. Maybe it’s all (or at least mostly) physiological—what goes on in there. It sure looks that way. A stroke, or a head injury, or a pill, can dramatically change a person. I’ve seen it from the inside. When I’m on an anti-depressant, all the dark thoughts that I had are still lurking in the shadows, and they still seem more real somehow than the positive thoughts, yet they have been robbed of their power. It’s as if I’m standing behind a bulletproof window, and can see the darkness coming at me, only it can’t penetrate the glass. Pills don’t make me into a flaming optimist; they just make me indifferent to sadness.

Unfortunately, it’s not just sad thoughts that bounce off the glass, it’s also my ability to be deeply touched by love, art, music, nature, innocence, heroism, and compassion. Poignancy becomes just another word in the dictionary that I can understand but can’t personally relate to. In short, to deaden what I hate about myself, the drug must also deaden what I love most, the two being somehow intertwined. That is why I don’t take the damn stuff unless I’m so screwed up that I become fixated on suicide. In the current circumstances, it’s not that I want to die; it’s that I want the pain to die. Unless you’ve been awakened time after time, night after night, by one of the worst pains you’ve ever had, you won’t know what I’m talking about. When the acupuncturist asked me to describe it, I said that it’s like someone stuck ice picks deep into both shoulders. If the pain were any worse, I would howl like a dog.

I’m reading a mediation book (break through pain by Shinzen Young) about the spiritual growth that is possible with chronic pain. He says that the pain is not the BIG problem; it’s the terror, the outrage, the refusal to accept the pain that’s the BIG problem. Yes, I can see that. Heads or tails. Suicide or saintliness.

I can’t hike because of my knee. Now I can’t bike because of my shoulders. I’ve never much cared for meditation, but at least meditation is something I CAN do. Maybe, for now, I need to accept that life is not NORMAL, and might not be normal for a long, long time, and that, just maybe, something good can come from that.

Sleeplessness

It’s a chilly Labor Day, too soon to start the furnace, but too cold to be comfortable without it. I am wearing both a sweater and a light jacket.

Two weeks ago, I postponed shoulder surgery, partly because I was afraid it either wouldn’t help or leave me worse off, partly because I dreaded the long recuperation (for the first ten weeks, my arm wouldn’t even be able to support its own weight), and partly because I wanted to give physical therapy another month or two. At the time, I showed little progress with therapy, and, to tell the truth, couldn’t actually say but what it was hurting more than it was helping. Since then, I’ve deteriorated greatly—a deep massage plus my reluctance to forego exercise seems to have triggered my decline—and now I don’t dare exercise at all.

Shoulder pain keeps me from sleeping on either side, and now my back is hurting me as much as my shoulders. Since my sleep apnea mask doesn’t allow me to sleep on my stomach, I’m challenged to get any sleep at all. An Ambien, plus an anti-inflammatory, plus Tylenol, plus heating pads and ice packs, enable me to sleep, at most, for a few hours before I awaken in pain. They also make me nauseous. Even if I went ahead and had the surgery, I would feel worse for weeks if not months before I felt better—and that on one side only—and I don’t see how I could bear it.

Of such problems as I have had, sleeplessness is the worst. To be so tired yet be unable to rest engenders a feeling very near panic. Just the thought of lying down fills me with dread although I can scarcely stay awake.

I suppose I will try a chiropractor and maybe an acupuncturist, although I can find little evidence to support them. But then the evidence for surgery is mixed too. My particular surgeon boasts of a 96% success rate (how would he know?), but the average seems to be more on the order of 80%.

I wish to god that I knew what to do. I am finding it hard to direct my actions from moment to moment much less to make major decisions.

Bears, Mountain Lions, and Surgery

The best times to go to the woods are in late spring and early summer when the most flowers are in bloom, and in mid to late summer when the berries are ripe. On our last trip, we dined on raspberries, dewberries, blackberries, thimbleberries, red huckleberries, salal, and even the strange tasting Oregon grape. My favorite, the lush orange salmonberry, was all gone, and I will grieve its loss until next summer. When we go to the woods again (we venture out once a week), we will take berrying buckets and stock our freezer.

The coast range has far more berries than the Cascades, and far more bears to show for it. On our last bike trip before Peggy’s mother died, an adult bear crossed the road 300 feet in front of us. As I grew abreast of the spot, a movement caught my eye, and I spied its cub frantically climbing a small tree no more than ten feet away. “Oh, look at the little baby bear,” I cooed to Peggy—who had not seen it. She made no response, and when I looked back at where she had been, she was disappearing down the mountain in a cloud of dust, and I was unable to catch up with her for quite some time. When I finally did, I said simply, “You were going for help, I suppose,” knowing full well that Peggy had considered it a case of every man, woman, and dog for itself—her being powerfully afraid of bears. My only terror is of mountain lions, and I worry mostly about our dogs because the question in my mind is not whether a mountain lion would eat them, but why wouldn’t a mountain lion eat them.

Peggy took a spill last weekend, and came away with some bruises and road burns. Logging roads are often paved with poorly packed rocks of uneven size, so it is not unusual for our wheels to be thrown several inches to the side. No one can bike in such places without an occasional wreck.

I am scheduled for rotator cuff surgery toward the end of the month. I can hardly sleep for fear, only fear is too weak a word. I try to calm myself by reciting poetry, but I can scarcely focus long enough to get through a single verse. My days are less terrible than my nights only because I can at least distract myself with work, even if I am so panicked that I make one stupid mistake after another. One might think that with all the surgeries I’ve had, I would handle myself better, but the reverse is true. Even when I have confidence in my surgeon, I have no confidence in my luck. It’s not that I consider myself unlucky, but that so much can go wrong, and so much of what can go wrong can never be made right. How many times have I wished I could have screamed “Don’t do it!” at myself as I walked to the hospital for knee surgery, even that short walk being longer than most of the ones I have made in the years since. My intention was to prolong my hiking years, not to end them altogether. Now I can but bike, and I won’t even be able to do that for four months after my next surgery. I won’t be allowed to so much as lift my arm for six weeks, and nothing more than my arm for another month.

Some might interpret my terror as a premonition, but I have little to no faith in premonitions. What I do have faith in is my ability to made prudent decisions, but no matter how prudent I try to be, there is always uncertainty, and there is always the possibility that I will learn something after the fact that would have led me to choose differently. Oddly enough, the more fearful I become, the harder it would be for me to back out of surgery in the absence of a really good reason to do so.

I have spent hours combing the Internet for alternative treatments, but the trouble with alternative treatments is that they are seldom supported by hard data. I can find study after study about surgery, but no studies whatsoever about Rolfing, Tragering, acupuncture, chiropractic, and so forth. If they could but offer me some reason to believe in them (other than their own authority and the anonymous testimonials of their patients), I would jump at the chance. Yes, medical doctors sometimes kill their patients whereas homoeopathists never do; and, yes, medical doctors are glorified parts’ technicians whereas alternative therapists treat the whole person. But I see no other option. I can have surgery now, or I can have surgery later. Or—as I’m told—I can have surgery now, and still have surgery later since an enlarged tendon can’t be reduced. The most that a surgeon can do is to remove some of the risk factors that might lead to a tear.

Friendship's End

(This entry contains slang sexual references.)

Mark and I got together a lot until we both moved to other parts of the country, and didn’t see one another for twenty-five years. What follows is the post mortem of our friendship, not that I am in a position--a month after it ended--to fully understand what happened, or to know if I might have done better.


I wrote:
You wrote that you seldom use your Frequent Flyer mileage. Maybe we could cut a deal.


Mark wrote:
Now when did you start needing somebody like me to foot your travel? Get online, find some rich ole horny woman to fly you wherever you want to go! You still throw down don’t you? That’s my plan when I get to be your age.


I wrote:
If I had something I didn’t want, and you did want it, I would either give it to you or sell it to you. Such is what I had in mind. Why would you throw something away rather than to let someone else have it?


Mark wrote:
I’m just busting your chops. I’m just trying to accumulate enough to get platinum status. That’s when the perks really kick in...


I wrote:
Busting my chops? Yes, the image of being hit in the mouth fits.

Several weeks ago, I suggested accompanying you on one of your foreign trips, if you would have time away from work for me. This was a significant way for me to reach out to you as I rarely leave the county much less the country. My image was of us having fun together while broadening our intellectual horizons and renewing our face-to-face friendship. Your response was to ask why should you want to go with me when you could go with your latest piece of ass.

I was reminded of the time I drove to Missouri to see a friend who had moved there from Mississippi. As it turned out, he had no time for me because he had a new honey. When I complained, he assured me that he liked me, but that, after all, why would he want to be with someone who looked like me when he could be with someone who looked like her.

I concluded that you are of the same mind, that a male friend is only of value as a diversion when you are between females. I gave up any thought of ever going out of my way to see you, and I questioned whether it was even worthwhile to write to someone who holds me—as a male—in so little esteem.

You wrote that you DIDN’T use your frequent flyer miles because they were too much hassle. Peggy and I go out of our way to accumulate such miles, and she, at least, uses them to visit her family. When I suggested that you either sell or give them to us, you implied that I’m a freeloader. When I asked why you preferred to throw away something you didn't use as opposed to letting someone else use it, you said that you DO use your frequent flyer miles. Why?


Mark wrote:
Well, there is an unwritten rule among men that opportunities to get laid have to be observed, so I can completely understand if a friend wants to spend time with his woman vs. time with his male friends. As far as male friends, they are nice, we get together once a month to drink beer and yak, but I spend probably 10 times more time with my female friends. So yeah, I guess I am of the same mind in some regards.

So what have you got against just going out and buy a plane ticket like 95% of people who fly? You aren’t the one putting up with the bullshit security, cramped seats, crappy food, delays, cancellations, lost luggage, etc... so the one little perk I do have is an opportunity to upgrade with the miles I do have. Once I get platinum status life only gets better, and you want me to give that up? *ahem*...


I wrote:
“I guess I am of the same mind…”

This is very sad for me to know, and strikes me as an awfully shallow way to live. If you should ever reach a point in your life at which you value friendship over orgasms, I’ll be here.


Mark wrote:
Okay, shallow and laid, or intellectual and unlaid... that is the question... it might help to explain why there aren’t many intellectual people out there.


I wrote:
“Okay, shallow and laid, or intellectual and unlaid... that is the question...”

No, that is not the question. The question has nothing to do with how much a man knows about any number of particular subjects. The question is one of values, of character. No one can be friends with a drug addict because a drug addict will betray him. Women are your drug. You say you are of “the same mind” as Carlos, the man I visited in Missouri. Carlos was excited about my visit until he found a girlfriend. By saying that you are of “the same mind,” you are telling me that I am of no more importance to you than I was to him. You are telling me that you are willing to betray a male friend in a heartbeat, and not even because you LOVE a particular woman, but simply to get inside her pussy. A male is nothing to you; a female is something to masturbate into. Since you are of “the same mind” as Carlos, what happened to me when I visited him might just as easily happen to me if I visited you. Aside from the frequent flyer mileage and which time you were being dishonest (whether you don’t use it or whether you value it highly as a recompense for all your airline related suffering), you are telling me that, as a male, I should accept my unimportance to you as an “unwritten rule.”

You called me one night several years ago, and called me brother. That meant a great deal to me, maybe the moreso because the only brother I ever had was a half brother who chose not to have any relationship with me. I imagined that it meant a great deal to you too. Now you tell me that you are no better than a man who, if a slab of pussy was on one side of a balance scale and a longtime friend on the other, he would grab the pussy.

At 59, my lust for women has diminished greatly. Things about them that drove me crazy years ago now strike me as empty or even silly. Hormones clouded my view. They made that which was of little rational importance appear to have paramount importance. I can well understand why I betrayed Peggy (just as I can understand why you would betray your male friends). Lust can feel as urgent to extinguish as having your hair on fire. Peggy could never understand its power over my life. I can understand its power over your life. However, I can also tell you in complete sincerity that lust caused me to value the trifling over the profound. It caused me to betray a good woman for a string of sluts, and it caused me count my male friendships as less interesting, profound, and important than my female friendships (i.e. my latest piece of ass). Now, I don’t miss any of those women, but I miss my male friends (some of whom are dead) terribly. True friendship is of infinitely greater value than pussy; and male-to-male friendships are, at their best, of greater value than male-to-female friendships, because women will ever be like an alien species to us.

I have often been impressed by your empathy and compassion toward suffering animals, and I know that these virtues are permanent whereas your lust for women is largely hormonal and therefore temporary. Yet, for now, you have told me straight-out that you place little value on our friendship. What would you have me do with that information? I could hang around hoping that you don’t mean it, but I have found that people generally do mean what they say when they are telling me something that they know I won’t like hearing. Or, I could say that it’s okay that you don’t value me, but that would mean that I don’t value myself. My other option would be to think of you as someone who I also hold in little value, but we go back too far—and were once, I thought, too close—for that. While you were never my best friend, you were my good friend, and I imagined that you valued me similarly. Ironically, if I had never made a move toward becoming closer to you—by visiting—none of this would have come up, and I would have been left thinking that you valued me more than you do.

Short Rants, Etc.

Today's rants.

Littering
…is an ironic activity. I would have thought that people who litter are neat-freaks who can’t stand to carry trash around in their cars, but what I have observed is that litterbugs are pigs whose cars look like (what else?) a pigsty.

Capital punishment
…I’ve fixed three flats in three weeks on three of our four bikes. A lot of flats are caused by broken bottles, and a lot of bottles are broken on purpose, some of them on bike paths. It is the kind of thing that makes me favor capital punishment. I’ve never understood why capital punishment is reserved only for big things instead of things that are senseless—like breaking bottles on bike paths. Let’s say a woman kills her husband. He beat her for years, and one day she exploded, and blew the s.o.b. away while he was taking a nap. I could understand that. I could have sympathy for that. I could cut her a break for that—just so long as she didn’t litter.

Feelings
…I imagine that my feelings—or at least my emotions—run deeper than those of most people. I try to hide this, because to feel so intensely looks weak if not unstable. Maybe I am weak, and maybe I am unstable, but that’s beside the point. Besides, maybe I’m neither weak nor unstable; maybe I’m strong; but again, I’m talking about how I want to appear, although it’s hard to defend wanting to appear to be other than I am, especially considering that I usually have so little respect for those people whose respect I seek.

I’ll give an example of the kind of feeling I’m talking about. I cry when I hear Jimi Hendrix. I do this because he could make a guitar come alive like no one else, and because his life was tragic and ended when he was twenty-six. Sometimes, I even cry over a comedian if the comedian is really good. It’s not just sadness that gets me; it’s excellence. Only, as I see it, excellence is sad because its over in the flash that we call life, and because to be excellent in our society—maybe in any society—is like smelling good in a pigsty.

Damn cars
…A car nearly hit me today while I was on my bicycle. This happens rather often, partly because the law doesn’t require that cars maintain a minimum distance when passing. Such a bill was introduced, but the cops argued that it would be hard to enforce, and the truckers insisted that maintaining any required distance would be a hardship. Think about that. On one side of the scale was life, and on the other was convenience, and our lawmakers chose convenience.

Despite my worthlessness to legislators, I don’t think I should have to play Russian roulette every time I exercise my legal right to ride a bicycle. Furthermore, I should like it very much if the man who nearly ran me down today had to put his life in the hands of hundreds of harried, negligent, and even hostile strangers every time he runs an errand. I don’t think he would appreciate being passed that close, even if he were in his car surrounded by metal and protected by air bags and seat belts. Maybe he felt confident that he wouldn’t hit me, but no one’s skill or judgment is infallible, and it wasn’t him who would die.

Suicidal authors
…Having finished one biography of, and more than one book by, Robert E. Howard, author of the Conan series, I’ve gone on to one biography of, and more than one book by, Hunter Thompson, author of Fear and Loathing in Las Vegas. Both authors were messed-up people who shot themselves in the head—Howard with a .380 when he was thirty, and Thompson with a .45 when he was sixty-seven (I was surprised to learn that even a .380 can go all the way through a man’s head, but that’s another matter). So, one wonders, why did Thompson hold out for twice as long? Well, he—by implication—attributed his survival to illegal drugs. Howard didn’t do drugs—probably no one did drugs in Cross Plains, Texas, in the ‘20s and ‘30s—although he did get a little drunk with his friends from time to time. I’m also reading a book about the Beat writers, most of whom were also crazy, and most of whom also did lots of drugs and were incredibly self-destructive even when they didn’t out-and-out kill themselves.

I wouldn’t want it to be thought that I am only interested in insane-addict-suicidal-writers, although such qualities are a recommendation. The truth is that an insane society defines as sane those who mirror its insanity. This means that a certifiably sane person is unlikely to write much if anything that is arresting or original. Of course, many of the certifiably insane might really BE insane, and therefore have only gibberish to contribute, yet the insane are what I’m left with after having defined society as insane and those who adapt to society as equally insane.

Health
…I just came from an appointment with my shoulder orthopedist. He seemed much nicer today in little ways like shaking my hand and showing an interest in my condition, rather than not shaking my hand and sitting just inside the doorway looking bored. The reason for the change appeared to be the pretty young medical student who accompanied him. He gave me a steroid shot in my left shoulder when I last saw him, and told me to come back for one in my right if it helped. It did, and that’s why I was there, yet he declined to give me another shot for no apparent reasons than that no one told him that was why I was there, and he was running late, and he had a sweet young thing with a clipboard following him. He advised me to come back another day if I really thought I needed a shot, and I told him that I was there on this day for that very reason. Still, he demurred, and I left feeling mad at myself because I hadn’t insisted. The fact is that I need him more than he needs me, him being one of the few shoulder specialists in Eugene.

I don’t sleep well on either side or even on my stomach due to pain in my shoulders, and I don’t sleep well on my back because it too hurts by day and by night, but especially by night. I am tired of living with pain, but I don’t see an end to it. Everything I do to help myself either serves as a temporary fix or makes matters worse. My groin still hurts despite hernia surgery in early spring, and my wrist still hurts despite carpal tunnel surgery in late spring. Then there is the arthritic and chondromalacial pain in my left knee, tendon pain in both shoulders, fingers chilled by Raynaud’s; at least three sleep disorders; and, as of last winter, chronic back pain.

I imagine that I must surely be doing something wrong to cause all this pain, but I don’t know what to do differently. Some people say that I am simply getting old, but if the level of pain I am experiencing at 59 is normal and will increase, I don’t see why anyone would even want to reach seventy.

My challenge is to keep a positive outlook, because continuing as I am is unthinkable. Until my knee surgery three years ago, I was strong as a horse. Now, I feel like an old man who must be careful lest he further injure himself.