I often get asked about my “worst patient” or “most memorable call.” Surprisingly, it’s really not the gory stuff that sticks out. For me, it’s the patients that really make me think – that help me learn.
I’ll never forget my patient that completely reshaped my view of pain. It was 8+ years ago on the ambulance; my partner and I were dispatched for a “spinal injury.” When we got on scene, we found a male in his early 40s wearing a spinal halo. Apparently this man had been in a significant car accident 6 weeks earlier, suffering a spinal cord injury requiring surgical repair, and subsequent placement of a halo.
He had also been dealing with severe pain and resultant opioid dependence which was quickly turning into abuse. His surgeon was aware of this and was closely monitoring his pain medications. The patient had used the last of his pain meds that morning and called the surgeon for a refill. The surgeon, concerned for addiction, denied his request. His concern is legitimate. For the first time ever, in 2013, more Virginians died from prescription overdoses than auto accidents.
It’s important to step aside for a second here and note how a halo actually works. As you can see in the figure, there’s a metal brace that encircles the head, with metal rods pointing inward. These metal rods have screws on the end which literally screw into the skull bone. Desperate for pain medication, he unscrewed the metals rods from his skull, knowing that he would eventually be guaranteed to receive more pain meds. He would need the halo replaced, and it would be unethical to do so without analgesia.
I remember wondering how crazy and addicted this guy must be to do something so extreme to game the system to get what he wants. It wasn’t until about 4 years later after taking Neuroscience in medical school that it finally made sense to me. It was really much more simple that that. I’ll deliberately use the word “discomfort” rather than “pain.” For this man, the discomfort of his addiction was more extreme than the pain of unscrewing metal from ones own skull. In his brain, the screams for opioids drowned out any other pain, any other needs. He had a singular focus. I realized then that whatever addiction discomfort he was experiencing was way outside my own personal context of pain. I vowed never to judge people for their pain again.
On a side note, from an EMS standpoint, the call did present a difficult challenge: How do you stabilize c-spine and safely transport a patient with a known spinal cord injury but with a halo that’s not doing its job and blocks the use of any traditional stabilization devices? We opted to use cravats and boxed 4x4s to fill in the gaps between the halo and the skull, and dedicated one provider to manual in-line stabilization. He was transported to the Tertiary Care Center for Neurosurgical revision of his halo. I don’t know what ever came of his opioid addiction.