The patient who helped me understand that I really don’t understand pain

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.

2103_image
Spinal halo traction device

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.

~Steph

One thought on “The patient who helped me understand that I really don’t understand pain”

  1. Steph! Love the journaling! I’m always intrigued by the trauma and brutality of life that you encounter. I’m taking a creative writing class, so I used your story as inspiration for one of my own this morning. This is a first draft, so it’s a little rough 🙂 but I thought you might enjoy…

    Discomfort

    “Oh man, I’ve been dreaming about these pumpkin pancakes all week.” Stephanie says as she drops her fork onto the plate that the raspy voiced waitress just set in front of her. The handle landing in the fresh and fluffy mound of whipped cream.
    Her partner hops in the driver seat, Stephanie climbs quickly into the passenger side and they speed off towards 3469 Pinehurst Valley Road.

    The first thing to hit them is the smell. Cat piss has a special ability to churn an empty stomach just so. They ought to be used to it by now. They’ve found that many of the houses they visit that look tidy on the outside are often cluttered with empty fast food wrappers and soiled by neglected pets on the inside. This house, though, is actually quite nice inside, it’s just excruciatingly apparent that there are too many cats and not enough litter boxes. The purpose of their visit is easy to spot. They can see his doughy body from the doorway splayed out on the floor like a gingham picnic blanket and what look like child size ski poles tangled next to him. His red checks are a bit morbid, however. Blood has leaked down to his chin. He’s been lying here long enough for the blood to have become crusty in his right eyebrow.

    “Please help me.” He says towards the ceiling.
    “Absolutely. We are here to help you, sir. Did you fall?” asks Stephanie’s partner.
    “Yes and it made this god damned contraption come loose.” to the ceiling again.
    The screwdriver and pliers lying nearby suggest a different version of what is happening on this cupcake icing colored mauve carpeting.
    “Sir, lie very still. We are going to safely and securely get you to the hospital.” Stephanie assures.
    “I need something for the pain.” He says.
    “Sir, we’ve been instructed not to administer any analgesics, but to transport you to the Tertiary Care Center where they can assess how to best help you.” says Stephanie. Her voice is respectful, but carries just a hint of admonishment.

    “Well fuck you and fuck your mother!” He yells back and then moans. The force of yelling causes his jaw to holler back at him in pain as it jostles his now insecure skull.
    “Please leave my mother out of this.” says Stephanie. “Sir, we are looking out for your best interests.”

    “How do you know what my best interests are? You and that fucking asshole quack Dr Pastel. I was in a god damned car accident. My car is in the recycling bin and I have a mother fucking spinal injury. Don’t tell me about my best interests.”

    “Sir, please calm down. You are only making this worse for yourself.” says Stephanie’s partner.

    “Worse!? Is that a joke? There is no ‘worse’ possible. This is as bad as it gets, my boy. I can’t walk. I can’t fucking tie my shoes. I can’t even look down and see my own dick. And the two of you…in your white pants…and Dr Pastel…that short little know nothing… want to tell me I’m not in mother fucking pain!”

    Stephanie and her partner share a look that says “let’s just ignore this guy and do what we gotta do.”

    They soon decide that the best way to transport his broken body is to use cravats and boxed 4x4s to fill in the gaps between the halo and the skull, and dedicate one provider to manual in-line stabilization.

    As they turn the last corner of the twenty minute ride to deliver their patient, he looks up and into Stephanie’s face.
    “You have the most amazing eyes. But I guess people probably always tell you that. Anyways, I’m sorry for being such a dick. I’m just in so much pain” He says.

    “Thank you. And I want you to know I really am sorry that you are so uncomfortable.” She responds.

    “With all due respect, pretty eyes, I’m not uncomfortable. I’m in pain. Agonizing pain that feels like bamboo shoots being driven under my finger nails, pain that smells like meat rotting in the bottom of the garbage can, pain that tastes like sucking on aspirin, pain that sounds like a class full of kindergarteners playing the recorder all at once. You may not have to help me get rid of this pain. But please don’t insult me by not calling it what it is.”

    “I’m sorry you are in pain, sir.” Stephanie says before opening the back doors so this man and his pain can be exited from their wagon.

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