In the shadow of the opioid epidemic, how should we care for patients in pain? Reflections after breaking my neck.

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Kate Pendlebury shares her experience in trying to get treatment for pain after breaking her neck. (Photo by Ryan Loew/PublicSource)

I broke my neck four months ago. I fell in my backyard and landed on my head, fracturing my first cervical vertebra in three places and dislocating my first and second vertebrae. Within 24 hours, those vertebrae were fused with surgical screws, rods and spacers, and I woke to a series of frightening, disturbing — and probably entirely typical — hospital encounters. 

To friends, I’ve described my post-surgical hospital care as characterized by “pain mismanagement” — but I don’t think my experience was either unusual or against any rules of in-patient care. Rather, I suspect, it was the result of an attitude that is embedded in for-profit medicine and enhanced by institutionalized suspicion of patients’ accounts of their pain. 

I’ve found myself pondering what it is that drives the scorn many of us notice in medical personnel when it comes to pain care: is it narcophobia, understandably driven by the opioid epidemic, but inappropriately applied? Or is it a dimension of the objectification that is necessary to a model of care driven by profit? During my in-patient recovery, I was in too much pain to contemplate either question, but I was very aware that almost every request I made for adequate pain care was met with disdain — or simply ignored.

Exhibit A: ICU

After surgery, I surface into pain that slowly intensifies until it seems almost too great to vocalize. The only way to grab the attention of my nurse is to press the call button provided for the purpose. Simple, right? But the system depends on the nurse’s availability, interest in responding and ability to do something about the pain. The nurse will have to summon the doctor, interrupting both parties’ schedules and disrupting the routine of the ward. 

I am under the care of two nurses: the first of whom is prompt, cheerful and ineffective; the second of whom is slow to respond and ineffective. By the time the second nurse comes on duty, the surgical anesthesia has worn off and my best attempts at communication are creaks and grunts. On the rare occasion that the nurse responds to the call button, she mumbles indifferently that there is nothing she can do for my pain. My prescription is cast; she will not call the doctor. If the meds are not working, it is the patient who is recalcitrant.

Exhibit B: Reprieve

Happily, physicians have rounds. And when my neurosurgeon rounds, he doesn’t hesitate to inject a single dose of an unfamiliar and powerful anti-inflammatory. I have a respite. But the nurse on duty is irked by the fact that the injection was not preceded by an “order” — presumably, a bureaucratic hurdle designed to protect healthcare facilities and insurers at the expense of patients. I begin to suspect that nursing staff have been discouraged from calling doctors on duty — if not explicitly, then by the redundant labor required for changes in procedure.

Exhibit C: Voices

The anti-inflammatory has worn off, and I drift through degrees of pain. Once, near max intensity, I press the call button. Nobody comes, and when I press again, nobody comes. Perhaps they think I am faking it, gunning for drugs. I can hear talking nearby and laughter. “Help!” I call, and the voices cease.

Exhibit D: Headache

The most debilitating feature of my pain is the headache: a dense thing burning behind my eye. The headache is a sly creature. At times, it corresponds to the pain in my neck — but then it eases when the neck pain surges; surges when the neck pain eases. On my back, the headache pools behind my face. When I turn and heave to sit up, it disperses for a moment as the pain in my neck redoubles. 

One of the three painkillers I am now on reduces the pain in my neck; none make a dent in the headache. I ask repeatedly and fruitlessly to try an alternative; to speak to a doctor; to be, at least, acknowledged.

Finally, the resident on duty appears during a conscious hour. He is baffled by the headache — as if one has never before visited the neurosurgery ward. I mention that once before my accident I had a positional headache, and this information is suddenly and inexplicably translated into a “previous migraine diagnosis.” It appears my headache is unconnected to my surgery, my broken vertebrae and the fact that I have recently fallen hard on my head. I shall have to tackle my “migraines” after discharge, for the neurosurgery ward does not traffic in headaches. 

Kate Pendlebury recounts the troubling experience she had getting pain treatment after breaking her neck. (Photo by Ryan Loew/PublicSource)

Exhibit E: Ice

I push the call button and eventually an assistant appears. I know I am not scheduled for a painkiller, and I am coming to believe that my requests are reducing the nurses’ already strained compassion, but I am desperate. The assistant offers an ice pack; I agree and he disappears. He returns half-an-hour later with the ice, just as the nurse is arriving with my scheduled painkiller.

Interpretation: The Pain Scale

Pain is tricky: personal, difficult to explain and easy to diminish or ignore if it’s not one’s own — especially if its owner can be deemed unreliable. The Numeric Pain Rating Scale, though it has demonstrated internal reliability, offers no objectivity and little guidance for care staff. If my heart rate exceeds a certain number, a doctor will most certainly be called; not so if I rate my pain a “10.” Alternative pain scales offer greater sensitivity to the quality of the pain, but they take more time, and so cost more, and are seldom used. 

Effective pain management aids healing and prevents future pain. But when pain must wait for paper, pain control is thwarted. Perhaps bureaucracy helps to prevent medication abuse — but then why were the nurses stonewalling me when the most effective and appropriate drug wasn’t even addictive? 

As a white person, my experiences of normalized medical maltreatment were relatively benign. It is well-documented that Black patients’ pain is systematically neglected, discredited and mythologized in the United States. Pain management is an issue of equity — and an area in desperate need of reform.  Perhaps the answer would be to rebalance the pain scale, legitimize patient experience and transform a medical system into one that refuses to objectify patients in its drive for profits. 

Kate Pendlebury is a South African who has been living in Pittsburgh for twelve-and-a-half years. Kate describes herself a casualty of the gender disparities in the workforce brought, not by COVID-19, but by the absence of a meaningful system of social welfare. She has recounted the accident that broke her neck at her infrequently updated blog, The Wordsmithery. She can be reached at kate@pittsburghwordsmith.com.

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