Exploration of treatment journey contains important lessons for health-care providers
By Nicholas Stinson
September 18, 2023
Getting hit by a car is not what you would expect. If TV and movies are to be believed, you roll off the car, land on the ground, dust yourself off, and walk away. Unfortunately, not everyone can take an impact like a stunt actor. According to Transport Canada (2021), over 31,000 pedestrians on average are involved in motor vehicle collisions annually.
In early November 2022, I was one of them.
I was hit by a car and, instantly, my left tibia experienced a compound fracture and my left fibula was broken in several places. After the impact, I landed on my left side. When I tried to get up and walk it off, as I had seen in movies, I couldn’t; I was in extreme pain and only had one good leg. Lying on the road as people began to surround me, all I could think of was the blinding pain and how I had just lost the next few months of my life. I could see the classroom where I was about to write the last final examination of my nursing degree. The paramedics tried to get intravenous access to both arms, but I was in shock and pain, so I could not feel what they were doing nor be of any help. They ran out of IVs after two attempts and gave up. All the while, they were lamenting a shortage in supplies that led to my leg being stabilized partially by two teddy bears, which they normally use to help keep children calm.
I arrived at the regional hospital, where I improved venous access by wrapping my arm in a heated blanket and dangling it off the stretcher. I finally received my first injection of fentanyl. It did not provide enough pain relief but was better than being unmedicated. In the next four hours, I had called my loved ones, had coordinated my belonging and commitments, was sedated for a closed reduction, was joined by my parents and partner, and was back on the same ambulance to the nearest hospital with an orthopedics department. Due to overcrowding, I was not immediately admited, so the paramedics cared for me for two hours. Eventually, they had to leave, so they gave me a final dose of fentanyl and asked if they could have one of the teddy bears back. I was later admitted to the orthopedic medicine unit that I had been placed in while a student. This coincidence would later prove beneficial.
By 14 hours post-collision, I had had a VIP tour of the operating room (OR), a comforting gift of midazolam, the anticipation of a restful propofol sleep, and the promise that my leg would be straightened out by the time I woke up. Two hours later — drenched in a cold sweat, frigid, lying in a bright room, extremely sore, and with an external fixation device through my heel connected to my tibia — the nurse asked me to please stop anxiously fidgeting with my oxygen saturation probe. I apologized profusely and desperately tried to assess how the surgery went with my groggy nursing school brain. The procedure went well by my evaluation.
Ten days later, including two days in the hospital and a 22nd birthday, I was back in the OR. This time, the anticipation of relief was of someone who ran out of hydromorphone two days before and could no longer stand the tuning forks drilled into their bones. The anesthetist looked at me like a collection of blood vessels waiting to be poked. The nurses started the “drift to sleep” conversation too early: the conversation came to a lull, and I was filled with 10 seconds of quiet panic before I finally drifted off to sleep. I woke two hours later, blinded by pain. I was covered by a Bair Hugger warming unit and wrapped in a cast, both of which helped reduce my anxiety. I once again asked about the procedure: no rods because of vertical hairline fractures, one plate, eight screws, bone grafting on the fibula, and 47 staples.
I was shortly brought back to the orthopedics unit in time for lunch. I was projected to be five days in the hospital but was out the following afternoon. Over the next 12 weeks, my regular cast was replaced with an Aircast device, I would be partially then fully weight bearing, and I would be walking.
This article is a reflection on and insight into my experience recovering from a motor vehicle collision. I examine my journey through a community and population health lens as both a fourth-year nursing student and a patient. I explore pain, both physical and mental; access to care and resources; and the social and physical burdens of recovery. I describe my first-hand economic, social and health-care experiences as a patient in contrast to my education and nursing experience. I hope that by reading my story and considering my observations and suggestions, you might take something away that informs your own practice as a nurse.
The cost of pain relief
I found that at every instance of pain there was a cost to pain relief. Relieving pain requires a constant balancing of suitability, side effects and access.
Fentanyl detached me from pain rather than strictly reducing it and helped reduce my body’s other pain-related symptoms (e.g., nausea, chills and shock). The drug lasted only a short time and its sensation is difficult to describe. It created distress through the cognitive dissonance I experienced from knowing I had pain but feeling disconnected from it.I was given fentanyl only by the paramedics, who gave as much as possible to keep my pain under 5/10. My pain never dropped below 4/10 (or a constant hard kick in the shin).
Hydromorphone was the analgesic of choice in the hospital. This drug caused a “disconnect” between cognition and speech, leading to an inability to voice my feelings or emotions without being perceived by my family and friends as incapacitated. Constipation and brain fog were omnipresent. I feared running out of my allotment of this drug and the pain returning, and I feared developing an addiction. There was moderate to strong pain relief from hydromorphone with regular dosing as an adjunct to ketorolac.
Ketorolac gave strong pain relief at the cost of losing its effects two hours before the next dose. I experienced significant gastrointestinal adverse effects while on ketorolac. The fear of pain after the supply ran out was like that of the hydromorphone.
Ibuprofen was like taking a quarter of a ketorolac dose with all the same symptoms.
Acetylsalicylic acid (ASA), which was given to reduce the risk of clotting post-operatively, gave a mild to intermediate boost in pain relief but was discontinued due to the risk of bleeding. All nonsteroidal anti-inflammatory drugs (NSAIDs) were discontinued by the surgeon three weeks postsurgery, citing chronic use as a barrier to healing.
Acetaminophen gave mild pain relief, especially in conjunction with hydromorphone, ketorolac or ibuprofen.
Propofol, given all three times I was sedated, provided the most desired pain relief in the form of painless, deep sleep. When no analgesia would reduce my pain, I craved the relief of sleep. Midazolam reduced the anxiety associated with pain and procedures. Zopiclone was an effective treatment for insomnia and therefore relieved me of the emotional distress and physical pain that kept me up. However, it was less effective the more I used it and, following a long stint of use, resulted in more insomnia. For propofol, midazolam and zopiclone, I received pain relief at the cost of consciousness and control.
As for non-pharmaceutical interventions, heat to the leg brought moderate pain relief but required me to be stationary. Leg elevation reduced swelling and pain and improved healing but also required me to be stationary. Mobilization reduced pain mildly if elevated, but increased swelling if not elevated. Interaction with loved ones, which was a welcome distraction, and the regaining of autonomy and capacity significantly reduced pain but were not always possible.
Throughout this experience, I recorded the ideal treatment for pain based on my experiences of and desperation for pain relief. Here is a list of attributes you can consider:
- Significantly reduces pain
- Maintains cognitive capacity
- Maintains physical capacity
- Maintains alertness
- Affects only the targeted area
- Causes manageable or negligible adverse side effects
- Has a wide therapeutic window (i.e., large dose range)
- Is long acting
This list can serve as a framework for health-care providers in the treatment of patients experiencing pain.
Pain control in the hospital
Having your recovery and pain lie in the hands of someone else is frightening. When I was a student, I had completed two clinical rotations on the same orthopedics unit at which I was being treated, so I understood the schedule and routine. Nevertheless, waiting for a clinician to administer analgesia was exhausting.
In nursing school, I was taught to care unconditionally; in the hospital, I felt my care was dependent on a relationship. Whether this perception was unfounded or if there were nurses treating patients conditionally, the following question arises: Why burden a patient by having them rely on someone else for care that can be completed autonomously? When the surgeon visited me in the hospital one day after my second surgery, he asked me if I felt ready to go home. I gave him a resounding yes, was evaluated by physical and occupational therapists, coordinated my ride home, received a discharge plan from my nurse, and took a wheelchair to the entrance.
When I left the hospital, I was perfectly capable of managing my own pain with oral analgesics. As soon as I was home, in my own bed and in charge of my own care, my confidence in healing and recovery increased significantly. Considering my experience in the hospital, as well as the risk of hospital-acquired infections, I believe the following question is necessary for health-care providers to consistently reflect on with each individual patient: Is the hospital the best place for the patient?
Post-traumatic stress disorder
In my experience, post-traumatic stress disorder is depicted surprisingly well in film and on TV. (But why does everything I watch since the accident portray someone getting hit by a vehicle?) Characters see something that reminds them of the incident, the character freezes, and the scene cuts to a flashback of the event. The traumatizing experience stays present in both the mind of the character and the plot while causing ongoing mental anguish.
In my case, little reminders of the traumatic event, such as a crosswalk or a black car in the oncoming lane, are striking. When encountering such mundane things, I frequently freeze in fear and experience a vibrant and immersive replay of the collision; sometimes, my adrenaline kicks in and I can hear the collision and smell the distinctive odours from that day.
When I was younger, a health-care provider explained the pain scale as 1 being no pain and 10 being hit by a car. It is an exceptional coincidence and, with my collision now being considered the worst pain I could have, I am reminded of the incident every time I must rate my pain. Another example of persistent triggers were the seemingly constant back and forth with the insurance company, and the flood of other emails I had to deal with. It was exhausting. I have found intensive psychological therapy to be the most effective tool for managing the post-traumatic stress reaction.
Loss of control
Another important function of psychological therapy has been reframing my relationship with loss, specifically the loss of control. Lying alone on the cold asphalt, my thoughts were shrouded by things I no longer had control over. I could not walk, I could not control my pain, I could not feel warm, I could not get something to drink, I would not be able to drive, I would miss major school events, and I would miss my clinical placement.
Both on the asphalt and in the early stages of my recovery, it was hard to see what I could control, if anything. As I progressed further and further through my recovery, I was able to identify little things I could control. I worked hard to see that although I could not walk, I was getting better at using crutches, and although I could not visit my friends, I could keep in touch when and how I liked. I had hope. Being able to reframe and reduce my feelings of loss improved my health. I was able to sleep better, my appetite increased, I experienced less pain, my skin stopped breaking down, my swelling decreased, and I regained my energy. Reframing loss and finding hope were critical to the speed and quality of my recovery.
My level of health literacy positively changed my health-care experience. Completing two clinical rotations on the same orthopedics unit and sitting in on a surgery with the same surgeon who performed my surgeries maximized my understanding of the care I was receiving. For example, with the knowledge that a prolonged hospital stay increases the risk of infections, I knew I could ask for a reduction in stay. Moreover, when the first community nurse arrived for a dressing change, I could describe what they would be dressing so that they could prepare the necessary supplies. It may be easy to overlook or take for granted the optimization of care that health literacy provides, but increasing public health literacy would help maximize health outcomes.
Access to care
I was grateful that the ambulance arrived quickly, and I am indebted to the paramedics who cared for me with great skill and versatility during a supply and personnel shortage. It is a great shame that these paramedics work under such conditions and that the burden of systemic shortages falls on them. There is no reason why paramedics should be the primary health-care provider to a patient in the hospital, whether in a hallway or a bed. The ability, expertise and availability of paramedics are squandered when resources are lacking.
Access to resources
It is a myth that universal health care exists in this country. Universal health care would provide relevant and accessible care in an equitable manner to all. This is not the case, or else the hospitals I stayed in would have been fully staffed, I would have been admitted immediately to both hospitals, I would not have been transported from one hospital to another by first responder paramedics, I would not have taken up a bed without admission, and I would not have had to find transportation for my second surgery or follow-ups. Universal health care would also mean I would not rely on an insurance company to afford medicine, mental health care, physiotherapy, occupational therapy, or the assistance devices that make it possible to complete activities of daily living. Furthermore, universal health care must include more than having a hospital nearby; it should also include elder care, dental care, nutrition, safe working conditions and shelter.
I never realized how truly kind it could be to open a door for someone. Everything in my life post-collision required planning, including using public bathrooms and elevators. I needed help from others to shower, eat, move large items, and to get around. I needed items like crutches, a shower chair, a commode seat for the toilet, and pillows to elevate my leg. I needed to move in with my parents and I needed accommodations for work and school. I relied heavily on others for everything.
If I did not have a wide array of social connections and support, I would have found it extremely difficult to recover. Without help, I would have struggled with the accessibility of my apartment; I would have found transportation difficult, straining my access to food and care; and I would have been unable to coordinate my graduation and work arrangements. I am fortunate that I was generally able to diffuse my burden between many people and an insurance company; without this support, each day-to-day struggle would have fallen heavily on me alone. Both the quality and the speed of my recovery would have been at significant risk.
Recovery is costly. Therefore, it is necessary to ensure that clients can recover equitably, regardless of social status, economic status, culture or identity. All aspects of a client’s discharge must be comprehensively and thoroughly planned. Through the diffusion of burden, especially on a population level, there can be maximum community health.
What is the lesson? After all, I looked both ways but still got hit. I’m still trying to make sense of what happened and what we can all learn from it. Perhaps this article has been an exercise in fulfilling my own need to figure that out. As both a layperson and a senior in a bachelor of science in nursing program, with a potentially unfounded evaluation of the value of my own experiences and opinions, a summary of my learnings and recommendations is as follows:
- Thoroughly evaluate the costs and the benefits when treating pain.
- Balance pain reduction with cognitive capacity, physical capacity, general or localized relief, drowsiness, adverse side effects, therapeutic windows, and length of action.
- Empower patients to take control of their own care and location.
- Assist patients in reframing loss and finding hope.
- Promote health literacy on both a personal and a public level.
- Allow health-care experts and providers to make decisions for health-care systems.
- Provide equitable access to health care for all.
- Expand and maximize universal health care beyond its current application and diffuse the burden of health.
These recommendations are non-exhaustive and solely reflect the ongoing observations and reflections of a fourth-year nursing student, patient, and pedestrian victim of a motor vehicle collision.
Thank you to Sionnach Hendra (StFX Rankin School of Nursing faculty) for all of her support and for empowering me to write this article and share my experience.
Transport Canada. (2021, August 11). National Collision Database Online 1.0. https://wwwapps2.tc.gc.ca/Saf-Sec-Sur/7/NCDB-BNDC/p.aspx?l=en#o106
Nicholas Stinson wrote this article at the end of 2022, when he was a BScN student entering his final semester at the St. Francis Xavier University’s Rankin School of Nursing.