Vol 50: Deep breaths in the dark
Have you ever noticed that whenever you take a breath; not a shallow, routine, in through the nose and out through the mouth breath, but a deep sustained proper breath – everything suddenly gets a little better. Your mental clarity is enhanced, your posture improves and you immediately feel more relaxed and energetic. It’s subtle, but it works. Try it. Take a deep breath, hold it and count – ten, nine, eight, seven, six. Now slowly exhale and try to imagine if taking deep breaths at night were the only way to marginally appease the chronic enduring pain in your left lower leg.
This is the story of my patient hereafter referred to as Eddie. Three years ago, he lost his balance and fell fourteen feet off a scaffold while at work on a construction site. Fourteen feet, for comparison, is the average height of a one-story building. He landed hard, directly on his left heel and heard a snap. The impact was so severe it sent a shock wave of pain from his heel to his central spine. Eddie fell backwards and screamed in agony. Within seconds his mangled foot and ankle, now contorted into a pretzel fold, was swollen and throbbing with unimaginable intensity. He was 51 at the time.
Eddie has high blood pressure but fortunately doesn’t have any other medical issues and was not on any medication that may have complicated his predicament. He tried to move but couldn’t stand because the pain was simply too unbearable. His co-workers immediately ran to his aid and, given the intensity of his fall, feared that he may be paralyzed. When they saw that he was able to move, they helped to get him into a car and drove him to the hospital.
While there, bruised and bloodied, Eddie was examined but the extent of his injuries was relegated to his left lower extremity so an X-ray of that area was performed. It was significant for a displaced and severe heel and ankle fracture. His treating physician gasped when looking at the X-rays. Surgery couldn’t be performed at the time because his foot, ankle and leg were too swollen so Eddie was placed in a cast and advised to only ambulate with the use of crutches.
His pain, given its severity, had to initially be managed with schedule II narcotics. The high dose should have been enough to tranquilize him but it never abated his pain entirely. Eventually, he had to be switched to something less potent after a few weeks because of the pain medication’s highly addictive properties.
With no relief from the pain, and now on weaker medication, Eddie began to become depressed. His blood pressure was dangerously elevated because of his pain and doctors feared he might have a stroke if it couldn’t be better controlled. He was in a cast for three months and repeated X-rays showed adequate healing so surgical intervention was never employed. The doctor removed the cast and referred Eddie for physical therapy. For more than one year, Eddie endured the therapy and had multiple follow-ups with his orthopedic team but his pain never subsided.
He was caught in a conundrum of not wanting to get hooked on pain killers and not knowing what else could be done to ease the pain. He wasn’t even sure if he wanted to live. Ultimately his physician signed off on him and said that there was nothing else that could be done.
At this time, frustrated and afraid, Eddie sought the advice of another foot and ankle specialist. While there, he was given six steroid injections into his foot and ankle and was started on heat therapy in-office. Initially, Eddie noted some improvement but within weeks his pain had returned. From there he was referred back to orthopedics for a surgical consultation. But refusing to operate, they decided to inject the patient themselves after which Eddie’s pain was even more intense.
Eddie then opted to see me for another opinion at the advice of a friend. I immediately sent him for an MRI. While his foot fractures had subsequently healed, results were significant for arthritis (likely post-traumatic in nature) diffused throughout his left foot and ankle. A bone cyst in his heel was also observed. I advised Eddie to start ambulating with the use of a CAM walker boot to offload pressure to the area and to continue using his cane for added stability. I further recommended that he return to his original physician to discuss his recent MRI report findings but he refused.
After one month of ambulating with the boot and taking oral anti-inflammatories, Eddie continued to report 10/10 pain exacerbated by prolonged weight bearing, particularly at night. During the day, he doesn’t have to think about breathing. He just does it naturally. But at night, he turns off all the lights in his room and in the quiet of the dark, he makes a conscious decision to breathe slowly and deeply to deflect from the unbearable pain that he’s had to endure for so long.
At this point I had no choice but to diagnose him with complex regional pain syndrome (CRPS) and having exhausted all possible treatment options that I can provide within my scope of practice, I referred him to rheumatology and neurology for continued treatment of the same.
It’s never easy for a medical professional to look someone in the eye who trusts you and has come to you for help and say that ‘This is as far as I can go’. We are born and trained and take a Hippocratic oath that we will save lives but saving patients from pain is what we do far more often. It is in our DNA to want to help and in my heart, I hope that one day Eddie will be pain-free.
CRPS is a severe neuropathic pain that typically ensues following injury at a specific site. Patients often oscillate between a spectrum of symptoms including burning, throbbing and swelling, muscle spasms, stiffness and changes in temperature or color of the affected region. The etiology is poorly defined but is likely secondary to damage within the sympathetic nervous system. The mainstay of treatment center around therapy and oral medication.
Surgically excising his cyst and filling the area with bone grafting material coupled with concentrated therapy and analgesic and anti-neuropathic medications may ultimately be the key to the amelioration of his pain. Nonetheless, the take home message that he’d like to share with readers is to never give up and to seek medical attention as soon as possible. Beyond that, he emphasizes the importance of never being afraid to get a second and third opinion if necessary because the consequences of complacency can be dire.
During childbirth, expectant mothers are taught to breathe to help facilitate an easier delivery. Athletes conversely have a more controlled breathing pattern for optimal sports performance. Eddie never dreamt that he’d be forced into early retirement and dependent on disability cheques to pay his monthly expenses.
But his story is an important one because it reminds us all that despite our best efforts, medicine and therapy has its limitations and one injury can require years of treatment and still yield poor results. So, when you see or hear of someone going through a similar circumstance, take a deep breath and give thanks that breathing to you is natural and not a conscious concerted attempt, desperately made in the dark of night, to negligibly mitigate years of unending pain.
This is The KDK Report.
