Jonathan had stayed at work a little later than usual to grade some papers. He finished gathering his belongings and stuffed them into his messenger bag. It was after 2 p.m. on a Friday afternoon, and the community college campus had emptied out. He flung the messenger bag onto his shoulder, and that was the last normal moment he had for a long time. He heard a popping sound in his back and went right to his knees.
No one was around and he didn't have his cellphone with him.
"It took me an hour to get 100 yards to my car. It was very, very painful," he said. "When I got home, I called my chiropractor and then my GP." They both told him that he had strained his back and to come in on Monday - three days later. His doctor prescribed two different painkillers. Jonathan said, "The pain just got worse and worse over the weekend, despite the drugs."
He reported that by 2 a.m. Monday, "I couldn't stand, sit, lie down, walk - I couldn't do anything - without shrieking in pain." He called an ambulance and was taken to the local trauma center. "They said, 'Oh, you just pulled your back out.'"
Jonathan refused to leave and, after 18 hours in the emergency room succeeded in getting an MRI, which showed that he had herniated a disk and crushed his spinal canal. "The neurosurgeon said that I needed immediate surgery, or else I could end up paralyzed. Then he asked me if I had taken any aspirin recently. I said yes, 81 mg. He then said that he would have to wait a week to operate or else I might bleed out."
Jonathan continued, "They kept me there for three days on heavy pain medication, then discharged me because my health insurance wouldn't pay to keep me in the hospital just waiting for the surgery. The neurosurgeon gave me five prescriptions for narcotic pain relievers - a fentanyl patch, Dilaudid, OxyContin, Valium, and hydrocodone." He instructed Jonathan to use all five at the same time.
When Jonathan's wife went to fill the prescriptions, the pharmacist said, "I can't fill these. If he takes all five of these, he's at risk for respiratory arrest." After phoning the neurosurgeon, he very reluctantly filled them and said, "Someone will have to stay up with him all night to monitor his breathing." As predicted, Jonathan started having serious trouble breathing. He cut back to two drugs. "Even so, by Sunday I was psychotic. I was completely out of my mind."
Jonathan had successful surgery on Tuesday, 11 days after he'd injured his back. He said, "The worst part of the whole thing was the unsupervised weekend taking five strong narcotics. That was really scary. If my wife hadn't been watching, if I hadn't stopped taking (some of) the drugs, I think I would have stopped breathing."
Jonathan faced at least four major risks:
1) Dying from blood loss during surgery if he had it within a week of taking aspirin.
2) Becoming permanently paralyzed if he did not have surgery immediately.
3) Dying if the painkillers needed until he had surgery stopped his breathing.
4) Suffering permanent mental decline as a result of prolonged drug-induced delirium.
But no one talked with Jonathan or his wife about how big these risks were in relation to each other or about ways to reduce these risks.
An article in the European Spine Journal reported that it wasn't clear that having taken low-dose aspirin creates added risk for spinal surgery patients. Many studies point out that treatments are available to counteract the effects of aspirin so that needed surgery can proceed with less risk.
The surgeon did not help Jonathan compare the risk of operating right away with the risks of delaying. He did not say anything like, "One person out of 100 in situations like yours will die of blood loss during surgery. Twenty out of 100 will end up paralyzed if surgery is delayed. Fifty out of 100 will stop breathing if they take the narcotics I prescribed, and 30 will have permanent mental damage." (Numbers are for illustration only.) Jonathan was not given a choice about which risk(s) he preferred to take.
How can you protect yourself when you do need medical treatment, and different courses of action involve different risks? For each risk (such as bleeding out during surgery), ask:
1) How many patients out of 100 would that happen to?
2) How many of your patients has that happened to?
3) In order to avoid that risk, what other risks am I taking on? (In Jonathan's case, these included paralysis because of the delay, and death or other very serious side effects because of the narcotics.)
4) How many patients out of 100 in situations like mine would experience each of those risks?
5) If I want to have the treatment anyway, what steps can be taken to reduce the risk?
Even if you are able to get only partial answers, they may help you to decide which course of action you want to pursue, and help to prepare you to explain your preferences to your doctor.