A Clinical Case in Rural Australia

Barry Davidson (pseudonym) was an inpatient at a rural hospital in New South Wales, Australia from July to September 2021. A 52-year-old T4 paraplegic, Barry had been admitted under the general surgeons for management of NPUAP stage 4[10] pressure injuries from prolonged immobilization. The cause of these pressure injuries was Barry’s chronic abdominal and back pain, worsening dramatically over the previous few months to the point where any movement was painful. Living alone in rural New South Wales, it had become very difficult for Barry to continue managing his own care. While admitted, the surgical team investigated his abdominal and back pain. Blood tests and abdominal imaging found no pathology and a spinal MRI found old compression fractures of T4-5, now partially fused, but no acute pathology. He was further investigated for medical causes of his pain. Gastroscopy and colonoscopy were unremarkable, as were his kidney and liver function tests and full blood count. Ultimately, no cause of the chronic pain was identified. The network-wide chronic pain service was consulted, but they were only able to see Barry 3 weeks later, despite him remaining an inpatient. Due to the unfeasible waiting time for non-pharmacological services for chronic pain, he was commenced on oral paracetamol and 5–10 mg oxycodone by the Acute Pain Service, which worsened constipation and made him nauseous. He was then swapped to clonidine and rectal indomethacin. To encourage weaning of his dependence on opioids, he was also commenced on gabapentin and tapentadol. This regimen, however, led to a number of side effects including sedation and fatigue, so these were ceased in favor of duloxetine. Ultimately, he remained on regular oxycodone CR and PRN oxycodone and oxazepam. Barry was not fit to return to living alone; however, rural rehabilitation hospitals nearby thought that he was too complex to manage.

Barry was transferred to a smaller, rural rehabilitation hospital after 8 weeks as an inpatient, once his pressure injuries had healed. Despite this, the management of his chronic pain was still suboptimal. He recovered some function gradually with the help of nursing and allied health staff, while remaining on duloxetine, clonidine, indomethacin, oxycodone and oxazepam. Yet, his ongoing dependence on care prevented him from returning to his own home, and thus he was discharged to a residential aged care facility.