Fall Fall

Fall finally hit the Mid-Atlantic October 26th-28th. A mild-ish ‘noreaster blew in bringing an inch+ of rain while dropping temperatures significantly.  I started riding a bike again post Leadville, sometime early- September. It’s been nice.

We have bad roads (too much traffic, too few shoulders, too many bridges) to ride but we have an endless supply of trails (hundreds of total miles) leading in three-ish directions. Plus I found a couple shop rides that safely cover some miles on the roads a couple days a week. It’s a nice break from the impact of running.

Monday morning the 29th began almost like any other Monday. I say almost as normal Mondays are a run-day with one or both of our dogs. I’d been having a fair amount of discomfort under my right kneecap so I’d not been running much for two-three weeks after completing a 50k trail race in a beautiful NPS park a mere forty-five minutes down the road the first weekend of October. Difficult race, small group of entrants, somewhat technical with 2600 feet of climb.

I had some time to get in a few miles on the bike before starting work so I headed south down a trail I’d run, walked or ridden dozens of times. The Mt. Vernon trail runs 17 miles point-to-point from the estate of former president George Washington north to the Key Bridge in Rosslyn at the D.C. border. It’s an asphalt trail that winds through what were several acres of Washington’s land, multiple marinas, swamps and the Potomac riverfront area of Alexandria. Some of the northern miles wrap around and hug Washington National Airport as well as Arlington National Cemetery with much of the length of it within meters of the Potomac River and the GW Parkway, also known as part of Virginia State Highway 400. Sections of it remind me of the old Clive Greenbelt before it was widened and straightened.

Mt. Vernon Trail is anything but wide and straight. Hills and curves dominate miles zero through eight (running south to north). We live one mile west of a trailhead, a little south of mile marker seven.  I headed south on the trail with a 120 minute ride on my mind. I hopped off a little south of marker three to do a couple laps through Fort Hunt Park, land that was once part of George Washington’s sprawling Estate. It has a one way, 1.3 mile loop road that’s well used on the weekends and relatively empty during the week days. A nice couple-plus miles to lower your head and air it out. I hopped back on the trail continuing south with the plan being to circle the drive in front of Washington’s Mt. Vernon a couple times before heading back to figure how to chew up what would be my remaining 65-70 minutes from mile marker zero heading north.

This trail is known for its many water crossings: runs (we refer to them as streams or creeks in the Midwest), swamps and drainage ditches. Many crossings are traversed via old wooden bridges. The trail is 100% on National Park Service land—-which puts it among the many NPS assets that have been significantly underfunded and understaffed. In fact the current administration proposed cutting 6.4% of NPS staff as part of the overall 2018 Department of The Interior cuts of 12% followed by the administration’s 2019 budget of cutting an additional 15% off 2018 levels.  Funding for this part of the Department of The Interior comes from Congress during it’s annual budgeting process. Deferred maintenance is said to be approaching an underfunded level of around $11B (that’s a B) for all of NPS.  The National Park Service is clearly not considered a funding priority unfortunately and this 17 mile trail is testament to that. Worn down bridges, limited and unclean restrooms, rotting picnic tables, fallen trees that are not fully pulled away from the trail, constant flooding and standing water, potholes, buckles, several degrees off-camber caving sides, poorly marked and almost nowhere is the trail wider than eight feet. Yet it’s a popular trail because of 1) the high local population 2) the high tourist population and 3) the beauty of the land upon which it was originally constructed in 1972. I can count on one hand the number of times I’ve been on it solo during high-traffic; I intentionally avoid it or am with a bike or run group during busy times. It’s simply too unsafe and a shame it’s not considered a higher priority.

I’m familiar with most, if not all the flaws along the 17 miles. Particularly the hilly, curvy, bumpy three miles leading to Mt. Vernon. I’d just passed the one mile mark and relaxed a bit, most of the junk behind me, just a few minutes, a couple climbs and bridges till the estate. I was anticipating the final climb ahead while heading around some tight corners on a downhill to the final bridge.

This particular bridge is different from all the rest; it’s older, narrower and painted. I’m several meters into a thick forest and peer ahead to verify no-one is approaching while lining up a decent angle and doing a couple final feathers. I truly don’t have clear memory of specifically what next happened. My front tire touched the edge of the wet, lightly leaf coated old bridge and I was immediately down.  The left rail broke my skid, keeping me from dumping into a creek. My right hip, elbow and head (in that order) took the hits. Concerned about oncoming traffic and followers I quickly popped up to pull my bike (Jelly Belly) and myself across the bridge and stood leaning on a pole. Looking back (moving forward from here) my timings and details are foggy.

For a few seconds as I was reaching for my phone to unplug my headphones I considered calling Uber to haul me to a close hospital for a quick look. By the time I had my phone in hand and the keyboard opened I immediately dialed 911. That call was placed at 9:18 a.m.  Knowing the trail made it easy to explain where I was. Knowing the trail made it difficult to explain how first responders were going to get to me. Increasingly stabbing pain made me right on the edge of not really caring. Several uncontrolled gasps later I acknowledged to the operator I could hear the sirens in the background. I somewhat recall telling her I was going to pass out so needed to hang up. She raised her voice, pleading with me to hang on while I laid down. Somehow I grabbed something and fell again onto the wet, cold bridge. I had gone mostly silent as she was communicating with the drivers. I told her I was beginning to shake uncontrollably and needed to hang up. She again pleaded that I hang on until responders made contact. I heard the sirens stop and the saplings on the hill above me rustle then voices. I attempted to yell; surely it came out as little more than a normal outdoor voice. “Down here, down here. Down on the bridge. Wet, cold. Very cold”.   I heard voices close in and hung up the phone, twelve minutes after placing the 911 call.

Maybe 2-3 responders were hovering over me, talking both to me and the drivers back up the hill. I remember being so cold. Shivering uncontrollably. No, I did not lose consciousness (at least I’m as sure as I can be I did not). No, nothing else seems to hurt other than the right side. No I cannot move (I’m laying mostly on my left side with my right leg pulled/bent up a bit, the right foot angled outward, unable to roll it in or roll flat). Yes: year, place, date, name, age, etc.  Check.  I hear conversation about getting a stretcher through the woods and down the hill to the trail. Next I’m being told I would need strapped flat to an immobilizer. Let’s repeat. Strapped flat and immobilized. I’m unable to move and cannot process how I will be able to be made flat. Continue……..I would then be lifted up a few inches to the stretcher, stretcher would be raised and I’d be rolled back up the hill, through a few meters of thick saplings, then lifted into the ambulance. All before pain meds could be delivered. I think I can recall attempting to animate the situation as they were calling for more blankets but my speech was choppy from shaking. Something about a good weekend, little ride before work, great that Fall finally hit. I told them about the two types of cyclists and which I’d just become.

I felt the seatbelts, several, being draped over me indicating they were ready to tighten, straighten and roll. And lift. Tighten, straighten, roll and lift. A couple of them provided something of a warning.  When I thought the pain could not get any worse they started. Each individual action likely only took a few seconds yet it was rolled into one long exercise in delivering a variety of new types of pain.  I’m told the final big bumps would be over soon as they attempted to gently get me through the trees to the waiting ambulance. Transferred into the truck I was again as close to passing out as I would be. I’m sure what keep me hanging on was the speed with which they were again verifying my medical history as they were setting up an IV. A team of folks trying to get me some relief kept me alert. Somewhere here a second conversation took place about my clothes and the eventual need to get them off to do a more visible physical assessment. Again I repeated the number of layers, what each item was (bibs, arm warmers, buckled shoes, etc…) and explained I really needed folks to try and take them off individually as they are rather expensive and they’re not something I can easily purchase. Within a few minutes of being rolled into the truck I had an IV in me and the first of multiple injections of Fentanyl. Off we went to our local ER. Shivering gone, pain stabilized, yet at a searingly high level accompanied by something of a fog. I was moved into a room I think around 45 minutes after the crash.

The next eight-nine hours are a mix of films, shots, toe-wiggles, vitals, questionnaires, IV changes, room and bed transfers and most frustratingly a lack of information. Within minutes the final conversation about my clothes would take place. I insisted having me attempt to help them remove as much of the remaining items as possible, repeating the part about the expense of cycling clothing. One of the staff reinforced that part of the conversation but not my insistence on delaying their removal because of cost. In the end they had to fully cut off only one item, a couple others were snipped a bit—it was my favorite black long-sleeve tight, base-layer shirt as they needed to get the dozen electrode leads on me quickly to conduct ECGs.

A couple hours later films indicated I’d suffered a significant break to the femur, up by the hip. That prompted a barrage of calls to find an orthopedic surgical team available who could handle it. At some point early afternoon I was told a team was lined up at a different hospital. A Level 1 Trauma hospital about 30 minutes away. Calls were being made to verify if surgery could take place yet Monday or if it would be Tuesday and line up transport. At 4:58pm Amy reached me for the first time. I let her know where I was being transferred. Shortly thereafter I was yet again transferred to another bed, taken outside and put in an ambulance for the thirty minute drive to the  Fairfax Hospital Complex. By this time I’d worn out the creativity angle for whispering, blurting and yellow out f-bombs and other such naughty words so this multi-bed, vehicle and facility transfer was conducted in relatively mild R-Rated fashion.

 Care and treatment could not be more different at the two facilities. Both good–but our small, local hospital was akin to having your family take care of you. They may annoy you but it’s evident by their approach they truly care and pay attention to every detail. A trauma center is a trauma center. Tragedy and volume. Plus volume and tragedy. I’m over-the-top thankful I had one relatively close. Around 90 minutes after arriving at the new facility I met with one of the surgeons. He was the first to explain the break and repair in extreme detail, images included. A closed displaced fracture of the right femoral neck will need to be repaired. Two repair options were explained to me Monday evening as well as when I was being processed in pre-op Tuesday morning. Option #1: Internal Fixation. Option #2: Prosthetic replacement.

It took me some questioning and time to process as I was now thirteen hours since my last meal, eleven hours since the injury and over ten hours of a cocktail of narcotics flowing through me. Fortunately Amy was with me to present level headed questions and assessments and we landed on pursuing Option #1 if the injury would allow/permit it once they were inside to fully assess the damage. Option #2 would be exercised only if #1 could not be. That resolved I was wheeled up to my excellent suite where I would spend the next 72 hours minus time in surgery. My final experience with pain achieving a 10-of-10 was the transfer from ER bed to room bed. Up to this point each bed transfer had either four people or three with one being a visably strong male. I believe this transfer was completed by two average size/build female technicians. I ordered Amy out of the room when I realized they were not calling additional help. In spite of general fatigue, exhaustion and pain I managed to unload a final obscenity-laced scream. Hurt so good. Amy checked out and went home after another hour or so when we knew surgery timing.  Throughout the night my body failed to succumb to the conditions; staying awake all but about one hour the entire night. Between nurses, pre-op prep and nurse assistants (excellent Technicians) I was questioned, poked, prodded, cleaned, redressed, and generally engaged by staff or my bladder about every hour until the transfer folks came into the room around 6:15-6:30 Tuesday morning.

Early morning surgery is best–at least that’s been the case from my prior four (three knee and one nasal). Aroma of coffee and bagels filled the hallways and elevators, staff were chatty and alert. Several staff hovered around me, a couple with needles, others with what felt to be my 20th round of paperwork to sign. I wonder if anyone has ever contested their signed paperwork using the argument they were clearly under the influence of rounds and rounds of chemicals when essentially being assertively harassed to sign them. It’s taken me hours and hours spread over a few days to recreate as much of this as I’ve been able. Providers and their administrative staff gave me seconds to read and comprehend pages upon pages of small-print information fully drugged and with neither my contacts nor my glasses.  Several components of our healthcare system are truly fu*ked up.

I met Alireza Stephen Malekzadeh, MD, the surgical team leader, shortly after being parked into my bay. Dr Malekzadeh, Steve, is all business yet compassionate and thorough. Post-op I was happy he was leading the team. I met Bimal Gandhi, my anesthesiologist, shortly after being wheeled into my pre-op bay. He leads a couple programs related to certain types of injury anesthesiology delivery. Currently he is promoting a spinal delivery solution for my situation which is different from the traditional general (face mask). Either method I would also have a long needle stuck into my thigh with a local numbing agent directly delivered. Double the pleasure. I had a choice and I chose to follow his preferred method of the spinal, different from each of my other times. Within five minutes another lady appeared with information about a survey and a study related to anesthesiology delivery. Her team had received an alert that I was a candidate for a University of Pennsylvania medical study. Unfortunately by the time she gathered her paperwork and got to me Bimal had already made his pitch and I’d accepted. She said I could still change my mind and enter the study.

Entering the study meant I would be assigned a number and enter their randomizer which would determine the method of anesthesiology delivery for me. I had no time to weigh my choice or consult again with Bimal or his staff. She needed to know immediately. Multiple times I expressed my disappointment in her timing—-arriving after I had already made a choice. I felt guilt knowing I had a 50% shot I would not follow the recommendation I’d already agreed to. Decide.  I’m a believer in the importance of science, research and all things that could improve the overall healthcare system so I opted to be a part of the twelve month study. A couple more minutes and my number came back: the decision had been reversed for me; I would receive general anesthesia.  I apologized to the staff, (quite voluntarily) signed the forms for the study and within a couple more minutes was headed out the big prep room, down the hall and into surgery. A final word with a couple of the surgical team staff and I woke up in recovery after 2.5+ hours of surgery (on the longer end of Dr. M’s estimation) plus time to come out of sleep.  By now it was around 2:00pm Tuesday and I believe for the first time my pain level dropped below a five. Somewhat surprising considered I now had a bunch of foreign bodies in me in the way of rods, screws and plates. I enjoyed the moment knowing blockers would soon start to wear off and I’d be back to depending on room nurses for pain.

For the first time in about 32 hours I would have solid food. Hospital food never tasted so good even though I have no memory of what I had. I also have limited to no memory of a few conversations in recovery and my room right after surgery.  Moving forward I would be looking to check off the normal post-op list: start up antibiotics, remove a catheter, learn how to walk via crutches and walker (I’m what’s considered a ‘toe-touch’ patient on my broken leg),  begin talking about PT/OT required for discharge, begin the parade of the surgical team, begin conversations about home transport and home-care arrangements and wound care. I was still facing 1-3 more nights of inpatient interruptions resulting in continually unhealthy losses of sleep. Much of the time post-op up to discharge is a blur of forgettable repetition. Two of the surgeons made appearances in my room; Steven M. and I cannot recall the name of the other. They confirmed what they suspected ahead of time with a few more details, none particularly encouraging. Of the three possible ways I could break the bone I broke it in the worst. They had to deal with bone fragments in the ball joint meaning it was not a clean break. Best news was my general conditioning/fitness/health was helpful for my age meaning it was unnecessary to consider the option to put in an artificial hip. Bottom line: the surgical component went as well as could be expected and provided me……..’with the best possible chance for recovery’.  It was explained to me I had a 75-80% chance of recovery success. That is; a number of components in the healing process need to occur and past cases point to a 75-80% chance I will heal properly. While that left me emotional and momentarily speechless and breathless in a not-good way, I quickly, solidly voiced my appreciation and put an end to my pity-party.

Discharge was a C/F of incomplete information, confusion, conflicting information, delays and lack of comprehensive oversight. Six-thirty Thursday morning November 1 I was notified during rounds by a member of the orthopedic team I was cleared to go. After a myriad of dropped balls and general lack of case management oversight I was wheeled out to Amy eleven hours later. Were it not for the terrific help of my day-nurse it might have been a couple more hours. That being the case it would have resulted in another overnight as our driveway does not have enough bright light for me to ambulate as necessary to get into the house. What a poor spend of insurance reimbursement that could have been.  I anxiously await the multiple standard post-care patient surveys I will receive. Amy was terrific every day up to and including getting me home and into our home. Neither of us is in a dependent position very often so plenty of adjustments for both of us.

Getting close to three days at home and it’s been something of a blur of a manageable routine. Again being newish to the area we have yet to build up a support network so we’ve run and practiced several scenarios and circumstances with and by each other as Amy returns to work Monday. She’s been even more of a champ.  I’ll be mostly house-bound for a few more days. I’ll be swollen, in minimal to moderate pain for several more days. In other words I still hurt all the time there is no pain free time. It waxes and wanes according to the timing and volume of medication.  It’s beautiful out; leaves are changing colors and I have a good view during the daytime hours. We have a system around taking care of the dogs both while I’m here alone and when Amy’s with me. I have a normal diet although I’m generally not very hungry. I have a kitchenette and coffee-bar set up within reach. That was Amy’s highlight as she’s not a coffee drinker so wasn’t fully aware what it all involves every day.

I’ll get my staples out (hopefully) in about 2.5 weeks.  I’ll be on crutches and a walker for up to six weeks. Fully unassisted walking, spinning, walking briskly, cycling and running will occur many weeks and months down the road. All of these things are provided my body falls in the 75-80% bucket of successful healing. Many things will be necessary for me to hit that 75-80%.  Some within my span of control, many not. I’ll be working hard on the components within my span of control.