Wednesday, April 6, 2011

Another Crash

Wouldn't you know it?  No sooner have I exorcised my crashing demons by blogging about crashing than I suffer my worst crash yet.  And the indignity of it -- it was not a cycling crash!

Solvang was on Saturday, March 26.  On the following Tuesday, I went to a 90-minute class at Velo, which ended with a 30-minute standing interval.  My post-Solvang legs weren't so fresh to begin with and the 30 minutes of standing left me pretty darn tired.  But when presented with an opportunity to go ice skating that evening, I couldn't say no.  I love the effortlessness of motion on ice.  A few thrusts and strides and I can glide seemingly forever.  And I love messing around on the ice, doing figure 8s, swoops and turns of all sorts, but I don't jump.

Crash, Rip and Flop
So, there we were, Sophie and I, she practicing her cross-overs and spins and me goofing off, trying stuff on the outside edge, then inside, going forward and backwards, drawing loops on the ice.  Boom, I lost my balance and fell on my  butt.  No big deal, though surprising.  My legs kind of weren't there.  I got up quickly and thought that the legs must be pretty tired from all the riding.  But I thought nothing of it, continuing with my swirls and doodles.  I was skating backwards into a turn, when I lost my balance again and began falling backward.  My left foot got caught behind the right and under me and, as I fell, it had nowhere to go.  You know how a hand flexes in both directions, but the foot doesn't?  Mine did.  I fell, letting out a scream, as I felt something tearing and tearing and tearing awfully painfully in my left ankle.  "AAAAAAAARGH!!!" I said involuntarily and very loudly.  There would be no getting up quickly from this fall.

I sat on the ice and realized that I had no control over my left ankle -- it just flopped to the outside and I couldn't get it back into normal position.  Luckily, I was in a skate, which held my foot tightly.  Unlucky, I was on the ice and would have to get off the ice and then remove the skate before I could leave the rink.

Sophie asked whether I was OK and I told her, that I wasn't and that I was hurt badly.  I told her I hoped I tore ankle ligaments, but privately I feared a fracture or fractures.  I got on my hands and knees and got on my right foot, but there was no getting on my left foot.  I could not control it and it could not bear any weight.  Another skater asked whether I need help getting off the ice and I accepted gratefully.

He helped me off and I plopped down on a bench.  I went into shock, sweating profusely and feeling nauseous.  Sophie was near me the whole time, looking very worried and asking whether it hurt and if it was feeling better.  A rink employee came by to ask me about the accident and to fill out forms.  No, I was not going to blame the rink for my injury.  She offered to call an ambulance, but I declined.  I couldn't imagine going to ER with a 9-year old and keeping her in a hospital with me possibly until midnight.  Jessica couldn't pick us up because she taught until 10:00 p.m. that night and her phone was off during class.

Meanwhile, two huge problems loomed: (1) removing the skate, and (2) getting home.

Even if my car had automatic transmission, I don't think I would have attempted to drive, but since my car has standard transmission, driving was out of the question.  I could call a cab and get a ride home, but how to get the car back from the rink?  We solved the second problem thanks to a young brain.  Sophie suggested calling our neighbors.  After hemming and hawing for a while, I did.  I called and they said they'd come and get us.  They were on the way.  I still had my left skate on.  Hockey skates are puck-proof, so are difficult to cut off.  I had to try to take off the left one in the usual manner.  I unlaced it as much as I could.  As slowly and gingerly as possible, I began to tug the back of the skate off.  It complied.  Centimeter by centimeter, very slowly but, surprisingly, not painfully, the skate came off.  As soon as it came off, the foot just flopped over to the left and I felt it swell and swell.  "Oh no."  I tried to keep the foot stable, but it started shaking from the effort.  The rink employee brought an Ace bandage and we managed to stabilize the foot a bit.  I put the skates in the bag and, with Sophie carrying the bag, hopped to the front area of the rink, where it was warmer.

Our neighbors Matt and Kristen came together in one car.  Kristen drove away their car, Matt drove Sophie and me home.  The drive went OK.  I hopped up the stairs to the house and in.  I grabbed another Ace bandage and gulped down a handful of Advil.  Sophie put me to bed and wrapped me up just right -- not too tight and not too loose -- and the foot felt better.  Honestly, the pain was quite manageable as long as the foot remained sort of lined up.  Turning to one side or the other hurt and made it feel like parts of my foot and ankle were wobbling on their own and I had no control over what they did.  I lay in bed with the foot wrapped and elevated.

Jessica got home.  I relived the event all over again.

What's Up Doc?
One thing I like about Kaiser is you can call urgent care and get an appointment to see a doctor in a few hours.  Thus, I managed to get an appointed in Orthopedics for 10:10 on Wednesday, the next morning.  The ortho unwrapped my ankle and my eyes got big.  But not as big as the ankle, which was the size of a medium-large grapefruit.  The leg looked wrong.  The shin bone was going one way and the ankle bone was going the other.  They were roughly parallel, but looked disconnected, not like it says in the song (the shin bone is connected to the ankle bone...).  The doc explained that ankle fractures are very rare and that it's quite easy to sprain an ankle and do so severely, but breaking it really took some effort.

He sent me to radiology for an x-ray, which took five minutes and I was back in his office.  He began the discussion with "It's difficult to break an ankle..." and I wondered why he was telling me this again, when he put up my x-rays and continued, "but you broke yours in two places."  I said, "Fuck!"  He demonstrated, making a ring with his fingers and thumbs: "An ankle joint is like a horizontal ring.  Yours is fractured in two places and is what we call 'an unstable ankle.'" "Why would they call it that?" I wondered cynically, trying to keep my wobbly ankle from flopping about.  Imagine a horizontal ring -- hold out your right thumb and pointer fingers and form a ring by touching them to their respective digital partners on the left hand.  While the fingers are connected, the ring is firm and stable.  Break the connection between two of the digits -- the ring becomes a flexible circle with an opening.  Now break the connection between the other two fingers.  The result is two semi-circles that can move independently of one another and cannot support the foot.  That's what I had -- fractures on both sides of the ankle.

He explained that were I sedentary pencil pusher, he'd recommend a cast, but I'd develop arthritis within a year.  Since I am active, he recommended surgery and referred me to podiatrist surgeon.  A podiatrist and not an orthopedic surgeon?  Yes, they operate only on feet.  Feet is all they do.  Orthos work on shoulders, knees, elbows, hips, feet, etc.  Podiatrists do feet and only feet.  They know their feet.  They know your feet too.

So, I hobbled to podiatry.  A resident, Dr. Dickinson, saw me first.  He went over much of what the ortho had said and showed us the x-ray, which showed three fractures, NOT TWO -- confirming instantly that it's better to have a podiatrist rather than an ortho work on me.  The third fracture is on the back of the ankle.  It is relatively minor and is obscured by the Achilles tendon.  He recommended not messing with the Achilles and leaving this fracture to heal naturally, but on the other two, yes, we will operate.  Oh, and they have an opening Friday afternoon.  Wow, this is moving very quickly.  Jessica had knee surgery 15 years ago and they let her almost heal for over a month after her initial injury before operating, but this is not how it would be with me.  Under the knife I go in just two days.

OK, it's broken, we can't undo it, so let's work on getting better.   3:00 Friday it is.  Jake Lee, my surgeon came in.  More talk about anatomy, recommended course of treatment, and recovery (long and slow and inactive -- more later).  All of a sudden a cast technician comes in.  I guess I'm going to be in a cast for the first time in 48 years.  The tech pushes my foot up to nearly 90-degree angle, because it has to be in just-right position.  The pushing doesn't feel so good.  He wrapped some cotton tape around my foot, then put on a few layers of wet plaster cloth, which he wrapped with more cotton tape and an Ace bandage.

Dr. Jake and Dickinson the resident returned and took x-rays of my ankle.  Oops, the ankle is out of whack, the bone fragments are misaligned and we have to cut off the cast and reset the ankle.  They cut off the cast.  What's resetting a fracture?  It's pushing the bones back into place.  Dr. Jake started pushing on the side of my foot to get the bones to align correctly.  That feels worse.  He is pushing pretty hard.  What do we do when someone pushes? We push back.  This resetting business isn't going so well.  I ask him to ease up a moment, take a few deep breaths, relax and signal to him to push again.  It's going much easier and Presto! he got it lined up.  It looks good on the x-ray.  Dr. Jake is holding my foot and Dickinson is wrapping, as the two of them are starting to apply the second cast.  Dickinson is wrapping pretty tightly and I understand that it's important to hold the foot in the right place, but the foot feels awkward curled under, but that's how they're going to cast it.  They continue wrapping and casting and that's how it is.  Weird.  It'll have stay that way for two days.  They do a fist bump and do a fist bump with me.  OK, we're young and hip and happy with the work we did.  Sounds good.

I hobbled to the entrance.  Jessica pulled up in the car.  The cast weighs a ton.  It's hard enough to walk on crutches, harder with the cast throwing off the balance.  I got in.  We went home.

The next two days went by mostly uneventfully and quickly.  A couple of times, my arch cramped inside the cast.  There was nothing I could do about it.  I couldn't flex the foot or pull on my toes.  The best I could do was grab and pinch my lower lip in hope that activating this acupressure point would help relieve the cramp.  Not sure if it was that or simply time passing, but the cramps went away.  Ankle pain was not an issue.  I guess Dr. Jake reset it well.  The cast bugged my foot.  I am sure it had something to do with the injury, but also with the position in which it held my foot.  I asked Jessica to cut out some of the cotton tape the docs used to wrap the foot under the cast.  That relieved the pressure a bit, but it still felt awkward and uncomfortable.

Friday morning came.  On Wednesday they had told us that on Friday morning we'd receive a call with instructions, but to plan to arrive two hours before surgery would begin.  On Thursday night we received a call during which a nurse told me not to eat or drink or take blood thinning pain killers, where and when to arrive for surgery and we were all set.  Except on Friday at 9:30, we received another call from Kaiser advising us of a cancellation and would we be able to come an hour earlier at 11:00?  You bet, I'd go immediately to get it started as soon as possible.  But getting out of the house took longer than we thought and we arrived at 10:45.

Getting to Ambulatory Surgery Unit would prove a challenge.  We had to go all the way around the ground floor of the hospital, then up the elevator, then all the way around again.  This was a very screwily designed building.  And I'm not sure who decided that Ambulatory  Surgery was the right place for my ankle surgery since I couldn't walk.  I'm not so good on crutches, I learned.  Even worse on a completely empty stomach.  Being asked to walk around the block twice on crutches on an empty stomach was a bit much.  Half-way around the first floor, we came to an information desk, where I sat on the desk and requested a wheelchair.  The woman at the desk was surprised and immobilized by my request.  She seemed completely incapable of helping, but fortunately a nurse from another department happened by and said, "come on, I'll get you a wheelchair."  OK, so I had to walk the rest of the way around the first floor, but I was encouraged by the offer of help from a person who seemed to know what she was doing and gave a shit.  I hobbled enthusiastically after her.

She wheeled me to Ambulatory Surgery office, where we left my Kaiser card and began to wait.  The desk person finally registered me and by 11:45 we were in a tiny pre-op room that had a tiny bathroom, a recliner and a tiny TV.  The nurse left for me a goofy gauzy blue cap and two gowns (one opening in front and the other in back) and told us what and whom to expect: A nurse to fill out forms and take vital signs, then anesthesiologist to talk about anesthesia options, then surgical team to tell what would happen, then surgery.  I changed into my hospital finery and sat down in the recliner.  The nurse hooked me up to an IV bag of what she called intravenous Gatorade -- my first calories since the previous night.

We had a tiny room with bright lights.  It was a warm day.  Air conditioning was off.  Slowly, the room was warming up.  I was worrying a blemish -- my hands needed something to do to deal with the nerves, so I was picking at a zit, and picking, and picking.  Jessica ran out of patience watching me do this -- she was under plenty of stress herself and my activity bugged her -- and she gave me a worry stone, a heart-shaped red rock that I rubbed and rubbed.  It gave my hands something to do and I left the zit alone.

The nurse came in.  He checked my blood pressure and pulse.  He asked me a bunch of questions about my medical history and social habits, as well as perfunctory ones about my address, birth date and other stuff.  Then we waited for a long time again.  We'd been in that room for almost two hours and I was getting sleepy.

Finally, the anesthesiologist came in.  First thing he said was that he wouldn't be my anesthesiologist because he was going off duty, but he wanted to go over my options.  OK.  He started telling me about my options and none appealed.  I didn't want a spinal tap or an epidural, just because I didn't like the idea of a spinal injection.  Local seemed too much for me -- I didn't want to be awake during this.  With general, I worried about nausea and having a breathing tube shoved down my throat and resulting tracheal bruising.  Then another anesthesiologist came in.  It turned out that she would be attending during my surgery.  As the two of them talked about the same thing together, I expressed my reservations about each type of anesthesia, but then she said she was going to go with general and that was that.  Well OK, but ........  But then she said two things: (1) given the time of day, general made sense because they wanted to send me home after surgery and with spinal and local anesthesia they require a patient to use a bathroom before going home and that can take a really long time, especially in a dehydrated individual (me); and (2) now they don't shove a tube all the way down your throat, but put a sort of a tracheal opening piece of plastic there, so bruising wouldn't be a problem.  And I didn't care about nausea so much, so general seemed like an acceptable option.

Both anesthesiologists were still in pre-op with me at 3:15, when all of a sudden, everything became rush-rush.  A nurse came and wheeled me to OR.  Jessica gave me big hugs and kisses at the entrance and there I was in a big white room.  The anesthesiologist was there, as was my surgeon, Jake, and three or four other people whom I did not recognize behind their masks.  I lay down on the operating table, they swung out supports for my arms.  The anesthesiologist plugged a drug drip into my IV port.  Dr. Jake called a team meeting directly over me.  He announced my name and Kaiser number, the nature of my injury and described my surgery.

The Surgery
The anesthesiologist put an oxygen mask over my face and told me to breathe deeply.  I started counting my breaths and after the fourth or fifth breath woke up with a new cast on my leg in the recovery room.

Sorry, that's all I remember.  An hour and a half of my life gone and I have no idea what happened.  The cast was straight rather than crooked, so that was new and improved.  Post-op nurse called Jessica who rushed up.  Dr. Jake called her immediately after the surgery and told her everything went fine.  I felt OK.  A little nauseous, but not bad.  They gave me a pill for that and nausea was gone.  The ankle felt fine.  They gave me a pain pill for the road and told me to take my pain meds.  A nurse wheeled me to discharge area.  I half crutched, half hobbled, half hopped into the car and we went home.

I have to keep my weight off the foot completely for two weeks.  After two weeks, I am to come in for docs to make sure my incisions are healing well.  If they are, I get a stiff boot, which I am to wear for four weeks.  During these for weeks I am also to keep my weight off the foot completely, although I am allowed to flex my foot lightly to work on range of motion only.  Then I get to see my surgeon.  Assuming the fractures are healing right, I can start physical therapy.

The evening after the surgery was fine.  I took my pain meds like a good patient.  Two of those pills made me really drowsy and seemed to slow my breathing.  Several times during the night I woke up as I snorted in air the way someone suffering from sleep apnea would; as if my breathing stopped and the act of sudden inhalation woke me up.  That was freaky.  During the night I also got mildly itchy all over -- anesthesia wearing off.  That was bizarre.  I was lying there, scratching everywhere.  The ankle was OK.  This cast was better than the last, but still rather tight.  Every couple of hours, my foot swelled and first my little toe, then its two closest neighbors would get pins-and-needly, then numb, then hot, then the sensation would spread to other parts of the foot.  The only way I could deal with that was by taking my leg off the pillows, on which I'd propped it, and let blood flow to the foot better, while wiggling my toes vigorously.  If that didn't work, I sat up and let my lame foot dangle, again to encourage blood flow.  That hurt worse briefly, but the pain went away within 10-20 seconds and I could lie down again.  As the foot swelled, the cast felt tighter and tighter, impeding vigorous wiggling.

Saturday morning I felt pretty good.  Ankle pain was 1-2 out of 10, so I didn't take many pain meds.  A physician friend said a cast shouldn't feel tight, so I went to ER during the NCAA Final Four.  That was perfect timing: I was one of two patients in ER.  It turned out my cast wasn't too tight.  It was a partial cast that was wrapped too tightly with cotton wrap and Ace bandages.  ER doc cut off my wraps and wrapped the cast very, very loosely and it felt tons better.  I was in and out of there in 20 minutes; how often can you get out of ER in 20 minutes?  A funny thing about my ER experience:  my co-pay for the surgery was $15; my co-pay for the ER visit, during which my cast was unwrapped and re-wrapped, was $50.

As I said, I wasn't taking many pain meds on Saturday, so on Saturday night I paid.  My swelling-numbness-burning episodes became much more frequent, going from once every couple of hours to once every 10-15 minutes, with pain shooting to level 8, taking up greater portions of my foot, and lasting longer than on Saturday morning.  Doctors say, "stay on top of the pain," meaning take your pain meds before you really need them because if you wait until you really need them, you'll have to take higher doses at higher frequencies and it'll take time to get pain under control.  They told me this, but, naively, I thought I was out of the woods a day after surgery.  I learned about getting on top of the pain after it got on top of me first.  I get it now.  I am being proactive, honest.

Off With You!
With my poor drug-taking and swelling episodes increasing in frequency, the cast was feeling mighty uncomfortable even after re-wrapping.  Lucky me, Dr. Jake called on Monday afternoon to check on me and I told him about my problems with the cast.  Tightness was not the only problem.  When swelling was down and I stood up, the cast slid down on my leg and it felt as if it was resting on my ankle bones near incision sites where the bones were bruised or screwed together and that didn't feel good.  He told me to come in and he'd replace it with a boot, which is what I did on Tuesday morning.

The same cast tech cut off the cast and removed some of the dressing.  That was my third cast in four days.  Then Dr. Jake came in and removed the rest of the dressing.  And there it was -- my bare ankle.  Somewhat swollen with a 5-inch incision on the outside and a 3.5-inch incision on the inside.  Both stapled often.  The outside incision has 12-15 staples.  The inside has about 10. 

The boot is much lighter, which is great.  It's also bulkier (I found it's harder to get shorts on over it) and much warmer than the cast.  I am reluctant to take it off, then put on a pair of pants and wear the boot over the pants because I'm concerned about the fit and because I want to keep it on as much as possible. But it severely limits my wardrobe choices.

Mental Health Check
I have to say, I am in a good mood.  Of course, I would rather not have a broken and surgically repaired ankle.  But since I can't undo what's been done, only try to repair it, I am very enthusiastic about moving forward with the repairs.  I am working from home -- working less than I would have if I'd been in the office -- and am keeping of top of the things I want to stay on top of.  I have my computer, I have my music, I have food and drink in bed, and I'm blogging.  After not shaving for five days, I am experimenting with facial hair and am sporting an early Lenin-style beard.  Early returns on its aesthetics are positive.  The only thing lacking is live social contact.  I've told my friends that I want them to visit and two have visited me already.  I think I may be able to return to work by April 15 or so.  We'll see.


No comments: