Medical and Shop Update

In my last update I wrote a pretty introspective piece about lying on the ground in the woods, broken. I had been through a round of surgeries, and was in the midst of the weeks-long series of medical procedures involved in putting my leg back together. A lot has happened since then; in fact, the greater part of the whole medical process has occurred since then. And what has become even more clear is that the greatest part of the full recovery process is still ahead of me. I’ve just started to work on mobility in the knee joint, with some simple 0-20 degree knee bends.

Working on mobility!

Working on mobility!

My leg feels foreign to me, and the simple task of flexing the knee a little bit is surprisingly taxing, both physically and emotionally. Day two of working on mobility has been better than day one, and I trust that day three, and those that follow, will continue to improve. But I also know that there are a lot of challenges ahead. I’m happy that the shop is busy, and we have a lot of work ahead of us through the fall to keep my mind focused. I’m also lucky and relieved to have Amy’s understanding and support, as I embark on a journey that she’s been on for the past fourteen years.

Recovery from this injury is unlikely to be a process with a clear outcome. I will absolutely face some level of disability, and the nature of that disability isn’t clear. It’s easy to think in terms of activities that I can do versus activities that I can’t do. Biking and skiing are fine, while running isn’t going to happen. But Amy’s experience dealing with a similar tibial plateau fracture has had many more ups and downs, with both skiing and biking sometimes requiring real ergonomic adjustments to be tolerable, and with running being anything from two to three times a week, to not at all. Much of the variation just comes down to how much pain she wants to tolerate, and what her priorities and opportunities happen to be. For instance, when we’re on European ski selection trips there usually isn’t an option for skiing or biking, and we end up doing a fair amount of running, and it comes at a fairly high cost. Based on her experience, I have every reason to believe that I will be faced with many decisions on how best to manage my situation, and few absolute guidelines or restrictions.

My first x-ray, taken in Brattleboro VT, showed a Schatzker 6 tibial plateau fracture. That's probably why they seemed to be in a hurry to get me to a bigger hospital!

My first x-ray, taken in Brattleboro VT, showed a Schatzker 6 tibial plateau fracture. That’s probably why they seemed to be in a hurry to get me to a bigger hospital!

So, why all this talk about disability with something simple as a broken leg? Don’t people recover from those all the time? The simple answer is that my break is, in the words of more than one of my doctors “a really bad break”. It’s almost comical, in fact, how consistent that wording has been. My leg surgeon, Doctor Sparks, has used those words nearly every time we’ve met. Last week I had back to back appointments. Wednesday was a follow-up on the leg surgery with Sparks, and then on Thursday I saw my hand surgeon (remember the broken hand?), for the final visit in what has been an extremely satisfactory healing process. After giving me the all-clear on the hand, I showed Doctor Bettinger some pictures on my phone – some of the same pictures I’ve included here. As he scrolled through the images he said “oh, that’s a bad break”. And then on the next image he said “oh, that’s a very bad break.” And he even said it once more before I mentioned that my other surgeon had made sure that I understood that to be the case. He looked me in the eye, and he said “I’m just going to say it one more time. That’s a very bad break.”

This is a 3D reconstruction of my CT scan early in the process. If I heard the medical assistant correctly, I think they may have had that left-most chuck of Tibia all the way out of my leg at one point during the surgery. The apparent "break" in the Fibula is just an artifact from the 3D rendering. That bone is fine.

This is a 3D reconstruction of my CT scan early in the process. If I heard the medical assistant correctly, I think they may have had that left-most chuck of Tibia all the way out of my leg at one point during the surgery. The apparent “break” in the Fibula is just an artifact from the 3D rendering. That bone is fine.

My injury is classified as a Schatzker 6 Tibial Plateau Fracture (according to my online hospital listing of “current problems”). Schatzker is, apparently, a doctor who created a classification system for tibial plateau fractures with 6 being the highest number, or worst classification you can get. You get a six when you have a fracture through the metadiaphysis of the tibia, which is to say that the break extends down from the tibial plateau, and through the neck of the Tibia. As my hand doctor, Bettinger, took the time to explain, this full break through the meat of the bone, in addition to the tibial plateau, is what makes it a “very bad break”.

It’s worth noting that it was a full two weeks between my accident and the surgery. This was, in large part, due to the acute compartment syndrome that became the first order of business when I was first admitted after the accident.Acute compartment syndrome is a close cousin to the chronic exertional compartment syndrome that many skiers are familiar with. Both are conditions that arise when muscle compartments start to fill up, but return blood flow is cut off by pressure in the muscle. The muscle groups are enclosed in fascia, forming “compartments”, and when one or more of these compartments start to really balloon, the result can be painful, debilitating, and ultimately dangerous.

This photo, from the day after my first surgery, shows both the external fixator and the vac dressing that was used to drain the accumulation of fluid from the acute compartment syndrome fasciotomy incisions.

This photo, from the day after my first surgery, shows both the external fixator and the vac dressing that was used to drain the accumulation of fluid from the acute compartment syndrome fasciotomy incisions.

The chronic exertional variety of the condition is exercise induced; we’re most familiar with issues in the anterior compartments of the shin related to holding the ankle joint in a flexed position in skate technique. But other types of exercise related compartment syndrome occur as well. Curiously, and somewhat confusingly for the doctors who admitted me to the Dartmouth Hitchcock Medical Center, I’ve previously had bilateral fasciectomies performed to relieve chronic exertional compartment syndrome, back in 2012. I had a few different doctors review my medical files as I was being admitted, and say “haven’t you already been treated for this?” The reason is that the first concern upon being admitted was that I was displaying the signs of acute compartment syndrome. This is the more dangerous version of the phenomenon, that is general related to trauma. It doesn’t stop when you stop exercising; it just keeps going and can be threatening to life and limb. Actually, it’s limb first, and life later on. It needs to be treated, and so the first surgery was mostly about laying-open my shins with some big incisions. These were fasciotomies, meaning that they just sliced open the fascia, and didn’t remove any materal from the fascia as they would in a fasciectomy. But they were aggressive, big incisions compared with the relatively delicate and fine work done by my good friend Doctor Rick Powell, who is a vascular surgeon. If you want to see somebody with steady hands, look for a vascular surgeon or a neurosurgeon. If you want to see somebody who’s good with power tools, look for an orthopedic surgeon or a carpenter. My recent fasciotomies were done orthopedic style. They may have used a chainsaw. They left the incisions open for several days, with what they call a “vac dressing” in place. This is a vacuum pump with a tube that runs into the incision, which is covered by tegaderm. For several days they pumped blood and gore out of my shins. Mostly blood, I think. By the time I left the hospital after my last surgery my hemoglobin count was down to 7.8g/dl. No fear of upsetting the blood control people at the next Eastern Cup event (do they test waxers at Eastern Cups?).

This x-ray image was taken immediately following my first surgery, and it shows the joint with traction applied by the external fixator.

This x-ray image was taken immediately following my first surgery, and it shows the joint with traction applied by the external fixator.

At the same time as the fasciotomies they installed an external fixator, which I included pictures of previously. This device simply put the joint under traction, returning the leg to its proper length, and opening up the joint. Once the fasciotomies were done and the leg was under traction, it was simply a matter of time to allow my body’s inflammatory response to do its thing and quiet down. My friend and customer, Doctor Ken Newhouse from Wyoming (who has provided good context for a lot of the medical information in this write-up), has pointed out to me that the relatively low speed and impact of my accident wouldn’t normally be expected to cause the kind of inflammatory response that would require treatment for acute compartment syndrome. The implication is that I have a somewhat hyperactive inflammatory response, which may also explain my previous issues with chronic exertional compartment syndrome. It’s interesting to me to see the dots connect in that way.

One of the many images that was captured during the 3+ hour surgical reconstruction process.

One of the many images that was captured during the 3+ hour surgical reconstruction process.

I finally went in to be put back together on July 29th. Amy had warned me in no uncertain terms that the reconstruction would be just like starting the injury all over from scratch. She promised that I would experience pain just as bad as what I had felt at the beginning. I didn’t believe her, but she was right. Coming out of the surgery I spent over 5 hours in PACU (the Post Anesthesia Care Unit), the place where they oversee your transition from anesthesia to regular pain control medication. The problem was that I was in severe pain. I had an IV, of course, and the PACU nurses were able to administer lots of narcotics straight into my blood stream. But at the same time that I was complaining of pain, I was drifting off, and forgetting to breath, which is a side-effect of the narcotics. It’s not that I was forgetting, in fact, I was adamant that I had it totally under control. I was hooked up to a respiration monitor and I remember clearly that I straight-up didn’t believe that the thing was working correctly, and I resented the sound of its alarm intensely. Amy got to visit me in PACU, and was able to stay quite a lot longer than the normal 15 minutes that they allot for visitors. I guess that’s because it was already late evening, and there weren’t too many people left. But the other thing I remember clearly from my time in PACU was that I wanted to communicate to Amy that she was right, it felt just like starting over, and that I shouldn’t have doubted her, and also that I was sorry she had ever gone through the whole thing. Apparently the best way I could come up with to communicate all of this was to squeeze her hand really damn hard. She didn’t appreciate it, but it was done with the best intentions and the utmost love and appreciation for her support and guidance.

The result: a good view of the plate and screws that support my reconstructed knee. You can clearly see that the bone below the joint still has some big gaps. This is because first priority had to go to the joint surface. Those gaps will fill in time.

The result: a good view of the plate and screws that support my reconstructed knee. You can clearly see that the bone below the joint still has some big gaps. This is because first priority had to go to the joint surface. Those gaps will fill in time.

The next day I had a visit from my surgeon, Doctor Sparks. These post-procedure surgeons visits must really start to sound similar after a while for people who have been through a lot of surgeries. My guess is that it’s standard practice for the surgeon to show up and say how well everything went. So I expected as much from Sparks. But he was downright animated. He described in detail how challenging the procedure was. He described having to fish around for the lateral meniscus, which was missing, and eventually found crammed down into some crevasse in the shattered bone. That had to be repaired, and then stitched into place. He described how pieces of the articular cartilage were floating around, and had to placed back on the joint surface like puzzle pieces. He described how much care was taken recreating and supporting the joint surface, since this was the critical part of the operation, but how that meant letting some of the gaps in the bone further down in the tibia remain open (no problem – they’ll fill in before I’m ready to bear weight). He described it as an intensely manipulative surgery, and one that a lot of different doctors looked in on because it was an interesting and challenging case. So I was happy. He seemed really satisfied that they had done all that could be done, and that’s the best I can ask for.

The next challenge was pain control. My surgery was the last one on the schedule on Friday afternoon, so my first full day awake was Saturday – the weekend – and I was in serious discomfort. Even with the headroom created by my “new 10” in the woods after the accident, I was reporting pain levels of 7 and 8. The residents and interns on staff were not able to bring my narcotic doses up sufficiently to bring the pain under control without some help and oversight from people with more experience. In the end, I sent a text message to my friend Matt Koff, a doctor in the anesthesia department at DHMC who works in consultation with other departments. Matt happened to be in the hospital, and was in my room with in 15 minutes. Matt brought in another doctor from the acute pain control division of anesthesia, and she put me on a PCA (Patient Controlled Analgesia) pump with really high limits for the IV administered hydromorphone that had been working best for me. They monitored my self-administered dose for an overnight, adjusted my oral dose and watched for another twelve hours before prescribing an oral dose of more than double what I had started on Saturday morning. Part of that process was a follow-up visit where I was given a clear map for my home strategy to reduce the pain medication as I was able. That process has gone very well. I was told that it might take two or three months to get off the narcotics, but I’m already looking at ending them altogether about three weeks after the surgery.

During my two stays at Dartmouth Hitchcock I had quite a lot of visitors. I wasn’t keeping score, but if I had been, I don’t mind telling you that Scottie Eliassen would have won the visitor contest. For all that they can do with medicine, the good folks at DHMC appear to be incapable of making a good cup of coffee. Scottie became a regular at bringing me coffee. She also managed to recognize that I wasn’t eating anything from the hospital menu, and came up with appetizing food so I’d put something in my stomach. And she also helped me chase down insurance approval for the medications that the doctors wanted to prescribe, saving us hundreds, and maybe thousands of dollars. Having a good friend who knows and works in the system is invaluable. While I’d like to recognize and thank everybody who has visited, not to mention the big crew who have helped out with a huge list of chores around the house, I really need to recognize the dept of gratitude that is owed to Scottie for her stalwart help and awesome conversation in a totally unstimulating environment!

Although it’s been over a month since my accident, all of this has felt like something of a rush. It’s a lot of new information to take on board. It’s only been in the past few days that the rate of change in my circumstances has slowed down, and while that has happened I’ve gained a glimpse of the enormity of the process ahead of me. My right leg has become a pathetic, alien looking appendage that I’m not sure I really want to own. I’m just starting to exercise it, and the process is, as I mentioned at the outset of this article, both physically and emotionally taxing. I’ve got a decidedly first-world set of problems here, and my standard of care has been outstanding. But I’d be lying if I didn’t admit to feeling a bit sorry for myself at times. The good news, as I also mentioned at the outset, is that we have a busy fall ahead of us.

Steve McCarthy - our seasonal shop helper, has flattened and polishing pretty much everything you can see in this photo. The first batch of the fall season is a big one, and it's ready for final structure!

Steve McCarthy – our seasonal shop helper, has flattened and polishing pretty much everything you can see in this photo. The first batch of the fall season is a big one, and it’s ready for final structure!

In the shop, Steve has finished flattening and polishing a large batch of skis for some of our bigger eastern club accounts. These are both new and used skis from evaluations that we did in the spring, and subsequent ski selections in our May ski picking trip (all of those skis from May are in the shop now). Tomorrow we’ll start cutting final structures, and Amy will handle the feeding of skis for this first batch of final structure since my accident. In the meantime, I’ve got a big back-log of ski evaluations to dig into. I haven’t done much of that since the accident because being upright for any amount of time has caused a lot of swelling and pain. But that’s becoming less of an issue daily, and I’ll be diving into those evaluations very soon. In the meantime, I’ve booked tickets for a return trip to Europe for additional ski selections. Amy and I will be gone September 10th through the 21st. Because I’ll be hobbling around we haven’t extended the trip to include any fantastic adventures this year, and I doubt we’ll be sending back many spectacular photographs designed to make all of you envious of our lifestyle. But we’ll have good opportunities to get some good work done in three ski factories.

I’m starting to formulate a personal plan for the winter to make the best of my compromised circumstances. I have every reason to expect to be able to double-pole, if not much else. So my plan is to begin training soon to develop some actual double-pole capacity. And on the next ski picking trip I’m going to be sure to come home with some of the newly available double-pole skis that are being made for long-distance racers. When snow arrives, my plan is to test double-pole solutions in as many circumstances as I can; it should be a good project for a season of limited capacity. The first step is to get one of those Concept II Ski-Ergs in the house, since I surely won’t be on rollerskis anytime soon. Crutching is pretty good for the arms, but I don’t envision using it as an exercise mode, so some creativity will have to be brought to bear!

 

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