Wednesday, June 23, 2010

Velodrome Crash: the Long Story

I had been interested in racing the track for a while, but didn't have the confidence to try it out.  After a clinic last December, another 2-day clinic about a month ago, and then a great workout session the night before, I felt comfortable racing at the Hellyer Velodrome's “Get Ready for Summer” races on Saturday, May 29, 2010.  We would have our own women's category 4 field, rather than race with the guys.  The first race was a tempo race, with points given each lap for the 12 laps.  I think I came in first or maybe second for a couple laps, and I ended up placing third overall.  Our next race was a 12-lap scratch race, which is like a criterium in that the winner is determined by who finishes the whole thing first.

I'm #519 in red. photo by Steve Woo

Throughout the race, I felt like people were squeezing the group somewhat down track (i.e., towards the inside); for me to move around I would go up and around and advance.  I realized partway through that I did not feel comfortable advancing my position, and settled somewhere towards the back, looking for a good opportunity.  With three laps to go, I was in the sprinter's lane (the innermost lane on the track) behind a line of riders.  We were approaching turn three.  I have a few seconds of memory lapse here but the next thing I recall is riding on the apron pavement towards the warmup circle (in the infield area) and seeing someone down immediately in front of me.  I had nowhere to go.  It was a déjà vu moment from last year as I flew over my handlebars and hit the ground.  Stars flashed and I came to a stop, sitting up.  I assessed the situation and immediately felt relief--no great pain.  Maybe I wasn't that hurt.  But moving a little, I was certain my right collarbone was broken.  I felt angry, mostly, and was pretty quiet.  I noticed some blood trickling down my face and people were coming over.  It was very sunny, bright and hot sitting there on the black asphalt.

People began helping me while we waited for the ambulance.  The initial numbing shock started to wear off and I could feel the pain increasing, mostly in my shoulder.  Since I couldn't lie down, and I had hit my head, a friend stabilized my neck while I sat.  It was quite a while, so thank you, Evan. I felt bleeding in my pelvic area and thought for sure there must be blood gushing.  Once the paramedics arrived, I heard the words "dislocated" and "deformed" with regard to my shoulder, and was not amused.  The thought of someone pulling my arm to put it back in place was horrifying.  They were good about not forcing a certain position and got me on the spine board (yeah, here we go again) and into the ambulance.  I asked for morphine since last year I didn't get pain medication quickly enough.  The paramedic continued asking me questions and I felt sleepy but he didn't want me sleeping, I guess.  I felt like I was still bleeding in my pelvic area and mentioned it again.  But the bleeding was internal; the paramedic put an ice pack there and also one on my shoulder, which brought some relief.  I was most impressed that he was able to start an IV while the ambulance was moving without jabbing me all over.

I arrived at the Regional Medical Center San Jose, the closest trauma center, and things got busy.  I was very happy to see two good friends, Rita and Amy, waiting there for me.  The ER staff did some Xrays and other exams and cut off my favorite bib shorts and team jersey.  It wasn't until we were there for some time that they noticed a puncture wound on my shoulder, and soon discovered that the clavicle fracture was open, meaning that it had broken through the skin.  This has been my nightmare and the ultimate in bad injuries! Ahhh!  The surgeon came in and numbed it, thinking he could perhaps set it in the ER.  I felt and heard him tapping on the bone (ugh!) but at least it didn't hurt.  It became clear that surgery would be required.  Later I learned that the clavicle had fractured, completely shredding the ligaments attached to the scapula below, and piercing through the trapezius muscle and out through the skin.  Somehow it had also retracted back in a bit; so there wasn’t a huge piece of bone sticking out, at least.

 Waiting for the results to come in, I was still 
unaware of the compound fracture.

I was scheduled for surgery as soon as possible, the next morning.  They admitted me from the ER and put me on morphine to help with the pain.  I was nervous about the surgery but was comforted by the company of good friends.  They wheeled me to the OR where the surgeon explained his plan to repair the torn ligaments and to stabilize the fracture using a surgical device called a "tight rope."  Also, the anesthesiologist and I discussed diabetes management; he was interested in my Dexcom CGM, which he kept with him during the surgery. The next thing I remember was waking up with severe pain in my shoulder.  I was in a daze the rest of the day and would briefly see my friend Rita every now and then when I woke up.  Thanks for staying with me all day.  After some physical therapy to get me moving a little the next day, Monday, I was ready to go home.  I wanted to get back to San Francisco; if I needed further medical care, I preferred to go to my regular doctor.  Also, it was so hot in that hospital that I was constantly sweating and uncomfortable.  My friend June from my bike team stopped by after the Memorial Day Crit and graciously offered to wait for me to be discharged and to drive me home.  I was still a bit dizzy and unstable walking around but the medical staff seemed to feel it was okay to leave.  I noticed some pain in my right calf that I hadn't felt before.

 Before surgery

 After surgery: the two metal "buttons" connect the clavicle and 
corocoid process via "rope" and constitute the "tight rope."

I was glad to be home and was comforted by my having my roommate Radhika there.  Sleeping was still difficult and I woke up that night around 1:30 AM, a bit uncomfortable, but fell asleep again.  I had some weird dreams including one where I was outside in a storm at my parents' home in Utah, watching lightning strike uncomfortably close.  I thought that I might get struck and then a thick bolt, covered with burning embers, struck my parents' house, causing it to burst into flames.  Then the lightning came my way, striking me and throwing me down into a dark pit, where I was burned up.  Lovely!  I'm so lucky! I woke up at that point to severe pain in my right side.  It was around 4:30 AM and I was disappointed I hadn't slept more.  I thought I must have jammed my arm into my side or something--that the pain was just from sleeping in a bad position.  After standing up and walking around a bit, the pain started to subside.  Still, when I would try to lie down again, the pain would return.  Last year, the rib and L2 fracture diagnoses took about a week to come in, so I assumed I had just broken a rib that was somehow missed on Xray.  Or maybe somehow my side was slightly injured and my sleeping position further injured it.  I did sleep again for a bit and after that, I couldn't find any comfortable position.  I noticed that the pain in my side was completely eclipsing my collarbone pain.

A good cycling friend (and nurse!), Cheryl, came that morning to help me and stayed for quite some time; I was so grateful for her company and help.  I was feeling anxious about being home alone with this pain and was still somewhat lightheaded and unstable at times.  I was so happy to finally be able to shower and was put at ease to have her there. Throughout the day, the pain would get worse and then subside again.  My doctor felt like the trauma center most likely did not miss a rib fracture and helped me to get a new prescription for pain medication.  In the afternoon, a case worker from my health plan called; she was in the process of transferring my medical records from the trauma center, including my radiology images.  She asked how I was doing and I told her about the pain, that it was a "10 out of 10" when I tried to breathe deeply.  Basically, I could not breathe normally at all. It felt just like a broken rib. She recommended that if it did not improve with the vicodin, that I head to the ER.  I took another vicodin and the pain did improve somewhat.  But by about 4 PM when my friend Colleen arrived to visit, I felt like it was time to go in.  I was mostly worried that my shallow breathing would cause my blood oxygen levels to drop and that that might put any brain injury (if I had one) at greater risk.  I was still pretty sure I had a rib fracture--the pain felt very sharp and was consistent with where I fell.

Colleen braved the insanely steep ER driveway in her stick shift car and dropped me off.  I was becoming somewhat hysterical because I felt like something was really wrong but I hadn't been able to find an answer.  I had tried to get in touch with someone--anyone--to review my Xrays from the trauma center.  I knew I would not be able to sleep with this pain.  And I was becoming short of breath and very uncomfortable breathing.  I was seen very quickly (for an ER) and they started doing tests.  Let me tell you--if you have to be in an ER, Colleen is someone you want with you.  She had an uncanny way of making me laugh and relax and I was grateful for her company.  They did the chest Xrays and didn't find any broken ribs, and also started some blood work.  At the last moment, the attending doctor said he would run the D-dimer test to check for blood clots in my lungs.  He said that, due to my recent trauma and surgery, the test would likely come back as elevated, and that they would need to do a CT angiogram of my chest in that case.  He seemed to feel that it was unlikely that I would have clots, but that they would check it out anyway.

Well, the D-dimer test came back elevated. I asked, "How elevated is it?" and he responded that it is either elevated or not.  Oh.  I was hoping it would be like having a blood sugar of 150--a little high but not an emergency.  I was prepped for yet another CT exam and had the nasty, hot contrast injected as I held my breath.  The tech asked if I worked in radiology--I guess because I held still so well?  This is something I instruct people to do all the time so I guess I take it seriously when someone asks me to do it!  Back in the room, I waited with Colleen for the results.  I said, "I doubt it will show anything," and was not overly worried.  I didn't really know how serious blood clots were but they sounded bad.  After some time, a different doctor came to tell me the results.  She seemed serious when she said I had three small clots in my lungs.  I don't remember what else she told me but came to understand over the next hour that they would put me on heparin right away and that I would be admitted for treatment.  The nurse was having a difficult time getting the IV tubing set up and I was getting increasingly agitated as the doctor tried to explain again what was going on.  I asked if I would be okay and the only answer I got was, "It's good you came in."  Ugh.  They finally got the IV sorted out and injected a huge bolus of heparin.  My confidence was sort of shot with that particular nurse and I just hoped she was giving me the right amount.  Colleen was there and after the chaos calmed down, I started to relax a little.  Over the next hour or two, I could feel the pain lessening in my side with the heparin starting to work.  The IV heparin drip would continue for another day or so.

 I think the blood clot is that dark spot in the left wedge-like vessel. Get that?

I was moved to the telemonitoring floor where they would be watching my EKG constantly at the nursing station (in case I suddenly keeled over, I guess).  I was hooked up to the IV, the EKG leads/box, my insulin pump and had my Dexcom CGM handy.  Oh, and of course I had to keep my iPhone by my side.  It was impossible to move anywhere without dropping something.  I still can't find the clip for my pump so I have been carrying it everywhere.  I tried to see how low I could get my heart rate and was sort of disappointed it wouldn't go below 45.  I think I can get it to 42 when I am really rested.  I was hoping a 45 would set off some bradycardia alarm but alas, they were not concerned.  They frequently checked my blood pressure and temperature and regularly drew blood for lab tests.  Unfortunately, my veins were not happy and they had about a 30% success rate of finding one.  Most of the bruises have just disappeared.  They gave me pain medication when I asked, and I should have asked more frequently.   I was quickly breaking out in a rash all over due to some allergy and they decided it was probably from the morphine and/or vicodin.  I was not happy with the way vicodin was making my head feel, anyway, so we stopped the narcotics around noon on Wednesday.  Later, my doctor determined that the allergy was due to the IV cephalexin (antibiotic) I had post-op.

All throughout the day Wednesday, I had a stream of visitors who really kept my spirits up (and kept me distracted from worrying).  Those visits, flowers, calls and other help really meant so much to me.  Thank you, thank you.

I had an ultrasound exam to check for blood clots in my legs (negative) and a brain CT to check for possible brain injury, since a blood thinner could cause significant complications in that case.  I continued to feel sluggish in thinking and speaking, and since I work with people with brain disease and trauma, I know the signs all too well.  I was so worried.  At one point, the nurse said something that made me really scared and I called my mom and asked her to bump up her flight to that evening, instead of the next morning.  I think the comment, "I've had a patient die here from this," was not helpful.  I guess I wanted to know how serious it was; I think I would do better with statistics than a horror story, though.  After that, the doctor's suggestion that my prognosis was good didn't really stick well.

Thursday morning, I received the news that my brain CT was clear. I was feeling a little more clear-headed and was greatly relieved by these results.  The nurses had started me on a twice daily regimen of Lovenox shots on Wednesday, as well as coumadin.  The coumadin (i.e., warfarin) is a drug that interferes with blood clotting, and is the drug I will be taking for six months while the clots dissolve.  It takes a while to build up, so in the meantime, they wanted me on Lovenox as a backup.  Lovenox is a form of heparin that also works to block clotting.  The needles are huge and leave bruises that don't want to go away.  Since I was comfortable giving myself injections, I was sent home Thursday.  Thank you to Alissa for helping my mom with the flowers and for taking me home.

 Flowers from the hospital stays.

My INR, a measure of clotting time, was 1.5 when I left the hospital; they want me to be at 2-3 for the duration of my treatment.  I continued taking the Lovenox shots until the next Monday.  Since then, my INR levels have been 2.7, 2.3, 1.7, 1.4 and then 2.6.  I will continue going in for blood work a couple times a week until things stabilize better.  I have learned that the INR is affected by foods, exercise, sickness, stress, etc., which sure sounds like another fun drug that I get to take all the time (i.e., insulin).  But fortunately, there is a clinic with pharmacists who read my results and call me, telling me how much to take for the next few days.  I am looking forward to going in for blood work less often, since I'm getting weary of being poked in my arms.

As of now, the pain is gone except for my back and shoulder and occasional headaches.  The clavicle is healing well and I can already drive.  The road rash has mostly healed.  If it weren't for the blood clots, I could imagine being out on the road again in another week.  I am still easily fatigued, though, and don't want to ride until I am 100% confident of my upper body stability.  Although racing is completely out of the question, I have been told it is okay to ride my bike while taking coumadin, as long as I am extra careful.  But since I am always careful, I'm not sure what this will mean for me.  I was glad to connect with a few other athletes who have had blood clots and continued training to some degree while on coumadin.  Compared to last year, I am physically less injured.  But the clots present a different challenge that from here on out, seems more mental.  It has been hard.

I am so grateful to the many friends and family who stepped in to help me out, and for your continued support.  It would have been impossibly difficult without you.  Thank you.

Relaxing outside at Crissy Field.

Here are some additional pictures.  My mom tells me I should warn you that they could make some people queasy.  But I don't think they are so horrible.


Marcus Grimm said...

Though it's a horrible story, your recovery speed is impressive! I'm sure it doesn't feel that way to you, but I'm impressed. Best wishes for continued healing.


ecmoody said...

Anne, you look awesome in that picture on Crissy Field!

You'll find a system to make sure you take your pill everyday. I left mine by my deordorant. ha.

LindaF said...

Once again, Anne, you have been so brave and hard-working in the recovery process. My admiration for you never ceases.

Mike Fraser said...

Anne, I'm sorry to hear you had another incident. You sound like a strong person thought and that will carry you far. As for the nurse, I can say this because I work in Nuclear Medicine in a hospital, that nurse should NEVER talk like that in the hospital. Not just with patient's, but the hospital. It's gravely inconsiderate in my mind to talk to a patient that way, and very unprofessional.

Better days are coming.

Bernard Farrell said...

Anne, I don't know how I missed this until now. I'm so glad you're OK and (hopefully) on the mend. Let me know if you need anything.