Craig's Blog

Day 6 Post Crash

Day 6
Friday, 1 November 2013

My orthopaedic review occurred early on Friday morning. My previously, grossly, swollen shoulder was now thin, bruised and had a very abnormal appearance. A surgical repair was clearly required however, exactly which one could not be determined without an MRI. I was pleased that my shoulder was going to be fixed in terms of long-term function, but disappointed that I had not known this 24 hours earlier as I would have left my chest tube in-situ for my impending surgery.

Given that my left shoulder now felt like a bag of marbles every time I lay back on to the pillows, I knew that the MRI was going to be uncomfortable. The pain specialist did not think that topping up the paraspinal would offer me any additional benefits, as currently my ribs were quite comfortable.

The MRI was planned for 4pm. I had the maximum dose of the two different medications I could use for breakthrough pain as I left the ward to go to the MRI unit. I had only previously had one of these agents at a time.

Getting my left shoulder positioned into the small cradle that had been attached to the MRI bed to optimise shoulder imaging was extremely uncomfortable with my unstable comminuted fractures in my scapula (multiple little pieces pushed into each other). The massive amounts of pre-emptive analgesia must have provided some additional analgesia, but it didn’t feel like it at the time.

Going into the MRI tube was relaxing, because at last nobody was fiddling with my position. As the MRI machine started, it became quite noisy, but nowhere as noisy as I had anticipated based on the experience of others. Red laser beams were spinning around me to allow optimising of the images and for the next 20-30 minutes, I remained in the tube. Throughout this time, I had almost continuous hallucinations, which I am sure were due to my dramatic increase in analgesia. These hallucinations were like the medical/anatomical images that are seen on TV shows like House and CSI Miami. I remember feeling like I was spinning around the optic nerve to bright light at the end; the focus of the vessel pattern was becoming clearer as I got closer. I also remember a hallucination where I was inside a chest cavity as it received a blow from the left with the chest wall deforming under the impact of the blow and the ribs snapping all the way down the front and the back, generating a flail segment. I could then see the lung collapsing as the air escaped from the hole in the lung, caused by the sharp end of one of the many rib fractures.

Discussions with my orthopaedic surgeon that evening confirmed that my AC ligament was intact and my clavicle was intact. Unfortunately, my scapula was so damaged that the Acromion wasn’t connected to any bones, hence I had an unstable shoulder, similar to a complete AC joint disruption. He described some surgery he would perform at 8am the next day to insert some plates and hooks to try and hold this all back together.

I became concerned about the anaesthetic issues for tomorrow’s surgery. Earlier this morning, my paravertebral block had been removed as it had been there for the maximum possible (5 days). I also knew that anaesthetists were extremely uncomfortable performing anaesthesia on patients with a flail chest without a chest tube. I also wanted to know if I could have another paravertebral block inserted to cover the next weeks pain.

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Day 4 & 5 Post Crash

Day 4
Wednesday, 30 October 2013

The next two days are a blur. I can remember my eldest son visiting and that I had eight lines/leads/catheters attached to me. I can remember my wife asking for no visitors and spending most of this day and the next day sleeping interspersed with my breathing exercises, all with my leg elevated above my head. Fortunately, my haematoma was getting smaller each day.

Day 5
Thursday, 31 October 2013

Day five in the HDU was mostly spent resting, doing my breathing exercises and using my various means of analgesia to get comfortable. An X-ray late in the afternoon showed that whilst my left lower lobe still remained collapsed, all of the fluid had been removed from my left pleural cavity and my left upper lobe had expanded. Based on this, the decision was made to remove my chest tube later that day.

I was now well enough to be transferred out of the HDU to the cardiothoracic unit where I had my own private room rather. As the gross swelling around my shoulder had been reducing, it revealed how deformed my left shoulder was due to the multiple scapula fractures. My AC joint appeared distracted above 3cm, even though the ligament was apparently intact. My professional work and my cycling required that my shoulder was returned to the best possible condition as soon as possible.

Despite having my paraspinal catheter topped-up and additional pre-emptive analgesia; having the chest tube removed felt like having a hot poker being slowly pulled between my ribs, followed by the urgency of holding the suture tight to stop air re-entering my pleural cavity through the drain site. At least once this was removed, I had one less tube. I was now down to seven.

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Day 3 Post Crash

First Chest drain
Day 3
Tuesday, 29 October 2013

I spent most of day 3 in HDU resting quietly, doing my physio breathing drills and trying to keep on top of my pain relief for my chest wall fractures. I was surprised to get a text from a family member of the driver who hit me on Saturday. It’s hard to know how to respond to a text like this. I decided to keep it factual and told her about all of my fractures and lung injury and that I was in the HDU of the cardiothoracic unit.

After yet more X-rays of my chest, I was informed that my pneumothorax (air around my lung) had not improved in 72 hours and that there was increasing fluid in my pleural cavity (space between ribs and lung). This was not unexpected, given that I had a flail chest, something of which I was reminded of every time I coughed when the flail segment moved in the opposite direction to my chest wall. The surgeon recommended the insertion of a chest tube to drain the air and fluid in my chest cavity. Hopefully, this could be removed in 48-72 hours.

The chest tube was inserted in the evening. Having inserted chest tubes in other people when I was an intern and resident, I unfortunately knew exactly what was in-store. It was extremely difficult to get me in the appropriate position to insert the tube due to my five scapula fractures, my cardiac monitoring and all of my other tubes inserted into relevant body cavities. I was fortunately given significant analgesia via my drip for both the positioning and the insertion of the tube. There are two things that I can remember about the tube insertion; the first is that the tube was inserted in the middle of my flail segment. Whilst the dissection to insert the tube was not particularly uncomfortable, the pressure in the flail segment while the 8mm rod was forced between my two ribs whilst pushing the flail inwards is something I will not forget. It was moments like this that I hoped people who cause injury to others should get to experience some of their discomfort during the healing process.

My second memory was the warm body fluid running out of the tube and down my side once the introducer had been removed. The tube was quickly attached to a drainage bottle (later to be known as Mr Bubbles) and 1L of blood drained into the bottle along with the air that had been surrounding my partially inflated lung. Over the next 48 hours, 1.5L of blood drained from this chest tube into the bottle. It explained to me now another reason why I was feeling so seedy; I had dropped my haemoglobin from approximately 153g/L to 103g/L. Thirty per cent of my blood volume was in either my thigh or my chest. Fortunately, the blood in my thigh was going to be reabsorbed and recycled. I had an iron infusion to try and aid my body’s ability to replace the blood lost into my chest cavity and subsequently, the bottle.

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Day 2 Post Crash

Day 2
Monday, 28 October 2013

During my second day in HDU, my thigh pain progressively improved and my oxygen requirements reduced to 3L minute via nasal prongs. Around lunchtime, I was taken down to the operating theatre recovery area for the head of the pain team at SCGH to insert a paravertebral block. This block involved a catheter being inserted next to my vertebral arches to enable to release of local anaesthetic right next to the nerves that supply my middle ribs from approximately the 3rd to 8th rib. It was to remain inserted for the next 5 days to provide local pain relief and decrease my need for opioid analgesia. Given the magnitude of the pain in my ribs and shoulder, inserting the block was relatively painless. The block was very effective at providing constant low-level pain relief for the next five days.

I spent much of the rest of the day in a drug induced high, thinking I was invincible.

An interesting thing often happens when you’re involved in a near-death motor vehicle accident; unexpected people come and visit you. One such unexpected visit was from a clinical colleague with whom there had been 18 months of preceding acrimony. He held my hand and said that he sincerely apologised for his behaviour over the past 18 months and told me that he had a great deal of respect for my clinical skills and acumen. This visit and discussion came as an extreme surprise to me and it is not something I will forget.

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Day 1 Post Crash

Day 1
Sunday, 27 October 2013

I remember waking up in the High Dependency Unit, the pain was intense. I could barely move or breathe and there were tubes everywhere. My first medical review was by a Cardiothoracic Surgeon who brightened my day up immediately, because he was wearing a blue t-shirt that said ‘Christ is the reason for Christmas’. We discussed my injuries, my breathing and my ongoing oxygen requirements. He informed me that the current plan was to allow my chest to try and heal spontaneously, without intervention.

I was troubled by increasing amounts of pain in my left thigh. We had a look, only to see that my thigh was grossly enlarged with some superficial bruising and it appeared to contain an enlarging haematoma. Over the next two hours, I was reviewed by lower-limb orthopaedic consultants, a vascular consultant and plastic surgeons; there was the concern that my haematoma was causing me to develop compartment syndrome, where the increase pressure in a fixed space can cut off all blood supply to tissue and cause nerve damage. Compartment syndrome is relatively common in the calf after injury, but is quite uncommon after thigh injuries. The two treatment options were a conservative ‘watch and wait’ approach, or surgical release of the compartment (draining the haematoma) with delayed surgical closure. The surgeons informed me that there was an up to 30% risk of muscle weakness in the thigh after this procedure; this was clearly not something I was keen on as an individual or a cyclist. The conservative approach, if successful, resulted in a proportion of people with deep residual haematomas that eventually calcified, and caused pain with muscle contraction. Clearly none of these options were ideal. The decision was made to try the conservative approach for the next 6 hours. The surgical team organised a CT angiogram to see if they could identify the bleeding vessel injuring my thigh muscles which would enable them to block it via endovascular techniques to avoid surgery on my thigh.

The Radiology Consultant decided that I had had too much exposure in the last 24 hours so he suggested that an ultrasound of my thigh would be a good way of demarcating the location and size of the haematoma. This could be repeated in a few hours to look at progress over time. The Sonographer started scanning my thigh, taking some routine measurements and commenting on my absence of fat. She then became a very quiet Sonographer, which immediately made me worry. I’ve heard my patients say this to me when I’m scanning them and their babies with problems; they always say that the silence is meaningful. I asked to have a look at the pictures, which clearly showed a 12x10x8cm haematoma. She said she had never seen one this large before. The Radiologist reviewed the images and he stated that he thought the clot was stable and not increasing in size. I returned to the ward where I spent the next 72 hours with my leg elevated above my chest using an unusually shaped pillow. Fortunately, the 1L haematoma began to slowly absorb spontaneously without the need for surgery.

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Background and the crash

Background and the crash

Cyclist Awareness

Having returned from Trento on a UWCT high, Brad and I mapped out a number of target events during October, November and December. These events were the State Four Man Team Time Trial Championships, the Gents (Two-Up Time Trial) and the Tour of Margaret River (TOMR). This would allow me to race with the Unicorn-Specialized Team on three occasions before a planned ‘light month’ over Christmas, which was going to begin on 13 November. I was taking my son Henry on the ultimate Leavers’ trip; 10 days in Corsica riding three legs of the Tour de France, doing other mountain climbs and enjoying this French island as a Father and Son pair. The ultimate boys trip for two keen cyclists.
The State Team Time Trial Championships went incredibly well, with the men’s team winning the Master’s category by several minutes.

Saturday, 26 October 2013

Today was the day prior to ‘the Gents’ and after having a recovery week, I was keen for my planned 60-80 km ride at VTO1 (250 watts) on my Specialized SHIV.

To extend the normal Shelley Loop, to get enough distance to get in an 80km ride, I decided to ride around Wembley Golf Course and along the beachfront to Port Beach before doing the normal loop. I needed to make the decision when going along West Coast Highway to go along Curtin Avenue or Marine Parade – I made the wrong choice.

Marine Parade was not particularly busy, with the traffic moving along comfortably between 30-40km/h most of the time. I was enjoying my ride on my SHIV, and riding between 35-40km, fortunately on the bull-horns. Suddenly, a silver car that was driving toward me did a right-hand turn into Overton St. I don’t think she indicated, but I can’t be sure. She later claimed that she did not see me.
I remember screaming not again (this was the third time I’ve been hit by a car in 12 months), followed by ‘you stupid woman’. What happened next was like the Matrix movie flight scenes; I turned to the right and hit the car side on, and became airborne, going over the car. I was conscious at all stages of the accident and what happened afterwards. I hit the ground on my left-hand side and did not move. I could not move.

The pain in my left chest was excruciating and all I could do was pant. Just like the end of your tenth Mount Street repeat. The first things that came to mind was that another car was going to drive over me and that a well meaning bystander who’d watched too many movies about aeroplane crashes would try and stick their biro into my chest to relieve my pneumothorax. Fortunately, neither of these things occurred.

I realised that my head was OK, my brain was OK, and my hands were OK – three things critically important in my job as a high-risk Obstetrician and Researcher. I knew immediately that I had a punctured lung because I just couldn’t catch my breath. I was quickly surrounded by a group of passers-by who came to my aid and Colin, a cyclist who was riding behind me, was aiming to direct traffic around me.

I was fortunate that one of the people who came to my aid was a FiFo Occupational Health and Safety Officer who had good first aid training. She provided excellent care for me at the scene and kept my head and neck immobilised at all times.

The forty minutes that it took for the ambulance to arrive passed quickly, with people protecting my skin from the hot road. Colin and a number of others directed traffic at the scene. During this time, the traffic was crawling through Cottesloe. A number of wankers got out of their cars and shouted at those providing first aid that they should move me off the road to allow the important traffic to flow through Cottesloe. I could say nothing, but fortunately those around me replied with a tirade of abuse back at these idiots. After an extremely painful transfer, I was moved from my left side on the road to my left side on a gurney. All of this was aided by the Green Whistle and my trip in the ambulance was aided by a Ketamine infusion.

Over the next 6 hours, I was reviewed by emergency physicians, general surgeons, orthopaedic surgeons, upper-limb specialists, lower-limb specialists, cardiothoracic surgeons, plastic surgeons, vascular surgeons and numerous radiologists. I had more tests than I can count, abdominal and chest ultrasounds looking for intra-abdominal bleeding, heart and lung contusions and four CAT scans.

At the end of all of this, a kind cardiothoracic surgeon came up to me and held my hand. Having done this before many times myself in other medical situations, I knew the news that was coming was not good. He said that he was pleased to inform me that I did not have any fractures in my neck, nor did I have any abdominal injuries. He told me that I had 18 rib fractures on the left, with ribs 1-9 fractured both anteriorly and posteriorly. This meant that there was a large section of my chest wall that wasn’t attached to anything – a flail chest. He also told me that I had a lung contusion, a punctured left lung with air between the lung and the chest wall. To finish things off, I had five fractures in my scapula (shoulder blade) but there was far too much swelling to interpret this at this time. There was also a large haematoma in my left thigh that would be further evaluated the following day. My medical brain went into overdrive, and all I could remember was my trauma lectures as a medical student where I was taught that a flail chest and a punctured lung had a 25% mortality rate. My cardiothoracic surgeon must have seen the fear in my eyes, because he quite confidently told me that I would live through this experience. He organised for me to be admitted to the cardiothoracic surgical High Dependency Unit and I hoped that there would be no further bad news.

From day 1 until day 11 have been written in retrospect due to my injuries and drug induced haze.

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