Biking

The Crash of the (Im)patient

By Elisabeth Rosenthal |

Two weeks after the accident described in this guest post, every single move of my body hurts. My thoughts are slow and foggy because of the number of painkillers consumed. Without them, the pain is so relentless that I might scream like an animal.

The way we humans experience pain distinguishes us from animals. Not only because we created painkillers, but also because we can contemplate the effect of pain on the conduct of our lives. There are physical and psychological impacts. 

On July 13th, my wife and I went out for a short bike ride. I woke up in an ambulance, with my wife bending over me, thinking that I might die. I did not.

But I can not write, drive, or travel around much for a few weeks. And I cannot let Yonder go silent. So with some of my friends, we started to think about how to keep Yonder alive during my period of healing. The first week, the solution could not be better. My wife Elisabeth Rosenthal is a trained doctor and was a reporter at the New York Times for more than 20 years. I could not have a better writer for my story — luckily not my obituary.  

I hope to find more guest writers like my wife, to whom I am grateful for walking me — and now Yonder — back to life.

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Those of you who know Andrej personally know he lives life with gusto or, as the expression goes in Slovenian, he “lives life with a big spoon.” So it is perhaps no surprise that when he’s riding his bike, he careens down slopes at high speed. 

And so it was two weeks ago: I was riding far behind him on Adams Mill Road, approaching Rock Creek Park. It was the kind of hot and soupy day that might have originally earned Washington D.C. its nickname, The Swamp. I was slower than usual in the heat and even a little bit woozy by the time I crested the hill and searched ahead for Andrej. No biker to be seen. Annoying. He has a bad tendency of speeding ahead and not waiting for me.

It was then I saw a crowd of people hovering over a large, bright yellow object on the road. It was Andrej in his fluorescent jersey. He was crumpled in a heap, unmoving. Blood was coming out of cuts on his face and hand and knees – there was blood everywhere it seemed. He’d hit a pothole, said two men who had run to help. He’d flown over the handlebars. His helmet and bike had flown in different directions and were lying near the curb some 20 feet distant. 

A bystander was calling 911. I once worked as an emergency room doctor in a trauma center and I knew this was bad. But it is one thing to treat a stranger than to watch your husband lying totally unconscious on his back in the street. You don’t know how much you love someone until you face the prospect of losing them. 

As we waited for the ambulance to arrive, I alternated between spouse and doctor. He was writhing and moving his legs and arms. Good, at least no obvious spinal cord injury. I examined his head and saw the blood was not coming from his ear, but from a cut near his chin. I looked through his hair – no lacerations, just a bit of bruising. The helmet did its job before being knocked off. “I’m here – I love you, Andrej,” I said. I wanted that spoken if those words were the last he would hear. Maybe they would help him hang in there.

Among the onlookers were a nurse (he’d been taking his children to a nearby zoo) and a retired law enforcement officer named William. We tried to keep Andrej lying flat and still until the ambulance came; he needed to get on a backboard and in a neck brace to protect his spinal cord.

He would have none of it. As he came to, he became combative and vocal. “Fuck Shit Fuck Shit Fuck,” poured forth. The nurse and the cop looked at me askance. I was relieved. “That’s him, that’s normal,” I assured them. 

Then he was rolling on his side trying to get onto his knees. When we tried to push him down, he screamed in pain,  “It hurts, it hurts, let me move.” He fought against us, motivated, as it turned out, by a row of fractured ribs that I was then pushing against to hold him down and keep him still. It was awful. 

“What’s your name? Do you know this person?” the nurse asked him, pointing to me. “I’m Andrej. That’s my wife, Elisabeth.” 

Ok good, I thought. Oriented x 1, in medical parlance. 

“Do you know where you are?” the nurse asked. (That would be oriented x 2). 

“No, what happened. What happened?” 

He failed that one. 

Me: “You were riding a bike and hit a pothole and crashed. Do you know what city we’re in?”

“No.”

“We’re in Washington.”

“Why are we in Washington? What happened to me? It hurts. It hurts.” 

Possible serious head injury. 

Me: “Don’t worry the ambulance is coming. We’re going to the emergency room. Hang on baby, I love you,” I said, desperately worried now.

“What happened? What happened?” he asked. “Where am I?”

This was getting bad. Was there bleeding in his brain? Who knew. A fire truck pulled up, sirens blaring, and firemen jumped out. The nurse and I knew what to do but we needed an ambulance’s monitoring equipment. Damn, where was it? Two minutes. Five minutes. Seven minutes. We needed to get him to a trauma center. 

I started doing a review of systems. “Where does it hurt?” I asked. 

“Everywhere. Here!” he pointed to the lower right side of his chest. Moaning. More moaning. 

“Does your head hurt?” I continued.

“No.” 

That’s good. But does he really know what he is saying?

“Can you breathe?” 

“Yes.” Both sides of his chest were rising. 

“Your stomach?”

He seemed to be fading. “It hurts, it hurts, it hurts,” was all he managed between moans. 

Could he have a ruptured spleen or a lacerated liver, I wondered. Both are life-threatening internal injuries. 

I couldn’t bring myself to actively examine him. There was nothing useful I could do. I just held his hand. I guess it shows how profound an atheist I am that it didn’t cross my mind to pray. 

When the paramedics finally arrived, they put a collar around his neck to stabilize his spine, strapped him onto a gurney, cut back his shirt and hooked him up to monitors for the ride to the hospital. He was moaning, confused. “You his wife?” one asked. “You can come with him.” 

My promises of “I’m here, I’m with you, I love you” were then put to the test. I was happy to ditch my bike, but Andrej would kill me if I abandoned his beloved Giant road bike, with his maps of our route here, on the street. 

“Can I put our bikes in the fire truck?” I asked.

“No”

“In the ambulance?”

“No.” 

“What am I supposed to do?” I asked no one in particular, knowing that his injuries could be worsening by the minute. Time was of the essence. 

William, the retired cop, who was still watching, saved me:  “I’ll take them home with me. Let me give you my number.” Andrej is much less trusting than I am and I could hear his voice in my head: “You gave my bike to a total stranger?” I dialed William’s number to make sure that it worked. (William later told me that it hurt him when I made that test call, suggesting that I didn’t quite believe he was being helpful, acting from the goodness of his heart. I feel bad about that.) 

The one-mile trip in the ambulance to MedStar trauma center was agony for Andrej. But at least I could see data on the monitor: good blood pressure, decent oxygen levels. He wasn’t going to die on me. “What happened? Where am I going? It hurts!” he kept repeating. I answered as many times as he asked. 

Within minutes, he was whisked into the hospital trauma bay, the rest of his clothes cut off, examined; injuries tallied, I.V. placed, morphine injected, first-pass portable x-rays done. 

My husband needed what U.S. healthcare is good at acute, no-holds-barred lifesaving treatment. I was grateful he was on the trauma team conveyor belt – I was pretty sure the hospital was in our insurance network. I told the trauma squad that I trained as a physician and once practiced in an ER so they would pay attention to my observations. But I was happy to turn the care over to them and to become just a very worried and slightly too-knowledgeable spouse. (I didn’t mention that I write about America’s excessive health costs or its broken health system, though I did start to wonder about the bills we would get and if there was a trauma team activation fee.) 

And then there came bits of light. The chief trauma surgeon (a woman!) said the first x-ray showed a likely broken rib or two and a broken clavicle. Those injuries were not as terrible as I’d feared. The messenger, as well as much of the trauma team, were female, an unthinkable reality when I worked in an ER 25 years ago, where the trauma team was the cocky cowboys of the hospital. 

Andrej still wasn’t sure what hospital or city he was in, but snippets of his personality — the charm and the ornery — were trickling back. When the surgeon leaned over his stretcher and immobilized neck, she said, “Andrej, can you open your eyes? Can you see me?”

He opened his eyes and said, “Yeah, you look good.”

When he saw me on the other side of the bed, he again asked what happened. I told him we were going to ride in Rock Creek Park and he hit a pothole and was knocked unconscious. 

He had two responses:

  1. “Where is my bike? Is it ok?” (Phew!)
  2. “Weren’t we supposed to have dinner tonight?” 

I replied yes, we had dinner plans with Shannon and Greg. He insisted I let them know we weren’t going to make it. “Do it now,” he requested, “You should.” Really it wasn’t high on my list of priorities at that moment but I promised I would. 

With that, he was whisked off to the CAT scanner to have his head/neck/chest/abdomen/pelvis looked at. Wow, I thought, the x-rays alone in this first half-hour are likely to cost over $50,000. 

It wouldn’t be an encounter with US healthcare without a wallet biopsy. At that point, I was put in the hands of the billing folks, to hand over insurance cards and forms saying that I would pay if my insurance didn’t. With my husband semiconscious with at least three broken bones, what could I say?  

With the business of healthcare settled, I was then approached by a lovely chaplain, who wanted to make sure I was OK. I don’t believe in god and this was not a spiritual venture, though by this point I was most grateful. I felt that whatever Andrej’s injuries, they likely didn’t involve his brain or his spine. I was grateful that he was taken to exactly the place he needed to be. I was grateful that I was riding with him so that he didn’t get knocked out when he was alone and grateful that some five years ago my reckless husband started wearing a helmet. I was grateful that, though he’d had a blood clot in his leg a few years ago, he was no longer on blood thinners. And finally, I was grateful to the bystanders who’d interrupted their Saturday outings to help people they didn’t know. And really, really grateful that we have great insurance coverage.

When you’ve worked in an ER, you see every day how bad it can get.  It seemed there was a lot to be content and calm about at that moment. I felt that way, even as the results of the CAT scans showed more serious damage: six broken ribs in total, some with several breaks. Not just a broken collarbone but a broken shoulder blade too (a hard bone to break – only with very high impact trauma). And just for good measure, a broken fingertip on the middle finger of the other hand, an almost comical development.  

More worrisome, the scans also showed a collapsed lung. Andrej needed a tube surgically inserted between his ribs to drain the blood in his chest cavity, allowing the lung to re-inflate. Once again I was ejected from the room so a resident, another woman, could do the procedure. 

A few hours later he was in intensive care, where he became far more lucid and the injections of opiates dulled the pain. He got a Fentanyl patient-controlled pump that allowed him to press a button for more when the pain kicked in. He pushed it a lot. Though much is written about the overprescribing dangers of opiate painkillers in the US, when it came down to alleviating the agonizing pain of this kind of injury, they were magic.

With his pain controlled by the opiates, he became Andrej. His obsessions – often slightly irritating – became dear. He bemoaned that his phone was scratched up in the crash, not apparently appreciating the miracle that it was still working. (His Strava map shows the exact point of impact.) He sent me home to get all the accouterments he planned to use in the ICU: the iPad and chargers, the books and glasses. The exact clothes he wanted. You’d think he was going on vacation. 

When I got his devices hooked up, he complained that the Wifi in the ICU sucked. With the whooshing of ventilators in the background, I pointed out that most patients there weren’t using devices and probably didn’t care. 

Everything that makes Andrej a free spirit who rides down hills at breakneck speed makes him a pretty horrible patient. He doesn’t like being confined. He doesn’t like being told what to do. At some basic level, he feels that everything is going to be fine and people worry too much. He pulled off the awkward gauze bandage the plastic surgeon had put on his finger. He wasn’t allowed to eat in case they needed to do emergency surgery to stabilize his lung. He tried to talk me into giving him the banana I had in my bag. I said no. Then he tried to charm the nurse into feeding him. 

A day later he was transferred to the floor. And two days after that, moments after the tube draining blood and fluid from his lung was pulled, he was angling to go home. He felt trapped. They were not doing anything useful in the hospital, he said. 

To my surprise, he convinced them. They pulled out the IV, through which he was still getting occasional rescue doses of narcotics. With discharged papers already signed, he summoned me to drive over to get him. 

“I’ll walk down to the lobby and meet you there,” he told me over the phone. 

“That’s a terrible idea,” I blurted out. “I don’t think they’ll let you. I think you should come in a wheelchair.”

“No.”

When I arrived at the entrance, a nurse wheeled him out the front door. Like I said, all the things that make Andrej fun to be with also make him a terrible patient. 

The US health system is great when you need aggressive care and might die. When that is no longer a risk, the system often falls apart. By the time we got home from the hospital, 15 minutes later, serious pain was starting to build. After all, he had nine bone fractures. 

In the hospital, he had been given 1-2 opioid pain pills every four hours, with an extra dose IV if needed. When I went to the pharmacy to fill his prescription for painkillers, he’d been given a total of five pills. Five! He wouldn’t make it through the night on that. In the news each day, we hear that America’s opiate epidemic is fueled by the overprescribing of prescription pain pills. But in Andrej’s case, the pendulum had swung way too far in the other direction.

We had a hellish first few days. Luckily, I had an old unused prescription for painkillers in the medicine chest. I dusted off my medical knowledge and looked up how to convert the doses of one opiate to the other. For nearly a week, I played MD again, maxing out safe doses of every painkiller we had: opiates, Tylenol, Advil, lidocaine pain patches. I even got my hands on some marijuana gummies in the hopes that would help. 

The discharge package with instructions he had signed (but, in his haste to flee the coup, clearly hadn’t read) was not helpful at all: The diagnosis was incomplete. There were two slings, but no instructions about when and how to wear them. There were four pages of printed instructions about tetanus shots. But nothing about shoulder fractures, rib fractures or the finger fracture. I know in the grand scheme of things the finger fracture wouldn’t kill him but, still, it had never been splinted. 

The instructions merely said to call three separate clinics for follow-up: trauma, orthopedics and hand/plastics – one for each type of fracture (rib, collarbone, and finger). In U.S. medicine, every body part has its own specialist and no one seems to think much about the whole person. 

When I called, schedulers at two of the three clinics initially said they were fully booked and no one could see him for at least several weeks. Was I supposed to jury-rig his care? Were we supposed to fly blind until then? What happens to patients who don’t have a medical professional as a spouse?

There were no doctors available to see him for follow-up but, mysteriously, physical therapists immediately began calling, wanting to come to our house to treat him at home. When the first one arrived, she had no idea of his injuries, nor access to his x-rays. We had no idea who had ordered the treatment – which doctor, for which body part? His shoulder was too painful to move at all. His ribs didn’t need PT. We sent the physical therapists away. Does everyone who leaves the trauma service automatically get a dozen sessions of home PT? That’s a good way to make money. Don’t let them in the door, I told him. I didn’t want us or our insurer to pay. 

The good news is that two weeks after the accident, we finally went out with Shannon and Greg for that dinner.  After a few frustrating phone calls and several visits to the hospital, Andrej’s pain is under control, though it will be a long haul to full recovery. After a few irate phone calls to various clinics from me, “Dr. Rosenthal,” Andrej has managed to see the specialist for each body part. They were great, and we have a good plan for his recuperation.  

Yes, I’m grateful to all the people who helped my husband recover from what could have been a deadly injury. The bystanders. The paramedics. The trauma doctor. The interns (doctors for about 10 days at that point) who poked their heads behind the curtain just to ask how he was doing.  ICU nurses. The orthopedist who just yesterday gave us advice for how to heal his shoulder. They are amazing people, but boy do they work in a messed up system. And now that he’s healing, we’re waiting for the bills.

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