70 degrees of freedom

Again, the feeling like being a toddler on Christmas eve...
Thursday is the day I get to set my brace from 30 to 70 degrees of flexion.
'Progress!!' my mind screams, and I feel one step closer to running the moors again!

I need something like this this week.. It's spring. Autumn and spring are my favourite times of year to run. The changing weather and with it the changing trails give me a feeling of joy, peace, happiness and makes my soul feel open to the world. It's one of the very few times that I feel part of anything, like I belong to the earth.

So, the recent change in weather, the lengthening evenings, the sprouting plants, the buzz coming up through the earth...and being unable to run on it...it's driving me mad! Like a terrible itch that I just can't scratch, or a glass of water that is just out of my reach!  So far I've been trying to deal with this by burying my head in the sand, keeping the curtains closed, ignoring the sunshine and cursing the singing birds every morning. My weekly alcohol intake has definitely increased as I try to numb the call of the trails.

I've been trying to scratch the itch with my evening workout regime. I've got some pretty good sessions going now, with the help of Jason as a sparring partner. Getting my heart rate up a little and breaking out into a light sweat, it does make me feel a little better and takes my mind off my loss.

But, nothing replaces the trail.
So yesterday I went for a walk. Well, a hop. Off-road. And it was.....well, it was wonderful. I put my long-distance playlist on my MP3 player (lots of hypnotic music. Gregorian chant, Byrd, Tallis, John Tavener and Arvo Paart.). I left the road through our village and I went up one of the trails and through the fields. I got stuck in the mud, I sat on a gate and watched the birds, I washed my crutches in the stream.
And so I discovered that I can find peace and contentment, even when I'm not running. I can even get a fleeting sense of the meditative state that I feel during an ultra. It's a very, very valuable lesson to learn

Always there for me. 

Stuck-in-the-mud

Now, to 70 degrees of flexion, and whatever the next stage of my recovery brings!

Victories:
Learning that I can find at the very least a shadow of my running contentment by being in the right environment, at the right time, with the right music and the right frame of mind.

Things you shouldn't say to an injured runner - warning, sense of humour failure!

Below are a selection of comments I've had from a few *less than* thoughtful people since this happened (none of whom are at all likely to be people who would read this blog which is why I'm happy to publish them!)

In each case what I really wanted to do was to pull the person inside my mind and let them feel my pain and loss at not being able to run, and the effect their comment has had on my psyche. Or maybe to invite them to witness me sobbing uncontrollably during my designated 'sadness' times. Then maybe just think a little.


1. 'It's the worst patella fracture I've ever seen. This is going to really affect your running.'
This statement comes under the headings 'blunt' 'thoughtless' and 'stating the bloody obvious'. Yes, my entire knee is going to function differently. And you think that will impact on my ability to run? Wow, you frickin' genius.

2. 'At least you'll lose that terrible gaunt runner physique, and become more womanly.'
So I'm going to be unable to run, AND I'll get fat? Double whammy saying this to a runner who used to be anorexic!

3. 'All that training and you won't be able to compete this year'
Yes, I had realised that, but thanks SO much for reminding me.

4. 'Well that's your cardiovascular fitness out of the window. No amount of weight training can maintain that without your running'
And my resting heart rate used to be 45 and is currently 70. How about you give me another kick while I'm down?

5. 'Hey, tried running yet' - followed by a wink and a laugh
No. No I haven't. I'm not weight bearing, my knee is only flexed to a max of 30 degrees, and I know that it's going to be another 4-6 months before I can even contemplate this. But, hey, GREAT joke!! What do you mean, 'sense of humour failure'?!

Each of these comments has elicited the same response from me. 'Yes, it is terrible. But it could have been worse, I could have cracked my skull open or snapped my neck'.

In short, we runners are a physically tough but sometimes emotionally sensitive breed, and sometimes, just sometimes, it's better to think about the impact of what you're saying on a delicate and endorphin-deficient mental state.
Rant over.

Short and SWEET!

Oh by all the Gods, I just managed my first straight leg raise!!
And then managed 2 more!!!!

It's the little things that are now a massive deal to me!
I'm going to have a beer to celebrate!

Quads-r-us!

The beginning of the end of the beginning

Delayed publication due to police investigation.
This is a long blog, documenting my recent accident. I've written in detail.

Over the Christmas period I had suffered from a depressive episode, which had really taken its toll on every part of my life. It also resulted in me having to cancel my plans to travel to Sierra Leone, as I was not in any fit mental state to manage such a major change. I had to come to terms with how my plans would have to change. I was still able to run, but I was getting very little joy out of it because of the exhaustion that comes with depression and I knew I was doing it more to preserve my little remaining sanity. Endorphin chasing to take the edge of the misery. By the middle of January I was more settled on some new medication and was starting to feel small tendrils of hope pushing up through the mud. I had plans for courses to go on,  races I wanted to do, aims to get selected to the GB trail team again and a bit of traveling I might manage if my mental state continued to improve.

On 20th of January I fell whilst training on the coastpath, splitting my knee open on a rock. The cut went right down to the bone and needed suturing, and the knee itself was very swollen and painful. Dad told me that I wouldn't be running for a couple of weeks at least. I limped around in a bad mood for days, snapping at family, whinging about how I was going to get fat. By day 9 I tried to go for a run, got 3 steps and was stopped by the pain. Huh. Well, at least now the wound was closed I could swim. And with the AoA a definite no-go, I was pretty confident I would heal in time for Transgrancanaria in March, which was my first A-list race of the year. I could not wait to hit those mountains!

On 30/1/16 I went for my first swim. 3.5K later and my knee was feeling a lot looser and I was feeling a lot more optimistic! I spent lunchtime cleaning my road bike and then late in the afternoon I decided to give my knee a try on the bike. Setting off up the hill from home I felt a little stiff, but my knee handled the rotational movement well and so I carried on down through Horrabridge towards Tavistock, planning to do a loop of the town and head home again.
I worked hard down the hill from Grenofen as it was raining and I didn't want to get cold by just coasting. I wasn't thinking about anything in particular.
What happened next happened so quickly, but the time involved also seemed to become stretched out. I saw a car pulling across the road into my path, turning off the far lane into the car park of Lidl. Directly into my path. Seemingly moving so slowly. In my mind, I knew I was going to hit it. I was cycling down the road with no reason to stop, and had not been slowing for any reason as I had right of way, I was probably doing between 15-20mph, and now, here was this car, in my path. I thought briefly about what I could possibly do to avoid this. But these thoughts were fleeting, I think I screamed 'No No No' and in my head I was just thinking 'NOT now, this CAN'T be happening.  Everything is just starting to get better'
I don't remember impacting the side of the car, rolling over the bonnet, cracking the windscreen on my way. I don't remember landing on the road on the far side of the car. What I do remember next is intense pain in my right knee and an overwhelming feeling of despair at what, even at the point, I knew were going to be serious injuries. I started crying uncontrollably, screaming and screaming, rolling around in pain (I never understood that phrase before...I do now) while people tried to calm me down and protect my C-spine. I remember hearing a lot of screaming children and people trying to get my details off me while I continued to scream and cry and shout that I just wanted Jason. My knee was in so much pain and I felt it would be more comfortable if I flexed it, but couldn't move it. Wave after wave of despair and fear washed continued to wash over me, and I started to shake uncontrollably. Someone told me everything was going to be ok,  and i just sobbed back 'why this now? Everything was just starting to get better'. When the ambulance arrived I was scooped off the ground into the back, and given entonox for my pain. The paramedics put all the heaters available on, but I was still shaking violently and the Entonox did little for the pain, but did make me hyperventilate. As we reached Derriford I came close to passing out.
In resus I was met by one of the ED consultants 'Hi, I'm Higgy, I'm one of the ED consultants'. I responded it 'Hi, I'm Sarah one of the medical SHOs' at which point he recognised who I was. Jason arrived and I began to calm a little, partly due to the bolus of morphine that I'd been given on arrival. I stopped sobbing and tried to think 'ok, it'll be fine, I'll look stupid because all this is just going to be bruising'. Higgy examined me, cleared my C-spine, my thorax and pelvis. He checked out my left knee, which had a gaping open wound over it. Asked me to straight leg raise, which I could with no problem. Checked my right knee, minor abrasions to the knee surface, asked me to straight leg raise.....and I couldn't. He poked around my kneecap for a bit and then said 'you've broken your patella'.
5 minutes later he had to ask me to try to calm down. The waves of despair and fear were back, and this time they were a tsunami. I knew the implications of a patella fracture for a runner. I went for imaging, and when he had reviewed that he had more bad news. It wasn't a simple fracture. It was smashed into lots of bits. Pretty soon after that I was seen by Mr Stitson the orthopaedic consultant who painted a doom-and-gloom picture of the extent of comminution, difficulty of fixation, potential need for a partial patellaectomy and uncertain long term function. I asked if I would be able to compete again in the future, but all he could tell me was 'we'll just have to wait and see'. The draw-back of having done 8 months of orthopaedics is I have a good understanding of what was going on in my knee and why they were being so pessimistic. I spent the rest of the evening trying to think of the positives; I'm young, I'm very fit, I don't smoke, I have no other health issues, it's not an open fracture and my bone-stock will be good due to the impact exercise I do.
So, Saturday evening left me lying in bed, waiting for my operation on sunday morning, and trying to come to terms with how quickly my identity had changed, and just how different 2016 was going to be compared to what I had planned out. No TGC. No world championship trials. No race to the stones/race to the King double, and no West Highland way. And, most of all, no opportunity to represent my country at the sport I love the most.
Maybe I will still get these chances in the future. Maybe it will only be as a finisher and not a winner. Maybe it won't happen at all.
In the words of  Mr Stitson, "We'll just have to wait and see."

Punching fate square in the face

Well, it's been 3 weeks since my accident. Actually, it's really been 2 and a half, but I'm counting it from the dates of my fracture clinic appointments.
I always like to have things to look forward to and focus on, it keeps me going when my mood drops. Before this happened I had some major points of focus in the coming few months, and my plan was this:

Interview for CMT in February
Transgrancanaria in March.
Skiing holiday over Easter
Expedition medicine course end of March
Hoka Highland Fling for the GB trail team trial at the end of April
MRCP exam in May
West Highland Way race in June
Race-to-the-stones and Race-to-the-king double over the summer (I had free places courtesy of Threshold events)
Spartathalon
I was planning on applying for Less-than-full-time training when I get my CMT position so that I could manage my running around work.

My current list of focus points is as follows:

25th of Feb - DonJoy brace gets set to 70 degrees of flexion!!
10th of March - 6 week fracture clinic appointment when I find out if I can start doing aqua-jogging and swimming!!!!
Thankfully I still have MRCP exam to focus on, and I have managed to postpone my CMT interview until March (it was originally due 1 week after the accident, and I was just in too much pain to manage). I may even make it to the May edition of the expedition medicine course so thankfully that isn't out of the window.
Maybe I'll even manage a 10km race at the end of the year.....

Funny how your plans can change so quickly. In the few seconds it took me to smash my knee I have managed to lose a whole years worth of plans, which were mainly focused around competition. I'm finding it a challenge not to dwell on this, and trying so hard to focus on my new goals and plans. In an attempt to manage this, I have set aside 15 minutes each day when I am allowed to sit, feel despair, cry and dwell on my losses. It sometimes spills over at other times, but it does help to have that designated time of misery.

So, back to the present.
I'm feeling so much better, physically. But I'm drastically limited by the fact that I can't put any weight through this leg. I was allowed back to work this week, which was wonderful, it was so nice to be doing something positive. It has been a bit strange having to repeat the story over and over as people ask me what I've done, and I have found it difficult when people have asked how it will affect my running. But I think it has also served to help me see my purpose beyond running. I love my job, and it was so good to be back.

Now I'm getting more mobile I'm desperately trying to find ways to maintain some kind of fitness. It is extremely challenging! My upper-body strength was pretty good before hand, but I'm now having to use my arms and torso to do any form of exercise, and so I'm finding my weak points very quickly! Our front room is starting to resemble some sort of mini-gym as I buy gadgets that I can use to help with fitness. I'm also lucky to have my own personal boxing coach (I knew Jason's Krav Maga lessons would come in useful one day, I just always assumed it would be to beat off muggers in the rough end of Plymouth!). I have also discovered that I can sit on my bike on the turbo trainer and pedal with one leg (thanks to Kirsten for that stroke of genius!). I'm still a little limited with this due to the pain in my 'good' knee which, although not broken, still took a heck of a smack.
So, my evening workout is currently something like this:
10-15 minutes on the turbo trainer (low intensity as I'm cycling with one leg)
10 minute push-up set on the Swiss ball
15 minute abdominal set (sit-ups, crunches, oblique sit ups)
15 minute boxing set with Jason (this is the only work out I can currently do which gets my heart rate elevated much. Basically, I lie on the floor, Jase stands over me with the pads, and I do sets of jabs, hooks and elbow strikes as dictated by him. It is exhausting, and brings me out in a sweat. I love it!!)
10 minutes bicep/tricep/shoulder/lat work with dumbells.
5 minute isometric quad exercises.

In short, I'm going to end up resembling Popeye. But, it gives me daily focus and a tiny endorphin hit, and so until the 10th of March, this will have to suffice.
If anyone who has read this would like more detail on how to do the exercise set I'm using, please drop me a line!


Take that, fate! Stand still while I punch you repeatedly in the face!! 

Victories:
Managing my sadness in a controlled manner
Finding ways to maintain some core fitness
Reconfirming to myself how much I love my job.

Brace brace baby!

My 2 week fracture clinic arrived! Well, it wasn't quite 2 weeks to be honest, it was 11 days. But the op note said, and I quote:

Ahem-hem: 'Convert from back-slab to brace at 2 weeks. Brace set at 0-30 degrees for 2 weeks.'

Oh, thank god. This back-slab was REALLY starting to hurt me. All the padding underneath had slipped down, and it was now just bare POP rubbing against my skin, and more importantly, against my frickin' surgical clips, OUCH! Add to that the fact that it now smelt a lot like how I imagine a dead badger left out in the sun for a week would smell. I could not wait to be rid of the damn thing!

I woke up on Thursday morning feeling like a child on Christmas day. My fracture clinic appointment wasn't until 16:10, so I had to spend the day amusing myself whilst I mentally bounced off the walls in excitement. When the time came to go to my appointment I nearly rocked up with my own pair of scissors!

I was waiting outside clinic and was met by Kirsten, one of the lovely people I know from my time in the T&O department. Kirsten is awesome, like a cross between a big sister, a mate and a partner in crime. It was so good to see her and the other lovely people in fracture clinic. I do feel lucky to be under the care of a department where I used to work, and in a hospital where I know so many people. while I sat waiting I must have got 'Hello, what on earth are you doing here?' from about 6 different members of staff, from consultants to porters. It really is like a big (slightly dysfunctional) family!

So, into fracture clinic. I can't describe the moment of ecstasy when they took the backslab off! I can only imagine what it is like for people who have to be in cast for 6 weeks!! The surgical clips came out. (a quick note, I'd been warned about this by loads of people...'oh, it really hurts, really stings when the clips come out'. It really doesn't! Out of around 20 clips, maybe 2 of them stung a bit. So, if you ever have to have surgical clips out, don't sweat it. You may well find it completely painless!)
The wound was looking good, and the 2 ortho SpRs who were running clinic (one of whom I know as a runner and one of the nicest surgeons you could hope to meet!) were happy with the wound and so happy for me to be fitted up with the Donjoy brace.

Donjoy brace with hinge set from 0-30 degrees of flexion

"Sad wounded pixie" face. Used in an attempt to look pathetic so people do stuff for me/give me free stuff.

Brace time. The clinic physiotherapist fitted me with the brace. As it went on, all I could think was 'oh my god, I look like a Borg, this is COOL! Mis-spent youth). She then told me that my quad strength was non-existent.

I'm sorry, what? I think anyone who knows me would know why this would ruffle my feathers slightly. I told her that I was a long distance and mountain runner, and my quads were my best feature. Her answer was that, as soon as the patella fracture occurred the quads would have lost strength, and now 2 weeks down the line, they would need building up from scratch. Fair enough. I asked how, and she described the static quads exercises that I had already been doing. I told her that I was already doing those. Her answer was 'fine, then carry on'. I said that I was a competitive runner and that I was keen to keep my overall strength as much as possible during the rehab period. She just shrugged and told me to do the exercises. I asked how often, she shrugged again and said 'until it hurts'. I asked if there was anything else I could do to maintain base fitness while I was TWB only. She said no. I asked when I would be able to start swimming. She said not for another month and even then I probably wouldn't be able to swim, it would just be aqua-jogging.

Basically, this girl really pissed on my enthusiasm.

I left fracture clinic feeling like the whole thing was a massive anti-climax. I spent the evening in a really bad mood, and the brace was hurting like hell. I have 30 degree flexion now, but suddenly it seems like an age until I will be trying to ease back to normal function. I know that it is early days, and I know that I have progressed so much even in the short time since the accident. But in the space of 24 hours my mood has dipped from positive and enthusiastic to so negative that I could barely be bothered to get out of bed the following day.

Reflecting on all of this, I know I set myself up for a fall. I was so excited and fixated on the cast coming off I didn't think about the other side. But the whole experience was made so much worse by the negativity and thoughtlessness of one member of staff. All I can do is take it as another lesson for myself for my own practice. Negativity is sometimes a necessary thing in communication with patients but it HAS to be tempered with a balance of positivity and empathy, or you do more damage than good.

Victories:
Cast coming off and my body having dealt nicely with the surgical wound.
Reflecting on the situation and working out how I can put the lesson into my own practice.

Not for the faint hearted

Just a warning before you read this...it contains details which will not be at all surprising to anyone of a medical background, but may be slightly shocking to those that aren't.
I'm going to talk about my bowels.
Yes, I am.

Since the accident, I'd been using quite a lot of opiate analgaesia to manage the pain. This started with a lovely dose of IV morphine from the guys in resus, and continued with frequent doses of Oramorph and Tramadol when I got up to the ward (I was initially given codeine, but it had no effect on the pain. Interestingly my dad also reports no analgaesic response to codeine. A quick tutorial, codeine is a pro-drug and only becomes active when it converted to morphine by your body. Around 6-10% of the population have an abnormally functioning gene for, and therefore have reduced levels of the enzyme that converts the pro-drug, and so for them codeine has limited effect as an analgaesic. I'm assuming both my dad and I fall into this group)

When I got home from the hospital I was using 20-30mg of oramorph every 4 hours. The pain was so bad I felt like I wanted to use more, but having never had opiate analgaesia before in my life I was worried about how my body would handle such high doses anyway, and I was concerned about becoming tolerant to the effects and therefore being left with pain that didn't respond to the drug. I was also prescribed tramadol, but knew that there was a risk of interactions between that and my regular antidepressants so I didn't want to use too much of that.

I was interested to see how my body handled the new experience of opiates. With the first few doses in the hospital I felt quite swimmy and sleepy, but not in a particularly comfortable way. They also left me feeling just on the edge of losing control of my body, which is an experience I hated. This was particularly noticeable with the fentanyl I was given prior to anaesthetic. I've heard the anaesthetists describe the midazolam/fentanyl bolus used as induction like 'getting a large G&T', implying that it is a pleasant experience. I've also spoken to other people who have loved the feeling induced by these drugs. Not me. I hated that feeling on being right on the edge of consciousness.

Luckily I didn't seem to be prone to the nausea that opiates can cause in some people. I did seem to become massively sensitive to electric light, and I found it really hard to be in brightly lit areas. Interestingly this didn't apply to daylight. My balance was really affected and I kept getting limb jerking which I'm pretty sure was due to the drugs.

And, the constipation. Oh yes, I knew opiates caused constipation, I've managed plenty of people in hospital who are suffering from this side effect. In my own practice I never prescribe any opiate analgaesia without an antiemetic and a laxative to go with it. I myself have never suffered from constipation before. I'm active, I have a good diet, I eat lots of fibre. I'd never had to worry about not having a bowel movement.  But now, I was bed-bound, I was not eating anything much, I was dehydrated and I was taking regular oramorph. And I was, stupidly, not pro-active in preventing it.
On Wednesday (4 days since my last bowel movement) I started taking regular laxatives. I wasn't in any discomfort, but I was worried about how this might progress. On Friday, still no bowel movement, I was feeling quite 'heavy' and I added a second type of laxative to the first. On Saturday I sent Jason out to buy suppositories. Later that day I managed to finally go (without the suppositiories). It was intensely painful, exhausting and something I hope never to have to experience again.

Last resort.....

So, there you have it. Of all the side effects of drugs I have experienced, this is definitely the worst. It is comforting to know that you can take medications to correct the problem, but I will NEVER underestimate the distress that constipation is causing one of my patients ever again.

Victories:
Opening my bowels!!
Realising that this experience will definitely make me a better doctor