Here’s to 2014 (Back in the Saddle)

Above: me at the ruins of Apamea, Syria, on our 2008 London to Cape Town motorcycle adventure. Photo by Tom Smith.

After the emotional chaos of 2013, I have a good feeling about 2014. I now have objective evidence that my strength is slowly returning. First I was able to lift my right arm above my head, then I was able to lift one pound, and then two. A recent neurological power exam showed some modest improvement as well. The fasciculations, which had relentlessly persisted for the first several weeks after my surgery, have finally started to decrease in frequency, and now I only notice them after I exercise. For the first time, I am convinced that ALS is off the table. That is worth celebrating. Yes, I still have significant weakness and atrophy in my right shoulder and arm, and I will probably never recover to where I was before. But I believe I will recover to the point where I can practice medicine. I feel like I have been given a second chance at life. It feels good to have a goal: to regain enough strength to return to my residency training and become a Neurologist.


The emotional impact of facing my own death, and worse, becoming trapped in my own body, has forever changed me. I am not the same person I was before. I think how I feel now compares to the feeling that comes after a motorcycle or snowboarding crash: a lack of confidence, a sense of fragility instead of invincibility, and overall tentativeness. I have been reminded of how fleeting health, and life, can be.

My views on doctor-assisted suicide have also been shaped by believing I would die a slow horrible death from a degenerative neurological disease. I firmly believe that we should embrace doctor-assisted suicide as a society. I know this to be the right choice – not because of specific legal or ethical arguments, but because I felt it to be right when I faced my own death. There is no expunging a feeling that powerful. And as powerful as empathy may be, I don’t believe that a person can truly know how it feels until they face it themselves. I am excited that 20 years after Sue Rodriguez brought her case to the Supreme Court that another case may be heard soon arguing that the prohibition of doctor-assisted death in terminally ill patients is unconstitutional. Maybe the law will yet be changed.

There is no way that my experience as a patient could not impact me as a doctor. I always cared; I was always empathetic – but I think that this experience will only enhance those qualities. I have also witnessed the awesome power of a correct diagnosis first-hand. I was diagnosed within 48 hours of my first presentation to the EMG lab (thanks to Dr. McNeil and Dr. White). If I had not been a Neurology resident working at at tertiary care centre, how long would it have taken me to be properly diagnosed? Would I have been properly diagnosed at all? Reading similar case reports to my own case, I have found that no one was diagnosed correctly initially. In some cases the correct diagnosis took many years. I have been lucky enough to have had a surgical repair of my dural tear within a few months of first noticing my symptoms, which started 8 years after my initial CSF leak! How different would my life have been had I not been inspired to apply to medical school after my initial dural tear 8 years ago? A delay in surgery would almost certainly mean less chance of recovery.

I am looking forward to 2014. I am excited to get back in the saddle. As with every crash I’ve ever had, I expect my confidence to come back. It will just take some time. I am so thankful for the love and support I have received from my friends and family, and even complete strangers who have come across my story.

Looking back at my blog, I see that last year at this time I was concerned about the deteriorating humanitarian situation in Syria. Syria has always been one of my favourite countries because of the warmth of its people and the richness of its history. Last year I made a video montage of photos from our trip through Syria (which we rode through on our London to Cape Town motorcycle adventure in 2008). I will share it again now, because as bad as it was last year, it is even worse now. My heart goes out to the people of Syria. They have suffered so much death, and millions are living day-to-day in refugee camps. The destruction of their country is a tragedy on an astounding scale.

Advertisements

The Most Inappropriate Man in the World

I am pleased to report that I am recovering from my spine surgery in the comfort of my parents’ home in Lethbridge. The cellulitis is fading more and more every day. The pain is much better and I am now off pain medications (although there is still some pain in the background). I can get my right arm up above my head, which is a big improvement, but I am still unable to lift even 2 lbs above my shoulder. This is discouraging, but the fact that there has been some (albeit minimal) improvement is encouraging. I am still experiencing frequent fasciculations in my shoulders and arms, which is a constant reminder of what I thought I was facing.


As the year comes to a close, it is tradition for us residents to present a video at grand rounds that gently makes fun of ourselves. This year I was recovering from surgery so I could not be involved in much of the filming (although Colin, the director and producer, did come over to my place to shoot some scenes). Thus, we decided that I would put together a stand alone “commercial” that is a spoof of the Dos Equis “Most interesting man in the world” commercials – except billing me as “The most inappropriate man in the world”. I had friends send in their favourite anecdotes of me being inappropriate. I was amazed at the sheer volume of responses. And yes, I did steal my friend’s wedding gift but only because it was left in a hotel room and he had already departed on his honeymoon without it. It was a damn good bottle of Scotch and I didn’t want it to go to waste. But I always intended on replacing it, so you could say that I really was only “borrowing it”. 

Of course, because the intended audience of the video was a work audience, a large portion of my most inappropriate moments had to be omitted. Nonetheless, a lot of material still made its way in. The video that I have shared below is actually filled with one full minute of extra bonus inappropriateness compared to the theatrical release that was shown to my work colleagues earlier today. One conclusion that could be drawn is that I actually am inappropriate. However, I prefer to think that other people are just overly sensitive.  You be the judge:

Reminiscing about A Motorcycle Crash in Ethiopia

I have recently discovered the existence of video footage of our 2008 motorcycle adventure from London to Cape Town. I had forgotten that we had done some video blogging along the way. Recently Tom found the video footage in his archives. I have edited a couple of entries together and and you can view it below. What you will see is a video blog entry of the aftermath of my crash in Ethiopia when I hit a dog just outside of Addis Ababa, Ethiopia. This was actually my second crash in Ethiopia. I have previously blogged about my two crashes in Ethiopia. 


I had been trying to overtake a semi truck when a dog ran out in front of the semi truck right into my path. I didn’t have time to avoid hitting it. My front tire ran over it and it got wedged under my bash plate sending my bike (Rosa) flying upwards and then crashing down on her nose. I ended up getting thrown off the bike and getting pinned beneath it. It was a scary moment. Luckily I was not seriously injured. We managed to fix my bike at the side of the road to the point where I could continue to ride to the next hotel. Later that evening Jeremy would finish the repair job in the room surgeon style.

In the video you will first see Jeremy suturing my front cowling back together with zip ties. You can see that he was already a budding surgeon. Then follows my video blog account of the crash. Tom had already crashed earlier on the same day. He had attempted to overtake a semi truck in Addis Ababa and then got squeezed into a large cement pipe that was lying on the side of the road. The impact and subsequent crash knocked off both of his panniers. 



Above: Tom hit a cement pipe on the side of the road when he got squeezed trying to overtake a semi truck in the dense free-for-all congestion of the Ethiopian capitol, Addis Ababa. I ended up paying a local kid to ride with me on the back of my motorcycle to guide me to a place where I could buy some wire to reattach Tom’s panniers to his bike. However, because it was a Sunday, everything was closed.  We didn’t end up finding any open shops even though we rode around Addis for an hour. Eventually we must have found some wire because we did repair Tom’s bike on the side of the road.
 



Above: This photo was taken on the side of the road just outside of Addis Ababa, Ethiopia. I had just crashed because I hit a dog while trying to overtake a semi truck. I was lucky and only had some road rash on my elbow. We were able to repair my bike (Rosa) on the side of the road to the point that I could ride to the next hotel. While there, Jeremy repaired my broken front cowling with zip ties. The next morning we set off with my bike in working order – except for the return of electrical problems that had been plaguing me for most of the trip. They had been temporarily fixed in Gondor, Ethiopia. But from the time I crashed outside of Addis Ababa onwards, the only way to get my engine running was to bump start it. Often I could park it the top of a hill and use gravity to get it going. But Tom and Jeremy did their fair share of pushing my bike, even in the rough rocky roads of northern Kenya. It was finally repaired for good in Nairobi, Kenya.


Above: Video blog in which you will see Jeremy repairing my front fairing and me describing my reaction to my crash after hitting a dog in Ethiopia.

At the time the above video blog was recorded, Jeremy was still having significant knee pain from a crash of his own several weeks before in Egypt. Jeremy would feel the effects his injuries for the remainder of the trip, which we would later discover (months later back in Toronto) included a tibial plateau fracture.


Above: In Egypt, a few hours south of Cairo, Jeremy crashed his motorcycle at highway speed when he hit a speed bump that he had not seen until it was too late. It was covered with a fine layer of sand from the desert and we had just installed new knobbly tires in Cairo. When he reflexively tapped his brakes, it was like trying to brake on a patch of black ice. I was riding behind him. I saw every horrifying moment. I saw Jeremy and his bike go down. Jeremy was thrown from the bike and they both slid separately down the highway for a long distance. Jeremy had impacted his knee on the highway when the bike went down. After the crash, Jeremy was unable to weight-bear and had road-rash on his knee. Tom and I determined that he was not able to ride himself to the nearest town (despite his vehement protests), so we loaded his bike into the back of a pick-up truck and he rode in the cab (while we followed on our bikes) the one hour drive to Beni Suef. We didn’t actually seek medical attention until the next day when Jeremy’s leg swelled up and turned purple. Our medical school minds jumped to the conclusion that it was compartment syndrome. The English-speaking Egyptian doctor laughed at us (rightly), ordered an X-ray (which was normal), and sent us on our way. The whole thing cost $10. We felt bad that we were treated as VIPs and bypassed the people who had been waiting for hours, including a guy bleeding into his gauze covered axe wound. Jeremy would go on to successfully cross the deep sands of the Sahara unable to really put any weight on that leg.


Above: Google map showing the location of the small city Beni Suef, Egypt.


Above: Jeremy on a riverboat tour of the Nile near Luxor, Egypt, en route to visit the Temple of Seti. You can see the ugly bruising that was still evident on Jeremy’s left leg about two weeks after his original crash near Beni Suef. 

On a personal note, I am recovering nicely from my spine surgery, although I did have a minor setback. Two days after my discharge I had increasing pain and discovered that I had developed cellulitis. I have therefore remained in Calgary (instead of going to Lethbridge as originally planned) to keep an eye on my wound. I have been on a 7 day course of antibiotics. It is still red, but the pain is decreasing and it looks way less angry. I have also been persistently anemic. My parents have moved in to my place in Calgary and have been feeding me roast after roast. They don’t want me more than 7 minutes away from the Foothills hospital despite my protests. The pampering is nice, but I am getting restless and tempted to do more than I should. They rightly try to keep me in check. 

Despite the protestations of my parents, I did a full neurological exam on a family member yesterday. My back was killing me by the end, but I was happy to find that I could do everything except the power exam. I still have significant proximal upper limb weakness, especially on the right. I think there has been a slight improvement, but it is difficult to know for sure. However, being able to do an almost complete exam gives me hope that I may be able to still practice Neurology one day.

Above: Yesterday the mercury soared to +9 degrees Celcius here in Calgary after plunging as low as -30 last week (-44 with the wind chill). I took the opportunity to barbecue up some juicy ribeye steaks. This is me devouring one. It didn’t last long. Steak is medically indicated for my anemia, right?

Reconciliation over Retribution


“Today, a great light has been extinguished. The boy from the Transkei has finished his long walk. His journey transformed not just South Africa, but humanity itself.”

― Taoiseach Enda Kenny


Above: Nelson Mandela holds the World Cup. I chose this image because I feel some connection having gone to the FIFA World Cup in South Africa in 2010.


“I have walked that long road to freedom. I have tried not to falter; I have made missteps along the way. But I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb. I have taken a moment here to rest, to steal a view of the glorious vista that surrounds me, to look back on the distance I have come. But I can only rest for a moment, for with freedom come responsibilities, and I dare not linger, for my long walk is not ended.”

― Nelson Mandela

I am very glad that I had the chance to visit the Transkei, Nelson Mandela’s homeland, in 2010 by motorcycle. (The photo above was taken in the Transkei by Jeremy Bezchlibnyk). Nelson Mandela’s life-long fight for freedom and justice, and his message of reconciliation over retribution, is a message the world should never forget. 

To celebrate our graduation from University of Toronto in 2010, Ted, Jeremy, and I rode our motorcycles 10,000 km through South Africa, Mozambique, Zimbabwe, Botswana, and Namibia. We spent several days riding the rugged coastal region of Transkei, which is Madiba’s homeland.


Above: Ted and Jeremy in front of typical dwellings in the Homeland of Transkei, South Africa.


Above: Ted rides single track in South Africa’s Transkei region.


Above: Jeremy riding along the coast in South Africa’s Transkei region.


Above: A photo taken by Jeremy of me riding through the wild Transkei.

We also had the opportunity to attend a FIFA World Cup match, 15 years after South Africa hosted the 1995 Rugby World cup as a newly minted democracy thanks to Nelson Mandela’s life-long struggle. 

Nelson Mandela used the power of sport to unite a nation. When he donned a South Africa Sprinkboks jersey at the 1995 Rugby World Cup, it was a powerful symbol because these were the colours of his former oppressors. He showed South Africa and the world with that gesture that he was willing to rise above revenge and retribution. 

Above: Nelson Mandela presenting the William Webb Wellis Trophy to Francois Pienaar, the captain of the Springboks team after South Africa won the 1995 Rugby World Cup. Francois would later say that President Mandela had thanked him for what he had done for his country. He replied, “No, thank-you for what you have done.”

On a personal note I was discharged from hospital yesterday. I am in some pain, but doing well. My parents have been pampering me. The one advantage of recovering from spinal surgery at this time is that I can watch history unfold over the next several days without being interrupted by my pager going off.

Below is a video showing footage of our motorcycle trip through several countries in Southern Africa, including our trip through Mandela’s homeland, the Transkei.


I’m A Big Boy Today

Ever since I started residency as a wet-behind-the-ears PGY1 resident, there has been a certain charge nurse on unit 112 who has always looked after me. Nights on call were never as scary if she was on, despite how sick the patients were that we were trying to keep alive overnight. Now that it has become my turn to be a patient on the very same unit, she has gone to extraordinary lengths to make sure my stay is as pleasant possible under the circumstances. In fact, everyone on unit 112 has been amazing. The nursing care I have received has been extraordinary, and delivered with an extra touch of compassion. I guess maybe I wasn’t too much of a jerk to the nurses when I was working as a resident after all, or things might not have gone quite the same way for me

I’m so thankful that I was admitted to unit 112, which is the best unit anywhere in my opinion. In addition to my guardian charge nurse who took it upon herself to take me under her wing both as a resident and now as a patient, the other charge nurses, nurse practitioners, and RNs have been out of this world. I’m not sure if they would feel comfortable with me mentioning their names publicly here, but you know who you are

Although things are looking up now, I have gained a new appreciation for what a post-op neurosurgical patient goes through. I have especially gained an appreciation for the travails of patients assigned to bed rest. In my case I was told to lie flat for 5 days in the hopes of increasing the chances that the dural tear repair will seal and that I won’t have a persistent leak. This would have been unbearable if it were not for my incredible nursing care, my family bringing me gourmet meals from the outside, and the constant flow of visitors. 
Left: My mom feeding me a bowl of pho a few hours after my surgery last Wednesday! I was still coming out of the anesthetic. Right: A nice plate of pad thai and basil seafood to replace what was called “lunch” in the hospital. I’ve been eating like a king every day and haven’t even touched the hospital food until this evening.

In my opinion, being on forced bed rest really challenges the post-op recovery. You just can’t find a position that isn’t painful and you descend into muscle spasms. I felt like I could feel myself getting more and more deconditioned with each passing day. It is basically impossible to sleep. There is no comfortable position. Combined with the noise from the unit, the late night code blues, the unfortunate delirious patients nearby, and the beeping machines and call bells, there isn’t enough zopiclone to stay asleep for long.

But for me it wasn’t the lack of the sleep that was the worst. The worst was having to lay on my incision which was like lying on an axe buried into my back. But a close second was being unable to void once my foley catheter was pulled, which necessitated in-and-out catheterizations. By the end of the first night after my foley had been pulled and I still was unable to void and was on q4h caths, I insisted that the foley be replaced, and it was. It only came out this morning. What can I say? A man needs to stand up to pee. I was not allowed to even sit up. The knowledge of the impending in-and-out caths in the event of failure only added to the stage fright.

I was supposed to lie completely flat for 5 days. However, today (which was only day 4), I hit my limit. With the help of nursing I painstakingly sat up on the edge of the bed with my incision site burning with pain. I was slowly helped to my feet. Magic! Once I was standing, my back pain receded. I was light-headed for a moment, but then started to feel much better. Originally, the plan was to transfer me to a chair, but seeing how well I was doing my nurses asked me if I wanted to take a few steps. Damn right I did! We made it out into the hallway. I walked halfway down the hallway holding onto the nurses initially but by the the end I was walking on my own with the nurses only standing close by for support. I made it back into my room without difficulty. I sat down in the chair. My Mom, Dad, and brother arrived to visit me at that moment as they did every day, pleased to see me sitting up for the first time. 
The nurses left me with my family. However, within moments a wave of nausea hit me. I suddenly felt distinctly unwell and started to get tunnel vision. I slumped backwards. I was later told that the coffee mug I had been holding fell out of my hand onto the floor, my eyes rolled back, and I turned deathly pale. I had lapsed into unconsciousness. All of this happened at the worst possible moment – right in front of my Mom, who went running into the hallway yelling for help. I regained consciousness not knowing who I was or where I was for several agonizing seconds with a room full of strangers staring at me. Luckily I had not fallen out of the chair and the nurses immediately flattened the chair and I slowly recuperated. I began recognizing the people around me. I had hot clammy sweats. But at least I knew where I was!

That was my first adventure. My second would come later in the day. Throughout the afternoon I slowly worked up enough courage to go on another expedition. My main motivation was to avoid yet more in-and-out catheterizations as my (second) foley had been removed that morning. My patient and compassionate nurse coaxed me to the bathroom and gave me ample time to void into a jug. He even turned on the tap to simulate the sound of a waterfall and left me in peace. I thought for sure I would eventually be able to go. It couldn’t be worse than the stage fright of trying to take a piss at a rock concert or hockey arena with crowds of jeering yahoos pushing up behind and somehow I had been able to overcome such adversity on these occasions. 

Unfortunately, after a half an hour I had to admit defeat. It just wasn’t going to happen. Another in-and-out cath was coming my way. Just as we were about to leave the bathroom to make the return trek to my bed, the world started closing in on me again, much as it had that morning when I had fainted right in front of my mother. I told my nurse I wasn’t feeling well and he helped me gently down to the ground and told me to take deep breaths. I concentrated on breathing but I could feel the same cold clammy sweats and again I felt light-headed and my vision started closing in. I thought for sure I was going to faint. Maybe it was the feeling of the cold bathroom floor on my bare butt, or the cold ceramic toilet bowl on my leg, but this time I was able to cling to reality. Eventually I was able to stand up and use the IV pole for support and hobble back to bed. It would not have been the first time I had passed out on a bathroom floor, but I seem to recall more fun in the lead-up to the previous occasions. Still, I vowed “I’m never getting spine surgery again!” We’ll see how long that lasts.

I have to admit I was discouraged. I had fainted in front of my family. I had almost fainted a second time ha
lf naked on the bathroom floor next to a toilet with a piss jug in my hand. I couldn’t even take a piss. To be sure, what I was going through was so much better than what I thought I would be facing that it didn’t seem right to feel down. I had even overheard the nice elderly palliative lady in the room next to mine discussing with her sons how she would like to pursue the Sue Rodriguez option. When they explained that that wasn’t an option for her, her sorrow made me cry quietly into my pillow. And yet, I could not help feeling a bit sorry for myself. Only Phil was optimistic, telling me that he still thought that I could be discharged the next day (as I had been hoping). My guardian charge nurse, however, was more realistic and reassured my parents that I wouldn’t be going anywhere until it was safe for me to do so. Still, I like the optimism. Thanks Phil.

My nurse told I was actually doing well and to have patience. He had seen this before. I was not the first, nor would I be the last, to go through this. He had been working on the unit 18 years. It was normal for post-operative patients to faint and have trouble voiding, especially those on bed rest. Bless him. I went ahead and got catheterized once again. It actually wasn’t so bad. Maybe you can get used to it after all.

My family stayed with me for the rest of the evening and we chatted and watched TV. My brother had flown in from Saskatoon for the weekend. It was great to see him. I had even got a chance to FaceTime with my twin nieces from the hospital room the previous evening. 


Above: My brother Cailen, my Mom Susan, and my Dad Walter have been pampering me almost as much as the nurses. The little dog I call spot was picked out by one of my twin nieces, Ella. Below: My brother and I in the Harris Tweed hats I brought back from Scotland and my twin nieces Ella and Lily:


We had been drinking a lot of tea, coffee, and water over the course of the evening. I was on a mission. If all else failed, I planned on cracking a can or two of beer that a dear friend had snuck unto my room earlier that evening. Beer has been scientifically proven to break the seal, right? But I suddenly had a good feeling. Just before visiting hours were over, I shooed my family out of the room. I grabbed the piss jug. I pulled myself to the edge of the bed. And finally, finally, I felt the sweet sweet flow of success. I’m a big boy today! Things are definitely looking up, although there are still a few more important missions to accomplish.

Dural Tear Repair

I am pleased to report that I have had what seems to have been a successful spine surgery on Wednesday. I cannot thank the Neurosurgeons, Anesthetists, nurses, and nurse practioners involved in my care enough. The surgery went better than expected because when the dura was opened and the cord was exposed, the tip of the dural tear could actually be visualized on the left side. The cord could be pulled to the right and the 5mm longitudinal dural tear could be directly repaired with sutures without the requirement of a patch of synthetic dura. This has the potential to be a more definitive treatment. The extradural CSF collection was also fenestrated to allow quicker resorbtion. The diagram below was drawn by Jeremy based on Phil’s description. Thanks guys. I am so grateful that my problem would seem to be Neurosurgical as opposed to Neurological! But no, I have no interest in switching



Above: Jeremy’s diagram on my hospital room white board showing the surgical field – separated dura and exposed cord. I may not know the date or time, but at least I have some visualization of the surgery! Notice how the dural tear was visualized by pulling the cord to the right. The tear was longitudinal and approximately 5mm in length. It was sutured shut. Thanks!

The hardest part now will be lying flat for 5 days to try to seal the repair. I am only on day 2 and I have to admit it has been way more difficult than I had anticipated. My incision site is swollen and I imagine way more painful than if I were able to get up and move around. Bedrest is not nearly as restful as it sounds.


I also now have way more sympathy for things that our patients regularly suffer through quietly and routinely, such as midnight pokes for blood work just when they finally fall asleep, in-and-out catheterizations (ouch!), and being dependent on others for pain control. I will never make the mistake of telling someone how they “should” be feeling. I am not in that patient’s body. I promise I will make an effort just to listen.

The Highlands of Scotland


The motorcycle gang at the BMW rental shop in Edinburgh, Scotland, at the outset of our trip in July, 2013. Left to right: me, Ted, Tom, and Jeremy.

Tomorrow I will be undergoing spine surgery. My operation has been scheduled for 12:05 PM and may take anywhere from 3-5 hours, possibly longer. I will be checking into the Hilton at 10:00 AM. 


For the past week I have been resting at home in Lethbridge in nervous anticipation. To keep myself occupied, I decided to give myself a mega project: to edit 7 hours of helmet cam video footage from our recent motorcycle adventure through the Highlands of Scotland down to something watchable. 



Above: You can see the Contour+ 2 helmet camera attached to my helmet (Photo by Tom Smith). This little camera proved capable of some pretty good high definition footage in various conditions. I would reach up while I was riding and slide the switch forward to start recording and then slide it back back to stop. I filled up a lot of SD cards!

I hope you enjoy the results of this labour of love. My intention was to make it feel like riding a motorcycle through Scotland. I would never have had the time to spend a solid week on something like this under normal circumstances. But these are not normal circumstances.


The route we took through Scotland is shown above.
Day 1: Edinburgh to the Isle of Skye with a stop in the James Bond valley from Skyfall. 
Day 2: Stunning single track along the west coast to Ullapool. 
Day 3: Beautiful highland scenery on the way to John O’ Groats.
Day 4: A surprise visit to Dunrobin castle on the way down the east coast on a day that ended in Pitlochry
Day 5: To Troon to catch the ferry to Larne, Northern Ireland. (The fantastic leg of our trip through Northern Ireland will be subject of another post, time permitting.)


Eilean Donon Castle, Scotland. This was one of many pleasant surprises along our route. Photo by Tom Smith.


Dunrobin Castle, Scotland (Photo by Tom Smith). The sun was strong enough to burn off the morning mist allowing sunlight to bathe the castle, an occurrence that the locals called “Freakish”. This is the castle where Ted attempted a big skid in the parking lot that did not end as he had intended. It was a good one (while it lasted). Luckily Ted and the Nimbus escaped with only minor scratches.