While descending a winding mountain road in Northern Thailand on 25 January 2011 I suffered a fairly serious accident when I miscalculated a hairpin curve and went flying off the road into what I thought was a brushy culvert with my bicycle. Although I didn’t realize the extent of my injuries at the time, I had ripped the little finger on my right hand back towards the wrist, breaking two bones and tearing the webbing between my fingers, as well as cracking two ribs (the 5th and 6th) on my right side, crushing my clavicle/sternum joint and shoulder and injuring my right ear. Now, almost thirteen weeks later, after much rehabilitation and some procrastination, I’m ready to tell the story of the ride that day, the accident, my treatment at the hospital in the town of Pai, my 70-hour journey home to New York, the surgery on my hand, the prolonged and opiate-aided recovery, the detox from the opiates and my current rehabilitation.
While some of the reverse-chronology details can be found on my Facebook feed, I realize now (after recently posting a video of my emergency room visit in Pai) that some Facebook friends somehow missed the updates and there are others who might follow this blog and were surprised to find the narrative of our cycle tour end so abruptly. So, here is the story from it last left off, on the road from Chiang Mai to Mae Hong Song.
Slow Easy First Day: Long Ride Ahead (message not posted on 24 January)
(This posting was written on 23 January but not uploaded since we were in rural Thailand, off the grid and far from a WiFi signal.)
Slingbox is a wonderful thing, except when the Jets lose. All the marvels of modern technology allowed me to sit in the breakfast area of the Thaephae Garden Guest House and watch my TIVO back in New York. However, despite a third and fourth quarter surge, all the coolest technology couldn’t get us a Division Championship. So, as soon as the Jets had lost, we loaded up the van and drove just outside of the heavily congested urban area of Chiang Mai and took off on our ride.
The photo below is of Khun Jame loading the bikes and Markus, at our hotel in Chiang Mail
Our dilemma was that the distance from Chiang Mai to Pai was either one very, very long ride with huge mountains during the last eighty kilometers… or a two-day ride with a relatively easy spin the first day and some intense climbs and a shorter stretch on day two. Given that I had just done a twelve-hour time zone change and only slept about four hours last night due to jet lag, Markus and I decided on taking it easy today.
We rode for just two hours, from just outside of Chiang Mai to just before the huge climbs, leaving them for two big climbs tomorrow morning before it gets too hot and the traffic is still light.
Two hours on the bike averaging 30 km per hour is not necessarily an “easy” day. But, on a seven-day ride, the objective is to get stronger and stronger during the ride and not burn out on day one. The geography and topography was against us as we started and this was the best option. So, when we got to the lunch spot, rather than to decide to push on for the next three hours through some 15%-20% hills, we ordered Heinekens and our guide, Khun Jame, found us a very nice pair of bungalows for about US$20 a night. Our plans, tomorrow, are to fuel up on toast and eggs before departing just after dawn in the early morning calm.
We drank a few beers, had some good Thai food and saved the big push for the days ahead. This is a marathon, not a sprint and our worries were that we would hammer like hell today and feel like crap for the next seven days. My best multi-day events have been where I paced at the beginning and got stronger as the race went on. Let’s hope that strategy works here.
Below, a tasty Pad Thai as fuel for the day ahead.
January 25 2011: The 80 km of hills from near Mork Fal Waterfall into Pai (almost)
Markus and I had breakfast at dawn, with the intention of getting out on the road early so that we would be climbing during the cooler part of the day. As you can see from the Google Earth image above, the route for the day rose and fell through a series of hills, gradually topping out at about 1400 meters. All together, we climbed about 2000 meters of vertical elevation during the day, which was about what we wanted to do on the second day of a six or seven day ride with some big climbing days to come later in the week (or so we believed at the time.)
The three charts above are a good story of the day.. the accident occurred at about 68 km on the descent into Pai. However, I forgot to turn off my Garmin so the speed and elevation from 68 km until we arrived at the hospital in Pai were not from cycling. You can see from the heart rate graph that right at 68 km it (and I) fell sharply. The Garmin data from the moment of the accident shows that I was doing just about 53 k/hr at the moment of impact. It is not the flying off the road that will hurt you but the stopping and that was a pretty brutal deceleration!
We stopped mid-morning for a bowl of soup at a roadside café, which also had some amazing cellophane-wrapped baskets of fresh strawberries.
During the long climb I turned on a little micro video camera attached to the handlebars and recorded two segments of the ride up through the National Forest. (Unfortunately, although I had my camera recording on the descent and at the moment of my crash, for some reason the file didn’t save properly and the recording of the accident is lost. We tried to recover the file using several tools, but nothing worked… so the video of the crash is lost, maybe for the better.)
The video below was taken about an hour before the crash. It is shaky and with very little narration, but gives a good indication of the terrain and how the curves on the road are laid out in sort of a predictable pattern, which is significant later in the day on the descent.
Just after 1:00 pm that day we met up at the crest of the climb and this is a picture of Khun Jame:
And, Khun Jame took this one of me just before the long descent into Pai and the accident about twenty minutes later.
From this point, the road descended downwards heading into the town of Pai. Most of the descent was a mixture of long easy curves and some switchbacks, in a fairly predictable pattern that allowed me time to anticipate and slow down as necessary. However there were two factors that I think contributed to the crash: 1) I was riding with some cars that had passed me at the beginning of the descent and as the road got steeper and more curvy, they were slowing in front of me and keeping me from going as fast as I'd wanted (bicycles can go down curvy mountain roads much faster then cars); 2) although it was in the early afternoon, only three days before I had been in New York where my body clock said it was just about midnight. So at one point in the descent when I saw an opening I passed the cars and was accelerating down the hill as fast as I could in order to stay in front of them, all the while with a brain that might have thought it was the middle of the night. Maybe I wasn’t at my sharpest.
As I had just finished going around one switchback and was going down about a 12% grade the road turned to the left and then suddenly got much steeper (maybe 18% down) and there was a switchback to the right that I had not anticipated. I was going exactly 53.8 km/h according to my Garmin 800 when I had one of those awful split second choices; either attempt to brake hard, lean into the curve and probably lose it and crash off the side of the road down the cliff, or dump the bike and head towards the side of the road into what I thought was a softer landing in the bushes.
Minutes after the crash, I walked about 25 m up the road and took this picture back towards the place that I crashed. This picture was taken right from the point where I decided that I wasn't going to make the curve and I headed between the small white road barrier and the sign. It looked at the time like a better choice. In the picture you can see Khun Jame in the orange T-shirt standing just to the right of the road marker and I had aimed just between those two road markers.
Over the last 11 weeks I've had a lot of time to think about the moment of the crash and what happened. I really had thought that I was going to be landing in some bushes rather than plunging down into a ravine and landing in a pile of dirt. In hindsight I probably should've thrown the bike away from me, because when I landed I think that my little finger got caught in the handlebars and got bent back towards my wrist and as my front wheel slammed into the dirt I fell right on the stem, which attaches the handlebars to the frame, snapping my two ribs. Somehow I also landed very hard on my shoulder and the right side of my helmet, spraining the joint between my clavicle and sternum and slightly separating my AC joint at the top of my right shoulder.
I was conscious throughout the entire event, however as I tried to climb out of the pit I had to stop as I went into shock and the entire world got very dark and I came close to passing out. Just after the moment of the crash, I caught my breath and looked up out of the hole to see the car that I had passed several minutes before slow and stop to check that I was okay. At that moment Khun Jame pulled up, called down to me to see if I was okay, and the other vehicle continued down the road.
This is the hole that I landed in, about four meters down from the road and most definitely not a soft landing.
As strange as it might sound, one of my first thoughts in getting out of the hole, was to take some photographs of the crash site and the road up and down from where the accident occurred. I had been in too many incidents where it later occurred to me that I should've taken some pictures and so this entire event and follow up is pretty well documented.In the photo above, which was taken about 3 min. after the crash, Khun Jame is climbing out of the hole where he was checking to see if anything had fallen off of my bike. The photo below, taken later, is of my helmet which was pretty much destroyed by the impact. For anyone who needs to convince their children that they should wear bike helmets, please feel free to use this photograph as part of your sales pitch.
Within minutes of the crash, Khun Jame had loaded my bike into the van and I had absolutely no idea how badly I was injured. It's amazing how adrenaline kicks in during these times and makes you feel like a Superman. In the picture below, I was smiling but I can see by the droop in my right shoulder that it must've been slightly separated and I thought at the time that my ribs were only bruised and that my right little finger might only have gotten sprained.
The two pictures above are both taken looking back up the road from the crash site. You can see from the pictures that the road curved to the left and then immediately dropped off and hairpins off to the right again. At 50+ kilometers per hour I must've been almost airborne when I tried to brake off of the first curve.
Khun Jame and I got into the van and started the nearly 10 km trip down the hill into the town of Pai. I was mostly worried about my little finger and took a picture of it (see below) as we are heading down the road.
We drove that last stretch into town slowly, looking for Markus who had ridden on ahead and was unaware of what happened. I tried several times to call him on his mobile and send some text messages. We finally reached him when we got into the town of Pai and found him at a little restaurant drinking a beer and waiting for me to ride into town and join him. He certainly didn't expect us to pull up together in the van and certainly didn't know what to do when suddenly the gash between my fingers started spilling blood on the pavement and we all decided that rather than have a beer we would head to the hospital. I honestly at that point had no idea how badly I was injured and thought at the time that it might be best to check into a hotel in Pai and wait for a day before starting to ride again. Until there was major blood, only when we got into town, did I have an inkling that perhaps our cycling adventure was over and that this was much more serious than I had thought.
Khun Jame, Markus and I drove over to the hospital and walked into the emergency room. There was no wait and they attended to me immediately. Marcus took pictures and helped me remove my glove, rather than cutting it off. I'm still now firmly convinced that without the protection of my riding glove, that little finger would have been torn completely off. There was just enough structure in the glove to keep the finger attached to the hand.
It was probably my own stupidity and a fair dose of self-denial that I thought my ribs were only bruised rather than broken. So the nurses in the emergency room concentrated on my hand and the lacerations on my ear, and sent me off only for an x-ray of my right hand.
This is a snap of the x-ray taken in the little hospital in Pai, with a clear fracture of the right fifth metacarpal and although I did not see it at the time, a fracture of the next joint past the knuckle; the proximal phalanges.
The nurses began to work, cleaning up the hand while Markus pulled out his phone and began documenting everything. I don't think they let you do that in US hospitals, but Marcus took my favorite approach to these sorts of situations; it's better to seek forgiveness later than ask permission. The following two videos are not for the squeamish and probably have too much information, but there are fascinating look at the treatment. In one I learned the word for "pain" in Thai (GIP! GIP!) as I'm injected with painkiller. In the other one the Dr. puts one or two of the seven stitches between my pinky and ring fingers.
Kudos to Markus for this shot and these videos, since I would never have been able to sit there with a camera and shoot this stuff.
The Dr. also attended to my right ear, which had gotten pretty torn up probably by the helmet shards as it broke on impact. They thought that they needed to put in some stitches to reattach some places where it'd pulled the skin from the ear cartilage, but they just fixed it up with a number of butterfly bandages.
Markus also grabbed a picture (see below) of the two of us in the emergency room.
The doctor there, who spoke very good English, said that since I was from New York and "they have very good hospitals there in New York", I should go home to have my hand operated on within the next 10 days.
So after about an hour of scrubbing up the wounds, some x-rays, stitching back on my ear and my finger and a prescription filled for Advil, it was time to pay the bill. I was a little nervous and thought that I should call to my insurance company back in the United States to let them know that I've been admitted to an emergency room so that I could later get reimbursement for the hospital bill. However when the total bill arrived it was for 720 baht, or about US$23. I know that back home in the States this would've been a $3000 bill at least. So needless to say I didn't contact my insurance company and we paid the bill, loaded up the van and decided to head back to Chang Mai immediately.
It took us about 2 1/2 hours to drive from Pai back to Chang Mai. Markus had already called his wife Lisa, who had sent an e-mail to Pam telling her that I'd been in an accident. I decided that it was pretty important for me to call Pam so that she could hear my voice and know that I was okay before she got the e-mail from Lisa.
So, even though was only about 4:30 AM back in New York I called Pam, waking her up with the not so good news that I'd been involved in a bike accident and was going to make arrangements to come back to New York as quickly as possible. Although not pleased to have gotten a phone call at that time of the morning, she said later that it was the best thing to do so that she could hear directly from me that I was okay.
It was on the ride back, particularly going around those hairpin curves and going over bumps that I figured out the probably my ribs were more than just bruised. Later, on arriving back in New York, the radiologist who examined my x-rays said that he had no problem finding the two broken ribs. My biggest worry at that point was the pain involved in taking a deep breath and what in the world I might do if I ever had to cough or sneeze.
By early evening we were back in Chang Mai, where we had started two days before. Somehow I got out of my riding gear and somewhat cleaned up in the shower, but between my head, shoulder, ribs, and hand I was feeling pretty beat up. Lying down was a real problem, particularly rolling over on the one side. For that first night in Chang Mai, all during the trip home and for the next several weeks I slept sitting up in a chair or recliner.
The Long Trip Home from Chiang Mai to New York City: 70 hours!
That evening while in Chang Mai I called up United Airlines and spoke with the Global Services representative to see about booking my flight back home for the next day. She was able to get me a business class flight out of Bangkok to Los Angeles and a First Class flight from Los Angeles directly back to JFK. I then called Ian Hamilton, my travel agent in Cape Town South Africa, who was able to book me on a flight out of Chang Mai the following afternoon to make my connection on Thai Airways to Los Angeles.
Markus helped me to break down my bicycle and get it into the bicycle bag and to pack my gear in my duffel bag. After a fitful night’s sleep, Khun Jame drove me out to the airport where he and Markus helped get me checked in, my bicycle and duffel bag as well as my briefcase checked all the way back to JFK and escorted me as far as immigration and security. From there I was on my way alone, with a one-hour flight from Chang Mai to Bangkok, a short layover and a 12 hour flight into Los Angeles.Thailand is one of those places where you can go into a pharmacy and get just about anything you want without prescription. Looking back on it now, I probably should've gotten some heavy pain killers like Percocet, OxyContin or Vicodin but I really didn't want to do a long plane flight looped out on drugs. So I stuck with the one painkiller I know well and basically drank vodka tonics all the way home.
It was not a comfortable flight from Bangkok to Los Angeles. The business class seats on Thai only recline to a not flat 160° or so and every single bump and every one of my twists was painful. Looking back now, I probably should have tried to get a first-class seat on a more indirect route but would've had a better journey across the Pacific.
On arrival in Los Angeles, both Thai Airways and the United Global Services representatives were extremely helpful in getting me through immigration and customs and provided transportation over to the check-in counter for my flight from Los Angeles to New York. The only glitch at LAX was that while I could walk just fine, carrying my carry-on bag with my laptop computer and other equipment was just a little bit too much for the broken ribs. The counter attendants at check-in requested disabled assistance but the woman who showed up with the wheelchair said I had to sit down in the wheelchair and could not just put my bag in it. So I sent her away and went back up to the counter where one of the nice Global Services walked with me through security, carrying my bag all the way to the First Class lounge.
However at this point in the journey back home the only glitch was the weather in New York. A snowstorm was approaching and although they thought that they might get my flight off, after delaying it for five or six hours, they finally canceled the flight and made arrangements for the First Class passengers to be transferred over to a nearby hotel to spend the night, and we would be rebooked on a flight the next day as soon as JFK reopened. Normally this wouldn't of been a problem, but I was feeling fairly uncomfortable and just wanted to get back to New York and check myself into a hospital. I even considered at one point just getting into a cab and going straight to a hospital somewhere near LAX, but finally thought that maybe it might be better to get all of this taken care of back at home.
United Airlines was unable to provide direct disabled/handicapped assistance to the hotel, but I did sit in the wheelchair at this point and they took me to the pickup point for the shuttle bus to the hotel where I spent the night and returned to the airport the next morning. It took longer to open JFK after the snowstorm than they had imagined and the flight was delayed several more hours but finally I boarded and arrived Thursday night at JFK, just about 70 hours after having left Chang Mai.
This picture above was taken by my car service driver in the JFK parking garage. I've done a number of endurance events in my life, like triathlons and marathons and long-distance cycling events, but nothing quite compares to this journey from Thailand back to New York City. After the drive from JFK back to our apartment in Manhattan, I collapsed in sobs, so happy to be back home, wounded but at least safe and sound.
Pam accompanied me the next morning to my appointment with Dr. Beldner, the orthopedist hand surgeon, who took further x-rays, cleaned up my hand and made an appointment for surgery 10 days later. Pam and I then went to see Jeff Buckner, my personal family practice doctor, who prescribed some pain killers to help make me more comfortable.
And then four days later, Jennifer, who works with me in the IISD New York office, accompanied me down to the radiologist who took some pictures of my chest to see what was going on there. He had no problem finding the two broken ribs and when I returned to Dr. Buckner's office he increased my pain medication and we had a good talk about how to deal with broken ribs.
What I learned is that there is no treatment for broken ribs, no wrapping or protection and the only thing you can do for them is rest and wait. My two broken ribs, five and six, are both breathing ribs and therefore particularly problematic. I've tried staying very still and not breathing in order to give them a chance to heal but usually can't last for more than about 45 seconds (that's a joke) so these ribs are always moving and that makes the healing process that much more prolonged.
The other big problem is that we normally cough occasionally in order to clear fluids out of our lungs. However my breathing ribs were broken and therefore I was doing everything in my power not to cough and having problems taking deep breaths, actually fearing the thought of sneezing. I learned that most patients with broken ribs are prescribed pain medication in order to be able to withstand the agony of coughing. Because, if one does not cough, the lungs can fill with fluid and this can lead to pneumonia.
Beginning several days before I had begun taking 5 mg Percocet and the dosage was increased to 10 mg, which made me much more comfortable although I don't recall with great clarity everything that took place during February and much of March.
However, in my opiate induced haze, I did have the courage to cough and my pain was managed successfully so that despite some really broken bits I was comfortable and sedated enough so that I didn't try something stupid like trying to exercise. The biggest temptation was to sit down at the computer and do business, since friends don't let friends do business while on opiates. During this period, Jennifer provided a great buffer between me in Lala land and the organization that I lead in Reporting Services at IISD.
I have learned more than I wanted to about the physiological effects of large opiate doses particularly on one's general intestinal tract. I have a greater appreciation for G.I. regularity than ever before. Enough said.
On 7 February my right hand was operated on at Beth Israel hospital in New York, 13 days after my accident in Thailand. It was an outpatient procedure however I was under general anesthetic and woke up in the recovery room speaking Portuguese to a Brazilian nurse who was overseeing my return to consciousness. Dr. Beldner had inserted two pins to set the proximal phalanges and used two screws to repair the fifth metacarpal.
I had a foam splint attached to my cast to keep the hand immobile and upright.
Just about 10 days later I returned to the doctor's office and they removed my larger cast and replaced it with a smaller cast just up as the wrist. And then about 2 1/2 weeks later they removed the cast and the doctor pulled out the two pins, leaving in the screws.
I had fully expected that as soon as the cast was removed I would begin Occupational Therapy and I'd be back to cycling and have the full use of my hand within a week or two. However I learned that whenever the hand and wrist are bound up for a long time like this that the joints become stiff and scar tissue forms in the hand blocking the free movement of tendons. I had the cast removed on 4 March and had my first occupational therapy session on March 7. Now almost 7 weeks later I still have very little movement in my right pinky finger and am struggling each day with finger exercises and trying to get my wrists to bend without pain.
However the biggest challenge that I faced was coming unglued from the opiates. As Dr. Buckner explained to me there are two types of addictions that can take place with opiates; physical and psychological. On 7 March, I decided it was time for me to stop taking the Percocet and went from 16 tablets a day to just one tablet a day almost overnight. I had no psychological addiction and could stop without any problem, however over the next several days I got more and more paranoid and very irritable so that by Thursday of that week, when in a staff meeting, I totally lost it and started yelling at people.
What I now realize is that as I was coming off of the opiates the pain in my hand, shoulder and ribs were coming “unmasked.” The opiates had been doing their job and without them, Iwas in pain! I was feeling invincible and thought that I could simply tell my body it was time to come back to normal and had gone for a jog on the treadmill. Then my ribs really hurt again and I started taking the Percocet, thinking that I had read damaged my ribs. Suddenly, taking the pain pills again the paranoia and the irritability went away as well and I booked an appointment with Dr. Buckner to try and figure out what was going on. He explained that while part of my brain could tell myself to stop, another part of my brain felt that I had promised to give it opiates and that I had a physical addiction that needed to be taken care of through a gradual scheduled reduction. He prescribed a lower dose painkiller, Vicodin with acetaminophen, and over the next three weeks I slowly reduced my dosage so that by 13 April I was totally off the opiates and just taking Excedrin extra strength tablets up to the maximum 4000 mg a day.
The entire opiate and painkiller experience has been a fascinating one for me and I can now understand how seductive they are how easily it might be for some people to become addicted. I really didn't like the way they made me feel since I couldn't form sentences, quickly remember details or make good decisions. They were great for what they did but I'm very glad to have put them away.
Getting back to moving again has been a whole other experience. For two weeks in March, from the 14th to the 25th, my good friend and yoga teacher, Davi Cohen, came by the apartment to do some home yoga sessions. Just getting moving again was so wonderful as my body remembered the positions and the ways that it had moved two months before. In yoga there is the expression "samskara" , which refers to the etchings, lines or patterns in one's yoga practice. As I twisted and turned my body knew the samskara and it gave me great pleasure, a warm glow and even a tingling sometimes when I'd move back into old asanas. These last two weeks, when I've been taking public yoga classes at Yogaworks on the Upper East Side, it has been the best physical therapy possible. I'm also firmly convinced that having an active, advanced yoga practice four or five times a week for the year before my accident was one of the factors that both made the accident less worse in the recovery much easier. The core muscles and the overall tone and flexibility that comes from a vigorous yoga practice provided a base level from which it was easier to come back.
So today, 24 April, three months from the day of my accident in Thailand I finally felt recovered enough to tell the story. I'm still in a great deal of pain, as my ribs are healed but still very tender and my shoulder, both in the clavicle and AC joint, still move with some discomfort. Every day I spend hours working my fingers, doing hot and cold contrast baths and trying to get full range of motion back in my hand and wrist. Last week I rode my bicycle twice up and back to yoga, but only my fixie bike with the flat straight handlebars that I can grab easily with my right hand. Although my new Pinarello Dogma was finished last week and I had it delivered by John from Conrad's bicycle shop 10 days ago, I still don't have the confidence in my right hand arm and shoulder to go for a ride.
So for the time being it sits on the rack in the living room waiting a few more days until I feel strong enough to ride. Maybe there's just a little bit of hesitation too about getting back on a bike. I’m dealing with that.
The upside to the downside is that I have two great takeaways from the experience. One is that I have mastered the Dragon NaturallySpeaking voice recognition software and have written and edited this entire piece without using the keyboard since it's still very difficult for me to type with my right hand. Even though I may gain the entire use of my right hand again I don't think I'll ever stop using the voice recognition software for writing and controlling the computer.
The second thing that is my take away from this experience is something that my management coach, Steven Marks, told me. He said that for the rest of my life I should concentrate on going up so much faster and going down hills much more slowly. I think it's excellent advice!