Al, i saw your FB post as well! Very scary stuff. Do your best to take it easy the next several weeks and SLOWLY work your wake back to your old self. As bad as it is, it sounds like it could have been much worse. Take care and if you need anything while recovering in denver just let me know. I'm less than 30 minutes away.
Al, sorry to hear the news but good to know you're doing so well. 9mm is small from perspective of neurosurgical decision perspective but 9mm brain contusion is significant. Take it easy and when you do get back to activities they should all be free from symptoms.
Al - Very sorry to hear about your injury and I am glad to hear that your are "okay."
I emphasize with you on having to unplug from training for a time. It was just 4ish months ago that I had a bike accident: landed on my head and resulted in a severe flexural strain from C1-T5. I didn't lose consciousness, but in my left ear I had ringing and could hear/feel my pulse beating away for a few weeks. CT scan and MRI were clear though I was directed to take a month off with NO activities. It was a rough month and I had to skip the NOS, but I was better for it.
During my downtime I had to ride/run vicariously through other ENer's on the board. While you recover, I hope you will continue to impart your words of wisdom here.
Al, very sorry to hear. I played contact sports for years and have received enough head injuries that I may some day give Muhammad Ali a run for his money. I tried all I could to "speed up" or "short cut" the process and paid for it. There was not as sharp a focus on this type of thing then, plus what applies to everyone else certainly doesn't apply to me, right? Listen to the doctor, don't rush it or over do it when you do start to come back. Heal quickly!
I guess what YOU WOULD TELL ME in such a situation would be: "EXECUTE DOCTOR'S INSTRUCTIONS FLAWLESSLY" ... and I always do as you tell me!!! .... Brazilian wishes for a fast recovery !!!! Please keep us posted.
That is, I have six hour so of my life where I was awake and talking but I don't remember any of it. Apparently I was very entertaining and annoying.
Al - best wishes for a speedy recovery. My wife and I were skiing over NYE and commented how crazy it was that nobody wore helmets 15 years ago and now everyone does. It's really remarkable to think more injuries didn't happen back then. Glad you had a bucket on!
Rich - to the quote above....so you are saying that nothing really changed in the aftermath of your accident?
Al, I just watched the video. That's crazy! I'm so glad you're okay. And you've now made me revisit my non-helmet wearing tendencies the next time I ski.
Follow-up. primarily to document in this thread a protocol for return to activity after a significant head injury. This is basically a copy of my blog entry from today:
So I've suffered a significant head injury. Technically, I have an intracranial contusion (bleeding) in the upper left frontal lobe of my brain. There are several small areas of bleeding evident on CT scan, the largest being 9 mm. There is also swelling (fluid build-up) around my brain tissue. Imagine a large bruise on your thigh. After a day or so, it appears purple, then turns deep yellow and fades over time. Those colors represent blood which has escaped from small blood vessels torn when the leg was hit. The area is tender to the touch, and maybe a bit swollen. The same thing is now happening in my brain. That area of the brain is responsible for a number of higher level functions, including some aspects of movement, management of emotions, integration of personality, and awareness.
I have also suffered a concussion, which is a more general "shaking" of my brain. This stretches the nerve fibers ("shearing"), maybe even tearing them. Concussions disrupt the delicate chemistry of the brain, the flow of neurotransmitters between nerve cells which monitor and control every aspect of the body's function, as well as all thinking and feeling.
Years ago, when something like this happened, we called it "getting your bell rung". Before the early 70s, we did not have CT scans to quantify the bleeding, or even MRIs to help us better demonstrate the swelling and shearing. So returning an athlete to action was a matter of "shaking it off", and getting back in the game when you stopped feeling woozy.
Now, we know that the brain needs time to heal just like any other part of the body. Just as you would't want to start running when your ankle ligaments are swollen or torn ("sprained" ankle), you really shouldn't try to use your brain too much when it is in the acute phase after an injury like this. The risks are several: repeated direct injury to the head before healing has occurred leads to a higher risk of permanent damage; forcing the brain to work full bore before it's ready make the recovery process take much longer. So, very recently, protocols have been developed to help guide an athlete back to action. Example: the "concussion protocol" you may have heard referenced in football games.
The tricky part is, the wide spectrum of head injury. The diagnostic terms and studies are still in flux. What do I call my injury? Intra-cranial hemorrhage? Contusion? Concussion? Traumatic Brain Injury? Is it mild, moderate, or severe? What symptoms are relevant? What are the risks of long-term problems? While in the hospital, the neuroscience physicians gave me some broad guidelines to follow: take it easy for a week or two, don't do anything for two months which might run a risk of re-injuring the head, start back up with easy aerobic activity. But what might that mean specifically for me, a skiing-obseesed, high-functioning world class age group triathlete?
I didn't get very far when I started discussing that with the neurologist. When I brought up some of my specific concerns, he tried to mollify me be saying, "Well, I guess you could maybe just do some blue or green runs after a couple of weeks."
"That's not gonna happened," was my response. Meaning, if I'm out skiing, I'm going to be skiing to the limits of my ability. It's the only way I know to have fun. I'm generally in control, and, obviously, if this was the first incident like this in 47 years, then I must be able to handle that "stretch the limits" approach. But we both recognized that the risk of another concussion or, worse, contusion, shortly after the first, would be very risky - meaning, permanent damage or even death. So, no, I shouldn't downhill ski again this season.
From his perspective, it would be OK to do "aerobic" work within a week of the accident if I had no symptoms, and then work harder after another week without symptoms. I wasn't sure if we both had the same understanding of either "aerobic" or "symptoms", and he didn't seem inclined to spend time with me on the nuances of my particular lifestyle, or even if he would understand it.
So I dove into the inter webs for help. I discovered a CDC "package" for physicians which included a complete set of symptoms to follow in patients with mild TBI. And, a document from an international conference on concussion in sport, which produced a consensus statement on return to activity for athletes. Putting those two together gives me a comforting set of guidelines to follow for my particular needs.
First off, I will not be skiing again this season, at least no downhill skiing. Even if the risk of another accident is low, the risk of complication should I bang my head again is just too high. Luckily, it seems that this has become a terrible snow year. Meaning, my favorite kind of skiing, in fresh new fluffy snow, is likely not gonna be happening in the next two weeks. And the snow on the slopes is harder than normal, raising further the risks should I fall.
Next, when, how much, and how intensely can I return to swimming, biking, running, and weight lifting? For the purposes of the next six weeks, all the biking I will be doing will be inside on a trainer, to reduce the risk of a re-injury soon after the current one. The guidelines are a step-wise progression in both time and effort level, based on being symptom free for the previous 24 hours.
So, what are the symptoms? From the CDC pamphlet for physicians:
Signs and Symptoms
Signs and symptoms of MTBI generally fall into four categories: physical, cognitive, emotional, and sleep, and may include:
Physical
Cognitive
Emotional
Sleep
Headache
Nausea
Vomiting
Balance
problems
Dizziness
Visual problems
Fatigue
Sensitivity to light
Sensitivity to noise
Numbness/
Tingling
Dazed or stunned
Feeling mentally “foggy”
Feeling slowed down
Difficulty concentrating
Difficulty remembering
Forgetful of recent information or conversations
Confused about recent events
Answers questions slowly
Repeats questions
• Irritability
• Sadness
• More emotional
•Nervousness
Drowsiness
Sleeping less than usual
Sleeping more than usual
Trouble falling asleep
And the return to activity protocol:
1. Complete physical and cognitive rest until medical clearance (symptom free for 24 hrs)
2. Light aerobic exercise: swimming, walking, stationary cycling; heart rate < 70% (of max), max of 15 minutes. If symptom free for 24 hours, go to step 3; if not, return to resting until symptom free.
3. Sport specific drills (e.g., running, strides, flip turns), heart rate < 80%, 45 minutes. If symptom free for 24 hours, go to step 4; if not, return to step 2.
4. Non-contact training: weight lifting, interval "aerobic" training. Heart rate <90%, 60 minutes. If symptom free for 24 hours, go to step 5; if not, return to step 3.</p>
5. Return to normal training activities.
(I'm taking the 70, 80, & 90% of HR to also include 0.7, 0.8, and 0.9 IF for cycling)
I'm now 96 hours/4 days out from the original insult. I will wait another two days or being symptom free (whichever comes later) before starting in with 15 minutes of cycling or swimming, then following the return to activity protocol.
At the moment, I feel a little "foggy" in the head, but less than yesterday. I have a little neck pain, and am feeling a little "sad", meaning I occasionally feel like crying when discussing certain things. Also, I have some abrasions on my face and a fat lip, which Im using to stand in for the blood and swelling in my brain. When that's gone from my face, I will use that as a marker for my brain getting physically back to normal.
I'm feeling better, and less scared every day. Not quite ready to get back at it, but I do have a plan.
Great post - Thanks for presenting these logical guidelines for returning from MTBI. Even injured you are a great teacher and a source of wisdom and knowledge. Rest Up, life is to be enjoyed but it is also fragile. Prayers for a quick recovery.
Al...great plan you have developed. I'm glad to hear that you are getting better each day. I know you want to get back to training, but take your time. You have over a decade of triathlon muscle memory built up and things will come back to you quickly when your brain is ready. You have plenty of time to get ready for Kona. Take care my friend.
Al, I am hope that you are still making progress. I really like the format of your recovery plan, in that you have included numerous monitoring and self evaluation periods so that you do not go to fast without making sure you have considered everything.
I had a bad fall while skiing back in 2010....falling forward and I tried to stop and it just drove my own fist (while holding the ski pole) right into my face. I was banged up pretty good....but it took a couple weeks for the real damage to show itself in the form of a torn labrum in my shoulder. At the time the last thing that showed any pain was my shoulder....everything from my nose to my knees was hurting including my pride. After a heavy impact trauma like you have had it may take a while for other things to reveal themselves...so please be careful.
I've been skiing easily (for me) the last two days. The only injuries I sustained were the brain contusion, and superficial abraisions on my lip and nose, which are now healed. Arms, legs,chest. back all working and feel normal. So my biggest (really, only) concern is to keep from being too aggressive on the slopes or the road over the next six weeks or so. But I seem to be in that lucky group of TBI sufferers who is recovering without sequelae. Of course, the fact that I don't have to go back to work helps a lot - I can control how much activity I do daily with no worry or guilt.
According to my symptom checklist, I've been symptom free for the past 4-5 days, and have slowly increased physical activity over that time: walking x 2 days, short session on the bike trainer day 3, then two days of skiing, about 1/2 and 3/4 my usual amount, at about 40-65% of my usual speed, and only on green or blue runs, groomed, with no bumps, trees, or other distractions. I do not intend to do any "serious" skiing the rest of this year, but will be getting out every day for the next week while I am in Colorado, where it is warm sunny and dry
Glad to read you are recovering well. As you know, repetitive traumatic brain trauma is not additive. A second trauma before the brain is healed is much worse than the two traumas "added together". Be as disciplined with skiing as you are with triathlon. Stay focused inside your Box and remember your triathlon One Thing. (Guess I've been drinking the kook-aid!) Best wishes.
I seem to remember something about apoE4 and traumatic brain injury? The state of NY considered having boxers tested for the gene before they could be licensed to fight? I have been away from the forums for a bit but not much change. Al seems to always be in the news... phew, you dodged a bullet.
Posted By <a href='http://members.endurancenation.us/ActivityFeed/tabid/61/userid/1431/Default.aspx' class='af-profile-link'>Brian Quarton</a> on 10 Feb 2015 11:12 PM I seem to remember something about apoE4 and traumatic brain injury? The state of NY considered having boxers tested for the gene before they could be licensed to fight? I have been away from the forums for a bit but not much change. Al seems to always be in the news... phew, you dodged a bullet.
Several years ago, I had my genome screened. I do not have the APO e4 variant. Quick search shows those with the variant have increased risk of poor long term outcome after TBI. Another bullet dodged.
Comments
Al, i saw your FB post as well! Very scary stuff. Do your best to take it easy the next several weeks and SLOWLY work your wake back to your old self. As bad as it is, it sounds like it could have been much worse. Take care and if you need anything while recovering in denver just let me know. I'm less than 30 minutes away.
Al, bummed to hear this. Listen to your doc and come back smartly. Thank goodness you had a helmet. Best wishes for a speedy recovery.
Mike
I emphasize with you on having to unplug from training for a time. It was just 4ish months ago that I had a bike accident: landed on my head and resulted in a severe flexural strain from C1-T5. I didn't lose consciousness, but in my left ear I had ringing and could hear/feel my pulse beating away for a few weeks. CT scan and MRI were clear though I was directed to take a month off with NO activities. It was a rough month and I had to skip the NOS, but I was better for it.
During my downtime I had to ride/run vicariously through other ENer's on the board. While you recover, I hope you will continue to impart your words of wisdom here.
Wowzer Al harry scary experience and sending all out positive healing vibes your way. Steady as you go forward in your healing process !
I guess what YOU WOULD TELL ME in such a situation would be: "EXECUTE DOCTOR'S INSTRUCTIONS FLAWLESSLY" ... and I always do as you tell me!!! .... Brazilian wishes for a fast recovery !!!! Please keep us posted.
Al - best wishes for a speedy recovery. My wife and I were skiing over NYE and commented how crazy it was that nobody wore helmets 15 years ago and now everyone does. It's really remarkable to think more injuries didn't happen back then. Glad you had a bucket on!
Rich - to the quote above....so you are saying that nothing really changed in the aftermath of your accident?
Fortunate but unfortunate Al
get well soon..remember to take it easy till you REALLY feel better and not just think your better
Heal well!
Al, sorry to hear about your accident and injury. Take care of yourself so when you come back you can go your usual full bore.
Follow-up. primarily to document in this thread a protocol for return to activity after a significant head injury. This is basically a copy of my blog entry from today:
So I've suffered a significant head injury. Technically, I have an intracranial contusion (bleeding) in the upper left frontal lobe of my brain. There are several small areas of bleeding evident on CT scan, the largest being 9 mm. There is also swelling (fluid build-up) around my brain tissue. Imagine a large bruise on your thigh. After a day or so, it appears purple, then turns deep yellow and fades over time. Those colors represent blood which has escaped from small blood vessels torn when the leg was hit. The area is tender to the touch, and maybe a bit swollen. The same thing is now happening in my brain. That area of the brain is responsible for a number of higher level functions, including some aspects of movement, management of emotions, integration of personality, and awareness.
I have also suffered a concussion, which is a more general "shaking" of my brain. This stretches the nerve fibers ("shearing"), maybe even tearing them. Concussions disrupt the delicate chemistry of the brain, the flow of neurotransmitters between nerve cells which monitor and control every aspect of the body's function, as well as all thinking and feeling.
Years ago, when something like this happened, we called it "getting your bell rung". Before the early 70s, we did not have CT scans to quantify the bleeding, or even MRIs to help us better demonstrate the swelling and shearing. So returning an athlete to action was a matter of "shaking it off", and getting back in the game when you stopped feeling woozy.
Now, we know that the brain needs time to heal just like any other part of the body. Just as you would't want to start running when your ankle ligaments are swollen or torn ("sprained" ankle), you really shouldn't try to use your brain too much when it is in the acute phase after an injury like this. The risks are several: repeated direct injury to the head before healing has occurred leads to a higher risk of permanent damage; forcing the brain to work full bore before it's ready make the recovery process take much longer. So, very recently, protocols have been developed to help guide an athlete back to action. Example: the "concussion protocol" you may have heard referenced in football games.
The tricky part is, the wide spectrum of head injury. The diagnostic terms and studies are still in flux. What do I call my injury? Intra-cranial hemorrhage? Contusion? Concussion? Traumatic Brain Injury? Is it mild, moderate, or severe? What symptoms are relevant? What are the risks of long-term problems? While in the hospital, the neuroscience physicians gave me some broad guidelines to follow: take it easy for a week or two, don't do anything for two months which might run a risk of re-injuring the head, start back up with easy aerobic activity. But what might that mean specifically for me, a skiing-obseesed, high-functioning world class age group triathlete?
I didn't get very far when I started discussing that with the neurologist. When I brought up some of my specific concerns, he tried to mollify me be saying, "Well, I guess you could maybe just do some blue or green runs after a couple of weeks."
"That's not gonna happened," was my response. Meaning, if I'm out skiing, I'm going to be skiing to the limits of my ability. It's the only way I know to have fun. I'm generally in control, and, obviously, if this was the first incident like this in 47 years, then I must be able to handle that "stretch the limits" approach. But we both recognized that the risk of another concussion or, worse, contusion, shortly after the first, would be very risky - meaning, permanent damage or even death. So, no, I shouldn't downhill ski again this season.
From his perspective, it would be OK to do "aerobic" work within a week of the accident if I had no symptoms, and then work harder after another week without symptoms. I wasn't sure if we both had the same understanding of either "aerobic" or "symptoms", and he didn't seem inclined to spend time with me on the nuances of my particular lifestyle, or even if he would understand it.
So I dove into the inter webs for help. I discovered a CDC "package" for physicians which included a complete set of symptoms to follow in patients with mild TBI. And, a document from an international conference on concussion in sport, which produced a consensus statement on return to activity for athletes. Putting those two together gives me a comforting set of guidelines to follow for my particular needs.
First off, I will not be skiing again this season, at least no downhill skiing. Even if the risk of another accident is low, the risk of complication should I bang my head again is just too high. Luckily, it seems that this has become a terrible snow year. Meaning, my favorite kind of skiing, in fresh new fluffy snow, is likely not gonna be happening in the next two weeks. And the snow on the slopes is harder than normal, raising further the risks should I fall.
Next, when, how much, and how intensely can I return to swimming, biking, running, and weight lifting? For the purposes of the next six weeks, all the biking I will be doing will be inside on a trainer, to reduce the risk of a re-injury soon after the current one. The guidelines are a step-wise progression in both time and effort level, based on being symptom free for the previous 24 hours.
So, what are the symptoms? From the CDC pamphlet for physicians:
Signs and Symptoms
Signs and symptoms of MTBI generally fall into four categories: physical, cognitive, emotional, and sleep, and may include:
Physical
Cognitive
Emotional
Sleep
problems
Tingling
• Irritability
• Sadness
• More emotional
•Nervousness
And the return to activity protocol:
1. Complete physical and cognitive rest until medical clearance (symptom free for 24 hrs)
2. Light aerobic exercise: swimming, walking, stationary cycling; heart rate < 70% (of max), max of 15 minutes. If symptom free for 24 hours, go to step 3; if not, return to resting until symptom free.
3. Sport specific drills (e.g., running, strides, flip turns), heart rate < 80%, 45 minutes. If symptom free for 24 hours, go to step 4; if not, return to step 2.
4. Non-contact training: weight lifting, interval "aerobic" training. Heart rate <90%, 60 minutes. If symptom free for 24 hours, go to step 5; if not, return to step 3.</p>
5. Return to normal training activities.
(I'm taking the 70, 80, & 90% of HR to also include 0.7, 0.8, and 0.9 IF for cycling)
I'm now 96 hours/4 days out from the original insult. I will wait another two days or being symptom free (whichever comes later) before starting in with 15 minutes of cycling or swimming, then following the return to activity protocol.
At the moment, I feel a little "foggy" in the head, but less than yesterday. I have a little neck pain, and am feeling a little "sad", meaning I occasionally feel like crying when discussing certain things. Also, I have some abrasions on my face and a fat lip, which Im using to stand in for the blood and swelling in my brain. When that's gone from my face, I will use that as a marker for my brain getting physically back to normal.
I'm feeling better, and less scared every day. Not quite ready to get back at it, but I do have a plan.
Great post - Thanks for presenting these logical guidelines for returning from MTBI. Even injured you are a great teacher and a source of wisdom and knowledge. Rest Up, life is to be enjoyed but it is also fragile. Prayers for a quick recovery.
I had a bad fall while skiing back in 2010....falling forward and I tried to stop and it just drove my own fist (while holding the ski pole) right into my face. I was banged up pretty good....but it took a couple weeks for the real damage to show itself in the form of a torn labrum in my shoulder. At the time the last thing that showed any pain was my shoulder....everything from my nose to my knees was hurting including my pride. After a heavy impact trauma like you have had it may take a while for other things to reveal themselves...so please be careful.
Take your time, and one step at a time.
Get well soon,
John
I've been skiing easily (for me) the last two days. The only injuries I sustained were the brain contusion, and superficial abraisions on my lip and nose, which are now healed. Arms, legs,chest. back all working and feel normal. So my biggest (really, only) concern is to keep from being too aggressive on the slopes or the road over the next six weeks or so. But I seem to be in that lucky group of TBI sufferers who is recovering without sequelae. Of course, the fact that I don't have to go back to work helps a lot - I can control how much activity I do daily with no worry or guilt.
According to my symptom checklist, I've been symptom free for the past 4-5 days, and have slowly increased physical activity over that time: walking x 2 days, short session on the bike trainer day 3, then two days of skiing, about 1/2 and 3/4 my usual amount, at about 40-65% of my usual speed, and only on green or blue runs, groomed, with no bumps, trees, or other distractions. I do not intend to do any "serious" skiing the rest of this year, but will be getting out every day for the next week while I am in Colorado, where it is warm sunny and dry
Best wishes.