Rough Ride

Every doctor has a condition he or she hates treating, and for me impalement is it.

By Elisabeth Rosenthal|Wednesday, April 01, 1992
RELATED TAGS: PHARMACEUTICALS
One beautiful spring day when a junior doctor told me the paramedics were bringing in a man impaled on his bicycle, my first response was, Yeah, right.

No joke, he said. I felt nauseated.

Every doctor has a condition he or she hates treating, and for me impalement is it. Deep cuts, heart attacks, deforming fractures--I can view all these with calm. But the sight of a foreign body protruding from skin makes me weak at the knees. I even balk at removing splinters.

Unfortunately the ambulance dispatcher confirmed the report. A 19-year-old man had been riding his bicycle in a nearby park at about 25 miles per hour when he was sideswiped by another cyclist. He’d been thrown 20 feet in the air and had landed on his mountain bike with an impact so hard that it drove the end of the left handlebar and brake deep into his thigh.

The paramedics were rightly afraid to remove the metal, so they were delivering the cyclist to our emergency room with the handlebar still in his thigh. I imagined the grotesquely gnarled sculpture--part metal, part flesh--soon to be placed under my care.

He arrived moments later on a stretcher surrounded by a small halo of paramedics and policemen. Between the uniforms I caught a glimpse of the young man’s face. I was relieved to see he was conscious and talking.

My first efforts to approach him were stymied by the dense thicket of bodies around the stretcher that had now been settled in the trauma bay. I was muttering something about people’s morbid curiosity when I realized the human halo served a purpose: while four men maneuvered the stretcher, another three supported the remnant of a crumpled bicycle frame that was jutting from his left leg.

The patient, Mr. Schulman, was in obvious pain, staring at the ceiling, trying hard not to catch sight of his leg. He was quickly hooked to intravenous lines and monitors in case his condition should deteriorate because of blood loss from his wound. Each move of the bicycle caused him to wince with what must have been excruciating pain as the metal pressed on raw nerves and vessels inside his body.

The young man said he’d been riding his new mountain bike when the collision occurred, and on impact he just went flying. He had been wearing a helmet and didn’t think he had hit his head, though he couldn’t remember much about the actual crash. When the dust settled and he realized he was still alive, he had moved the arms and they both worked, then looked at his leg and noticed the bicycle piercing his sweatpants. Luckily his instincts led him to the smartest move: It looked so gross I just laid back my head and waited for help.

The park is close to several major hospitals and a glut of doctors live in the neighborhood. Within 30 seconds a surgeon out jogging was kneeling at his side. It was another lucky break: a macho passerby might have been tempted to pull out the handlebar. Leaving the thigh alone, the surgeon checked the lower part of the leg and found the man had some sensation, suggesting that no major nerves had been severed. He found pulses behind the knee, telling him that the major blood vessels of the thigh were probably intact. And so, prudently, he left the bicycle in place. The bike’s foam-covered handle, he reasoned, might be patching a hole in an artery wall that would spring wide open if it were pulled out. Or the brake lever might be compressing a major vein.

The park police called 911, and in minutes the ambulance crew had arrived. With the help of a fire department team, they sawed away most of the new mountain bike, leaving only a gleaming arc of red metal and black- foam-padded handle emerging from the sweatpants. They then wrapped gauze around the leg and bike parts so that the metal couldn’t jiggle during the ambulance ride.

I’m amazed I didn’t pass out, the patient said as he finished his story.

Does anything hurt now? asked one of the emergency room surgeons.

Just the leg, came his reply.

We checked his head, lungs, belly, and kidneys, and all were okay. No sign of concussion, fracture, or even bad bruises anywhere else. You were lucky you were wearing a helmet or you might not be alive, the surgeon remarked.
I know, he answered, suddenly bursting into sobs. My older brother died in a bike crash three years ago because he didn’t wear one. For the first time throughout his appalling ordeal, his composure fell apart. It’s okay, you’ll be fine, please don’t worry, we said, trying to reassure him. Fortunately, we are seeing vastly fewer deaths and head injuries since bicycle helmets became popular.

Although my stomach turned as we unwrapped the gauze around the handlebar and cut away his sweats, I was heartened to see that the wound looked quite clean. About four inches of handle had disappeared under his skin and through some thigh muscle, but there was very little bleeding or swelling around the entrance site. It was testimony, ironically, to how bad the collision had been. The handle had moved through the flesh with such force that it had neatly compressed large blood vessels en route, and the heat of the friction had apparently sealed off--literally cauterized--the small bleeders as well.

After giving him some morphine, we conducted another brief exam, feeling for pulses in his lower leg (they were present) and asking him to wriggle his toes (which he was able to do). The exam gave us hope that he would not only live but walk again soon.

If, for example, he had torn the huge femoral nerve, which runs through the thigh, he would not have been able to move his lower leg or feel my touch there. Nerves torn asunder cannot simply be sewn back together, since the lower portion of the nerve trunk dies. With proper surgical care the old nerve root can be coaxed to lay new tendrils down into the leg--but they grow extremely slowly, one inch a month, and in the meantime the muscles they govern atrophy from disuse. Muscles more than a foot or two from the nerve injury are usually wasted even if nerve contact is reestablished. A major nerve injury could have left Mr. Schulman lame.

A cut across the thigh’s femoral artery would have interrupted blood flow to the foot and could have been disastrous also. Torn arteries require immediate repair by a vascular surgeon to reestablish blood flow, or gangrene sets in and the leg quickly dies. But there was no sign of such grave damage. Encouraged, the surgeon rewrapped the leg to secure the handlebar and ordered X-rays to see where the metal parts were lying.

Hospitals are like small towns, where news travels fast. No sooner were the X-rays taken than people began to file through the emergency room. Medical students came from the library to view the films, and even the radiologists came out of their darkroom to see the person connected to these extraordinary images.

Is there a guy here with a bicycle stuck in his leg? one asked incredulously.

The X-rays showed the handlebar had lodged in the front of the thigh, with the brake lever gently cradling the long bone, or femur. The bone, astonishingly, had not been broken. The radiologist then injected a small amount of dye into the young man’s circulation and watched as it traveled through the arteries, just to make sure there was no leakage.

You really are lucky, I told Mr. Schulman, explaining that the metal had traversed the obstacle course of nerves and arteries that run through the upper leg without severely damaging them.

Will I walk on it? he asked, his thoughts turning from death to the practicalities of living.

I can’t see any reason why not.

It was one of those minor miracles, so commonplace in the emergency room. The peculiar curve of the handlebar, the split-second position of the leg as it pushed down one last time on the bike pedal-- these things had made the difference between health and disaster.

I knew from the start that Mr. Schulman’s day would end with a trip to the operating room. Yanking the handlebar might precipitate serious bleeding, and surgeons had to be ready to stem the flow. Moreover, bits of foam and gravel were almost certainly embedded in the wound, which would have to be explored and cleaned under general anesthesia.

As the weekend operating crew prepared a room, the senior trauma surgeon reviewed the X-rays and the leg one last time. Then, with that blend of confidence, arrogance, and decisiveness so typical of surgeons, he resolved that the handlebar should go--then and there. The metal parts were causing Mr. Schulman considerable pain, and the surgeon reasoned he could stanch any bleeding with pressure from his hand until the surgical suite was ready.

I doubt Mr. Schulman knew what hit him. The leg was unwrapped. A shot of morphine was given for pain, a dose of Valium for anxiety. And on the count of three, with a grunt from both surgeon and patient, the handlebar slid out of the thigh, leaving a telltale track of black foam.

We held our breath, half expecting blood to gush from the wound. But none appeared. When he realized what had happened, Mr. Schulman said, Thank God it’s out of there. Within half an hour he was in the operating room having the wound cleaned and closed.

Mr. Schulman did well after surgery, although one of the four quadriceps muscles in his thigh was so torn up by the trauma that it was removed. After a few months of therapy, he was not only walking but contemplating buying a new bike. I’m sure by next spring he’ll be back in the park, but this time probably not traveling quite so fast. Over the protests of bike racers, the park police have instituted a 10 mph speed limit.
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