2009 Annual Competition Winner - "The Roadrunner"
by Marc Shabot, MD, FACP
Dan looked terrible. Although I had not seen him in over a year, my 79 year old friend looked like he had aged two decades. His clothes were disheveled, his eyes sunken, his face pale and furrowed, his shoulders slumped, and his voice weak and shaky. He had the look of a broken man, defeated and vulnerable.
I asked how he was doing, and he said, “Bad. I broke my ankle two months ago, and all I have been able to do since then is sit at home with my foot elevated and watch TV.” We talked for a minute more, but I had to return to my duties at our Internal Medicine Alumni Society Dinner. Dan was there that night because we were honoring one of his close friends. I saw that he was depressed and made a mental note that after our CME course was over, I would pay him a visit. I had known Dan for almost forty years. At the University of Texas Medical Branch in Galveston, he had been a mentor to me when I was a student and house officer, and then a colleague and friend after I joined the faculty. He was a superb internist/cardiologist and an unusually caring physician. As an intern, I remember one night on call when I found Dr. Dan asleep in one of the vacant rooms in the CCU. He slept there that night because he was particularly concerned about one of his patients whom he had admitted there. Over the years, I came to learn of many other patients to whom he had gladly given more than was expected of a physician.
The practice of medicine was not the only thing Dan was passionate about. He was a long distance runner, and he had been running for close to thirty years, six days a week, 30-40 miles per week or more if he was training for a marathon. His exercise discipline always amazed those who knew him. His days centered around running, particularly over the past 15 years since his retirement. Dan is 6 feet tall, thin, and with a “short step” running gait, he was easy to spot among a group of runners on the Galveston seawall. Dan reveled in the fact that his total serum cholesterol was 87mg/dl and that he took no medications, not even aspirin.
As it turned out, it was sometime later that I learned the full story of how Dan broke his ankle and of his ensuing problems. The story begins with Dan running the Houston Marathon in 4 hours 40 minutes and taking 4th place in the 75-79 year-old category. He told me that in the post-marathon period, not surprisingly,one’s body is spent and fatigued. Two weeks after the marathon, and out for a five mile run, Dan felt particularly good and decided to run the last mile “fast”. The next thing he remembers is “the inevitable feeling of falling”, and he must have tripped and slammed onto the concrete. He landed face first, and on his left side. His front teeth were chipped, his nose and face scraped and bloodied, and a bump soon appeared on the left side of his forehead. His left shoulder, elbow, and knee also were badly skinned. He didn’t recall losing consciousness, and he remembers then running towards home and being stopped by a woman in a car who saw that he had been injured. She gave him a ride home. After cleaning up, Dan made his way to the dentist’s office. While in the dentist’s chair, he noticed that his left ankle was painful and swollen. A trip to the University Emergency Room followed, and films confirmed a non-displaced ankle fracture. He left the ER on crutches with his left foot in a boot. At his follow-up orthopedic clinic visit, he learned that if he planned to resume long distance running, surgery would be necessary to put a plate in the ankle for stability.
Twelve days after his fall, Dan’s surgery went well. He soon began physical therapy using elastic bands for resistance exercises. He also developed his own physical therapy routine at home, which included countless hours of crutch-assisted laps around the stone path which lined the perimeter of his backyard. Most of the day, however, he could only sit on the couch with his foot elevated and watch daytime television. Unfortunately, he developed problems with wound healing, which would delay his recovery and rehab. At the clinic visits over the next two months, the cast would be cut off, the wound inspected, and a new cast put on, and this cycle repeated. Day after day, my roadrunner friend was forced to spend most of his waking hours sedentary with his foot elevated. He remembers become smaller and smaller. The physical therapy with the resistance bands and his endless backyard trips on crutches didn’t seem to be helping him regain strength or stamina. He became more and more concerned about the disuse atrophy that he saw occurring to his left leg muscles.
From his wife, I learned that during the three months after his fall, he became more moody, irritable, and worried that he would never be able to run again. After the cast came off for the last time, she saw her husband walking all stooped over, and acting to her “like he was having a stroke”. She also found that “he had an answer for everything,” and that he got angry with her inquiries and suggestions. He informed her that he wasn’t having a stroke since his weakness was on both sides, and was not just one-sided. He attributed his weakness to pushing his physical therapy too hard and wearing himself out. Other things began occurring that should have been troubling. He recalls having difficulty staying in his own lane when driving and thinking that he had to concentrate more on his driving rather than let his mind wander. Also, at a dinner with three other retired physician colleagues, he had difficulty using his fork and getting food to his mouth. This went unnoticed by his friends, but he told himself this was due to muscle fatigue. After dinner, one of his friends had to help him get back to his car because of his generalized weakness and unsteadiness. Finally, this same evening after returning home, Dan realized that he could not control his urination, as he had wet himself, the toilet, and the bathroom floor. It was then he knew that he needed to seek medical attention.
The next morning in the University Emergency Room, Dan was seen by an ER physician who knew him from his years on faculty. Dan was thought to have a urinary tract infection. However, when the urinalysis came back normal, and blood work was ordered; it too was normal. Dan’s wife watched as all the doctors who knew of the 79 year old retired physician’s running prowess came in and marveled at his health. All the while, she repeated that “something is wrong with him” and that “he is not right”. After six and one-half hours in the ER, and with his wife insistent that something must be done, the ER attending physician agreed to admit him for observation. The resident from the Geriatric Service came to the ER to see the new patient. After taking a history from Dan and his wife, he thoroughly examined him. Dan recalls being quite impressed with this young physician and, as both a participant and an observer, he realized that his neurological exam uncovered deficits in cognition, motor and cerebellar function. A head CT scan was ordered and showed large bilateral subdural hematomas with mass effect but no midline shift. Later that night, the neurosurgeon drilled four burr holes and evacuated the hematomas. The next morning, his wife saw that “Dan was back, he had personality.
The first time I saw Dan after the alumni society dinner was six weeks later. He was in the checkout line at the local Wal-Mart Garden Center. To my great surprise, he looked fabulous. When I asked him how he was doing, he smiled and said enthusiastically, “Just fine.” I asked him what had happened since I had seen him at the dinner, and he told me about the subdural hematomas having been discovered two weeks after I saw him. I was floored because the difference in the> man I had seen just weeks before and the person standing in front of me that day could not have been more profound. Those of us who had come in contact with Dan after his fall and ankle fracture had been correct about his situational depression. But that depression proved to be only a small part of what was actually going on. In fact, the subdural hematomas played a far greater role in his difficulties than did his emotional struggles. Dan had rationalized his behavioral and physical difficulties to both himself and his wife and family based on what he knew as a physician. Further, his physician friends and others who saw him only briefly attributed his difficulties to the ankle injury, its slow recovery, and its impact on his psyche. We often see what we want to see, and our observations can be distorted by how we interpret what we think we are seeing. Whether the patient suffers from a space-occupying intracranial process such as a subdural hematoma or a mental illness such as depression, cognition, reasoning, and insight may be clouded.
Dan is now 80 years old. He is back running 30-40 miles a week, and has begun to train for another marathon. He and his wife are enjoying every day of good health, and they vow to “go until we drop”. As it turns out, the woman who had offered him a ride home after his fall had not stopped him while he was running home. She came back to his house two days later to see how he was doing, and it was then that she told Dan and his wife that she had found him bloodied and helpless, lying on the ground that day.