Differing opinions about the Trajectory of Treatment

Recovery is hard work

Beware the Doctors

Your Own Best Advocate

More than the Medical Community

Injury Extent-First Response

Pain Control

Aspects of Treatment

Specifics:
Skin Rescue

Specifics:
Foot Structure

Four Months Out:
Formalization

Always Begin Slow

The Weird Ones

Back to the Future

You are Nature's Tool,
Your own best Observer and Analyist,
and the
Doctor's Best
"Instrument"

You
Are your Own Best Advocate

The Evolution of the Situation: Surgery Refused: Jan 2011

I reached the point of basic recoverythrough some considerable headwinds.

Surgeons wanted to cut off at least the two big toes, if not the whole tip of my Right foot in early January of this year, 2011, when I hobbled into the VA critical care unit with this case of frostbite. As recently as May a surgeon advocated cutting off my big toe. As of last week all doctors and surgeons agreed that I was correct from the very beginning: None of my foot needed to be amputated.

I told the doctors on Jan 5 that I would recover all sensation and all use of all of the parts of my Right Foot in January. At that point in time the doc actually drew a line across the end of my foot, and my two biggest toes on the Right Foot were on the other side of this line. They said the whole front of the foot might have to come off, depending on how surgery went. If surgery went bad, the whole front end of the Right foot would have to come off.

I washed the line off my foot, and told them they had ms-diagnosed the extent of my injury. They, the medical staff, were also freaking out at the injury and the prospect of cutting off the end of my foot. They did not want to do it, but honestly felt it was necessary. I consider myself a practical analyst. I really tried to reassure and buck-up the medical staff, telling them that my analysis indicated that I would fully recover with proper care.

The doctors and surgeons were not convinced by my prognosis, but I knew that they figured that I could delude myself all that I wanted, but I would report in for amputation when the end of my foot died and turned black.

It was touch and go for the first three months. I worked hard to bring back all of the circulation, sensation, and skin damaged caused by the lack of circulation. I was doing four hours of active therapy a day. In the final analysis only the very tip of my right toe actually died, as you can see from the image on the previous page, and it is unclear how different the tip of my R big toe is actually going to look from the Left big toe when the healing and skin growth is finally complete.

At this very moment the skin on my toe is "welling up," as it grows over the bone. The skin on my toe is still growing skin as new as a baby's ass over the tip of my toe, so it is hard to predict just how the final form my Right big toe will finally look.

I'm voting that it will look exactly as it did before the frostbite, though many skeptics say there should not even be toes there on the end of my foot, let alone perfect toes.

Recovery is Hard Work

I have paid a high price and worked very hard to retain these toes. I have used constant therapy to recover most of the skin on the end of my right foot, and have paid dearly to recover the ability to walk for miles and enjoy the experience. Let me put my actions disputing doctor's diagnosis into context.

General Warning: Beware the Doctors

The first person I want to talk to after an injury is a doctor. Though many sprains and strains will not require medical care from a doctor, always consult a doctor if possible. This does not mean you will always choose to follow their advice.

I shattered my L kneecap in 1975 in the Navy. I refused surgery to replace my natural but broken kneecap with a teflon version. I watched too many Marines go into the same surgery with a bad knee and come out crippled. No thanks. Today my knee sucks, but it will carry me 25 miles under a heavy pack over difficult terrain without failing to both perform well and to produce pain. It took years to recover reliability in this knee, but I'm real glad I kept my own kneecap.

In 1982 I refused surgery from Kaiser to fuse my R wrist. Doctors insisted bone-to-bone action would scream pain forever. Today I can use snow-sticks while snow shoeing, and can lift considerable amounts of weight with my R wrist. Retaining full range of motion is well worth the occasional pains I experience. I'm real glad I kept this moving part moving.

In 2008 I refused surgery for Atrial Fibrillation. Today my heart beats like a champ, 99.99% of the time. And I'm ready for the .01%. Warning: don't take any strange drugs that the doctors offer that stimulate AF. Read the drug warnings and inquire of the doctors. Cyclobenzaprine, which the doctors gave me for my knee pain, triggered the AF. Thanks, Doc! That's Dr. Nagpal of the VA who so wisely gave me a strange drug I had never experienced, which is widely known to trigger AF, when I had a history of no side effects with the much safer Valium...Thanks again doc!

I only suffered a few years from AF before getting it under control.

This year I refused to allow doctors to cut the front of my foot off, and low and behold, my foot is looking damn good, except for the very tip of my big toe...Though I'm still at risk for infection, and not quite out of the woods yet, I'm DAMN glad I refused their kind offer to cut off my toes.

You are Your Own Best Advocate

My point here is that you are your own best advocate. Get all the facts, but make your own decisions. If possible, get a second opinion. Understand the amount of work and time you are willing and able to put into your own recovery. Check all the side effects of the drugs the doctors give you. Question the necessity of all the drugs they give you, and stick to the tried and true classics. Many of these new drugs appear to me to be downright dangerous. Don't let the pharmaceutical industry use you as a test dummy.

The drug companies have bribed the hell out of the Govt and the FDA, and they have cozy deals with doctors that make it vitally important that you read the labels of the drugs yourself nowadays.

Always find out if there are therapies and exercises to give you a running chance of restoring your parts before cutting on them or depending on drugs. Half the high blood pressure and most of the diabetes in this country could be cured with exercise. Three-quarters of the chronic and arthritic pain in this country could be controlled through exercise and fitness.

If I took an injury like this frostbite when I was in poor physical condition I would have lost the front of my foot. My point is that the level of physical engagement you maintain, your fitness level, is going to describe the healing trajectory of any of the injuries and setbacks you encounter. If you are in good shape you will be able to craft better outcomes. If you are not in good shape your injuries and setbacks can cripple or kill you.

Independent of your personal level of fitness make damn sure you cannot fix the part yourself through time, therapy, and exercise before they cut it off, drug it, or replace it.

More than the Medical Community: Great Docs and Family

There's a lot more to healing than the substantial knowledge of our medical community. The best medical practitioners we have are good because they are as knowledgeable at treating the individual patient as they are at treating a specific condition. Bringing these two factors together, the individual patient within the context of their injury determines optimal healing and recovery. Few doctors have this ability, and therefore they apply "cookie cutter" diagnosis and solutions that are not crafted for the specific individual.

On the other hand the general public can be characterized as fat, lazy, and, er..."undereducated..." It can be argued that the doctors don't have much to work with.

To be fair I must say that there are a few excellent doctors in the medical community. It appears that to get access to the high quality doctors you either have to be rich or lucky. Rich enough to buy the best, or lucky enough that you stumbled upon a decent doctor in your corporate health plan. But they do exist, and us mere poor citizens sometimes get access to them.

Without just such a sterling representatives of the medical arts, such as Nurse Practitioner Annie Skradski of the VA system out here in California, I would have likely lost my toes. By providing me with all the tools I needed to perform my home therapy, sanitize the situation, wrap the wounds, and deal with the dead skin, Doc Skradski allowed me to bring all my assets to bear on a successful recovery.

Doc Skradski provided me with all the medical supplies and drugs I required to prove her and her colleagues were wrong about amputating my toes/foot. Thanks Annie! Annie also monitored and consulted with me about concerns and issues related to my foot for the last seven months.

Doc Skradski brought in a number of other surgeons and specialists who consulted with me about my treatment program, disputed it, and who have subsequently been proven wrong. Doc Skradski always gave me the best advice of the medical community, then I applied that information within the context of my own treatment program.

Social Support

Being able to incorporate Doc Skradski's good information and invaluable supplies to my wound treatment program was only possible because of the emergency support from my sister. Without her kind assistance neither of these backpacking websites would progressed so far, and my toes/foot would likely be sitting in a bottle of alcohol somewhere. Blame her!

I am lucky. I have access to, and the support of a few good medical professionals and One good family member. These two factors provided the solid foundation of the stability I needed to put together a successful recovery program. Without medical and social support the trajectory and outcome of this injury could have worked out completely differently. You too will require medical and social support for a successful recovery from serious injury.

Evaluating the Extent of the Injury-First Response

Pain Control

Aspects of Treatment

You too must measure the full extent of your injury and deal with each related issue. In my case I can easily divide these issues into pain control, skin restoration, and structural issues. Each aspect of the injury requires specific treatments. The overall status of both aspects of the injury determines the drug therapy.

Skin Rescue and Restoration

Wound care and preserving sterility for the skin damage is supplemented by therapy to stimulate circulation and promote skin growth. The big toe and foot immediately required hot water therapy with massage to improve sensation, circulation, and strength.

Foot Structure

The muscles, tendons, ligaments and bones in the front of the foot suffered serious degradation due to diminished O2. The foot required stretching, exercise through walking, rest and recovery from walking, and also benefited from the hot water with massage therapy to improve deep circulation to all the soft tissues, the muscles, and the bones.

Four Months Out:
The Program Formalizes

In May all the dead skin on the end of my Right foot had finally resolved into fresh pink brand-new baby skin, except for the very tip of the big toe, which is dead. The skin on the second toe had shed like a snake sheds its skin; in one big piece. Underneath was fresh pink skin. Whew.

I was shedding skin like a snake for four months straight! At that point I was able to easily put my foot in a shoe and begin to train myself to begin to roll weight onto the front footpad of my right foot: The recovery program had started in earnest.

Prior to that point I only traveled as necessary for food and doctor's appointments. It was much too painful for any other travel. There was a two month long period of virtually no walking activity whatsoever. At the beginning of the third month I was able to begin short walks.

It took a month of painful work and rest to make my front footpad bear any weight and start working at all, and this was through extreme structural and skin pain.

Begin Slow

As you can see from my experiences above, whatever lower body injury you are recovering from is going to get irritated when you start stretching and walking on it. At the beginning of this process the goal is to get the part moving without re injuring it, or sending yourself off the deep end of pain. You must be very careful not to cause the pain to cross back to acute pain from the chronic level. Carefully begin probing your physical capabilities.

An injury should not be worked until it is substantially healed. At the end of the healing period gentle flexibility and exercise activity can help restore range of motion and circulation (or even aid the last stages of healing) without irritating or inflaming the injury. The first steps of recovering injured parts can be real baby steps, but they are steps nonetheless.

I am still working to get the front footpad back in shape. Exercise is still causing severe dull chronic pains, and progress is punctuated by frequent rest and recovery. By early June I was able to roll my weight all the way across the front footpad, and continue to apply body weight through the bottom of the big toe up to the wound line on tip of my Right big toe. A month earlier I was not able to put weight on the big toe, and could only hold weight for a short time on the footpad.

Over a period of three months I had very slowly worked my footpad and toes up to the point where they were capable of again supporting walking.

I am doing this as part of rebuilding a "normal" gait. After you experience an injury you are going to have to go through the same process of gradually restoring the strength of your various injured parts, but the process must be tailored to account for the specific needs of your specific injury.

At this point in time the trajectory of the pain and disability of my injury is downward in the face of increasing exercise. Yes.

The Weird Ones

For injuries such as Plantar Fasciitis and shin splints there is only one solution: Immediately cease all activity until the pain completely recedes. Do not try to hike or run through either of these injuries unless you are looking to disable yourself for a very long time, if not permanently. These are not the type of injuries you can work through.

You cannot bring these conditions back to health through exercise while there are virtually any symptoms being expressed. FULL REST IS REQUIRED for plantar fascists and shin splints.

STOP exercising when these symptoms occur, and treat them. Anti-inflamatories are recommended. You can build to top shape without incurring either of these injuries, but when either of them rear their ugly heads, pay close attention and do not try to "tough it out" by working through them. This will result in long-term disability and pain.

These are both essentially overwork injuries. Work will only hurt them more. Full cessation of exercise is required until the tissues peacefully reattach themselves to the bone.

Once you get these conditions calmed down and the symptoms extinguished, you can begin working your strength and flexibility back up, but you must continue to be ultra-sensitive to any reestablishment of the separation of tissue from bone issues which characterizes both of these injuries.

Back to the Future

The starting point of this process of healing and recovery was hot water therapy, drugs, massage, and gentle stretching and flexing of my injured foot. I find that I treat every lower body injury with a variant of this therapy, but adjusted to the needs of the specific body part and specific injury.

I only use ice on injuries when they are fresh. I use ice to treat the initial swelling and inflammation from the break or sprain. At the later stages of the healing-recovery process I find hot water to be quite helpful in restoring circulation to injured parts.

In this case the drugs I am taking are aspirin, to thin my blood to improve blood circulation to my hurting extremities, and morphine, to dull the pain. I have been using ibuprofen to treat the frostbite-induced aching bone and muscle pains in my R foot, as well as the pain of bringing my aching knees back up to speed. But I have stopped taking the ibuprofen to find the base level of chronic pain my foot and knees are experiencing.

The Whole Enchilada

I soon began to employ stretching to keep my other previously injured parts, being my knees, my hips, and my back from tightening up during the inactivity caused by a new injury. Every time you take a new injury it will affect your old injuries.

A month of sedentary inactivity after the initial frostbite injury sparked all of my previous injuries back to activity. Tight, sore and painful knees, along with hip and ass pains are now complimented by a painfully tight back. Man, sitting around will kill you!

I was faced with an interesting decision: either I get moving on a bad foot with an open wound, or my inactivity would continue to snowball all my old and new injuries together, and were pushing me over the edge.

Anticipate that your secondary injuries are going to come into play when a new injury knocks you down.

Accounting for the status of your Secondary Injuries

A doctor, a real jackass of a podiatrist, told me not to walk on my foot on the fifth month after the injury, after I had been working it back up to walking shape for over a month. I had already been walking 4 miles, which was making my foot feel better, as well as loosening up my back and knees.

Doctor Jackass also told me to cut off my big toe...

I made the mistake of listening to half of what this "doctor," said. I decided not to follow his advice to cut off my big toe, but I terminated my walking program. Things went rapidly downhill from there.

Within 5 days of terminating my walking program my back and knees were killing me, and the rapid progress in healing my foot structure (bones and muscles) seemed to be going backward. Structural foot pain started increasing. I restarted my walking program. After 5 days of returning to walking, my joints had settled down, and my foot was again continuing to build strength.

Your secondary injures are part of your recovery profile, and must be accounted for as part of the treatment and recovery of any new injuries.

The Feedback Loop

Treating a frostbit foot is a real challenge. External damage to the skin is complimented by internal damage to the soft tissues. Both aspects of the injury must be addressed.

By applying therapy, following the therapy up with a small amount of work (walking), and carefully assessing the repercussions of each action on my injury, I began the evaluation process to determine if I needed to apply more or less work to my foot. When my foot responds poorly to the work I rest it further and allow it to recover before trying again. When it responds well I increase the work and decrease the rest between exercise sessions.

Analyzing and responding to the feedback your body is providing should be a regular feature of your life.

Small Steps are Good

When my foot began to successfully handle 100 yards of walking I began to stair-step up the amount of work, gradually increasing the distances I put my foot through.

I supplemented this foot exercise "program," consisting of attempts to walk, with a comprehensive lower body stretching program. I began to stretch out my back and lower body in anticipation of expanding the walking program.

Soon I could walk a half mile for the same amount of pain I had previously experienced walking a 100 yards. Initiating the stretching program began to loosen up my back, hips and knees. By stimulating foot healing through working it without stressing it too much, following this work with proper rest to allow the structural bone and nerve pains to recede while maintaining continuous therapy, I have maintained the same level of pain that my first 100 yard walk initially brought me. But now I'm walking 5 miles in the hills.

I did this one step at a time. In this manner I have made slow but significant strides in strengthening the soft tissues and structure of my foot as the open wound resolves itself. The length of each rest and recovery period after exercise depends on how the tip of the toe and the foot's soft tissue and bones responded to that exercise session.

My foot is currently responding with one full day of deep aching pains and extreme nerve pain in the big toe following a five mile hike day. The bone pain moderates on the second day following the exercise, while the toe pain only moderates with pain killers.

Wild Card

The real potential fly in the ointment is infection. I have had an open wound of a steadily decreasing radius on my toe for seven months now, as it slowly heals, and Infection has been a constant deep concern during this whole period of time, up to and including the present time. That is the one wild-card factor that can cause a real setback in my recovery.

I have a full bottle of powerful antibiotics at hand (thanks Annie!) for me to immediately begin if the wound infects. I observe the wound very closely for signs of infection.

The Final Goal
Injury Recovery

Ideally, I will build up foot strength and improve the condition of my knees, hips, and backs so all will be capable of walking 5 miles without a subsequent day of significant structural and nerve pain.

At that point in time I will be ready to increase the difficulty and strain of the exercise by beginning to add-in sections of jogging to my walks in the hills. I am hoping the open wound will finally be sealed up when my foot and knees are good for jogging sections of my walking route.

My lower body goal right now is to finish both the external (close the wound) and internal (bones-muscles-soft tissues) elements of injury recovery while extending my aerobic exercises (walk) from 5 miles to 6 miles, and begin working up to jogging at least 3 miles of this distance.

The final goal

Once I reach the above goal of getting my basic walking skills back, I will begin to train up to my standard level of backpacking fitness for Long Distance Sierra Travel: Seven mile jogs over 750 feet of vertical elevation every alternate day. Alternate days are weight lifting days. Every day is a stretching and sit-up day.

Reaching that point marks successful completion of my standard program for being in top shape to begin a long distance trip in the High Sierra between Lake Tahoe and Mount Whitney

The next step after restoring our walking skills is to bring the jogging program up to speed.

Next page: Bringing up the Aerobics to the Max

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