30 November 2009

Further Update - Shoulder injury -- and random thoughts on cycle commuting and Japanese health care

Further Update: Checked in to Tokyo Medical Center on Tuesday afternoon.  On Wednesday, they were able to reset the shoulder with me under general anesthesia ... without making an incision or cutting up my muscles/tendons.  I'm out of the hospital this morning, with my upper arm heavily taped to my side/back for the next 3+ weeks so it does not "pop out" again.  Seems like everything went smoothly, and the usual pleasant surprise with a bill that is probably 10-20% what it would have been in the U.S. and leaves one scratching one's head as to how they can possibly pay salaries of the docs and staff.


Update:  The shoulder movement was not returning as quickly as it should have -- I cannot turn my arm outward or lift it up. I had my 2nd follow up visit yesterday to the doctor and still nothing showed on another x-ray -- so he had me CT scanned. The CT scan shows very clearly (1) a portion or the back side of the "ball" joint of my arm into my shoulder socket was crushed in the impact against the shoulder socket -- nothing that won't heal with time and still plenty of bone left all around it, but also (2) the arm is dislocated ... not all the way out of the shoulder socket, but about 1.5-2 cm shifted back from where it should be, and the jagged edge of the damaged part of the "ball" joint is riding/catching on the edge of the socket, which is why I have very limited movement, and also which prevented it from "relocating" to the right place on its own.

I'm going in Tuesday afternoon, for surgery, general anesthesia, Wednesday morning. They will try to "relocate" the shoulder and if that works, they won't need to make an incision.

If it does not, or looks like it risks further damage ... then they will do surgery to achieve the same result. Seems like the doctor wants to do this ASAP, says the longer I wait the harder the relocation will be/more damage to the non-bone parts. So I'll just get it done ... at least it is a major medical center with a good reputation from what I know (Tokyo Medical Center - Komazawa) ... rather than hunting for the best shoulder doc in Japan or hopping on a plane to get someone in the U.S. to deal with it (as some of my colleagues have said I am crazy not to do, given their perception about the difference between the higher end of orthopaedic surgeons in the U.S. and Japan, as well as their desire for an English fluent doctor). We shall see.

P.S. Maybe next time (if there is a next time) this doc will believe the patient when he says it hurts so much there must be a break or dislocation -- turns out there was both!


Original Post:

Komazawa Dori was a solid line of standing traffic on Thursday morning last week around 9AM. After passing Komazawa Park, at the Jiyuu Dori intersection, I could see not only the line of cars but also taxis blocking the shoulder that usually serves as an informal bike lane, so I went onto the sidewalk at the far side of the intersection, in front of the National Medical Center, slowing my pace.

The sidewalk is at an angle, tapering as it moves away from the corner, and a signpost of some kind blocked my view straight up the path. As I rounded the sign post, I came face to face with a college student (Y.O.) on a mamachari, going at full speed as he rounded it from the other side, starting to get a proper line to cross the intersection (late to class?). I swerved to try to avoid him, but we brushed left shoulder to left shoulder. At my very slow pace, and with my motion already to the right, that brush was enough to drive me off the bike and shoulder first into the pavement. ... If I had hit Y.O. head on, I probably would have done some serious damage to him, helmetless and probably 1/2 my weight, but as it was, he stayed upright and came back to see if I was alright.

I was not -- I lay on my back, a stinging pain in the shoulder immediately following impact. I could not move my arm. Anyway, Y.O. helped me over to the conveniently located National Medical Center, and spent the next 2 hours with me as I went through check-in, then by wheel chair to the orthopedics department, then down to x-ray/radiology, then back up to the orthopedics department, then to the sign out line, then the cashier. The bill was 6240 yen (US$70) without insurance. Then we walked across the street to one of several conveniently located pharmacies to get two types of pain killer and another medication to take to counteract stomach problems from one of the painkillers (another 3000 yen -- under US$35).

Fortunately, the orthopedist gave priority to a large foreigner writhing in pain and I did not need to wait long. I was skeptical when told there was no sign on the x-ray of a broken bone or dislocation, even though I could see the xray myself ... but was assured that, yes, it really could hurt THAT MUCH!!!!, even without either a break or dislocation. ... I've since heard colleagues mention scary phrases like "rotator cuff" (an injury one received upon being slammed shoulder first into the boards while playing hockey ... with a four month recovery period including rehab?). Maybe I will get my first MRI after I stop back at the orthopedist on Wednesday for follow up? Doesn't everyone get an MRI at some point in Japan (where the government-mandated cost is something like 10-15% the equivalent in the U.S.A.)?

The pain has gradually subsided over the intervening 4 days ... but it is only today that I can type at all with my right hand reaching the keyboard, and only with my arm very carefully positioned and without much stamina. And I'm still on painkillers and wearing a sling for the rest of the week--I hope no longer than that.

1. I may have a warped perspective, but I think Y.O. bears at least 75% of the blame for this accident, because he was going way too fast for an obstructed view part of a sidewalk, and did not seem to take evasive action. That said, my bike was not harmed, my insurance will cover any of the (modest, in Japan) medical costs, and I really did not see the point of calling the police or filing a report for an accident that occurred on the sidewalk, as opposed to going straight into the hospital for treatment.

2. I blame myself for deciding to ride on the sidewalk. I thought this stretch of fairly broad sidewalk, with very limited access from either side and relatively low traffic after passing the hospital entrance, would be safe, but sidewalks are a much more dangerous location than streets, in my view, since you are much more likely to have a Y.O. appear immediately in front of you, or to have a high school kid with gym bag come running out of a stairwell just as you pass. The only way to ride safely is to preserve an ability to defend oneself, and that is harder on the sidewalks.

3. Even when I stay in the street, however, I often recently come face to face with cyclists riding the wrong way on the shoulder, forcing me into traffic to avoid them. I always try to scream "hantai houkou" (wrong way) as I pass ... but I'm fighting a losing battle against the umbrella-bearing, mobile-phone-screen-viewing, wrong-way traveling cyclists of this town. There are more and more cyclist commuters in Tokyo with each year, most of them quite responsible, to the point of being ridiculous -- waiting at red lights at minor intersections even when there is no cross traffic nor a policeman in sight! In general more cyclists are a good thing because cars are more likely to expect and anticipate you -- but it is not so great when there are no bike lanes or other real accommodations. And I see more and more cyclists zooming right in front of pedestrians who are trying to walk across the street, terrifying them like something out of a Lucas Brunelle video of messengers racing across Manhattan, flitting through lines of traffic and pedestrians like schooling fish (There were 3 of these Brunelle videos among the short films I saw at Bicycle Film Festival, even crazier, much crazier than this one on Youtube -- music by ÜBERDOSE! -- from a few years back). UPDATE: You can see more Lucas Brunelle videos and material at his official site, including similar Stockholm and London rides ... but not yet the new NY rides I saw at Bicycle Film Festival.

4. I also am painfully reminded that the traffic, and risks, are much worse if I ride in at 9AM than if I leave home at 7:30AM. Now if I could just teach the clients to keep early hours, I would be fine.

5. The National Medical Center is impressive in at least one way. I have never seen so many elderly Japanese in a single place -- the equivalent of at least 10 or 15 country villages all sitting in the waiting areas around this hospital complex. Average patient age must be creeping over 80. Is this what the restaurants and trains of Tokyo will look like in 30 years? If it is, I don't think I want to be here to see it (at age 77).

6. What a great business the pharmacies across from the medical center have -- the one I visited, Terada, had an endless stream of customers, keeping 8-10 pharmacists busy at all times filling prescriptions. The shelves and bins were overflowing with more prescriptions, just waiting to be picked up.

I'll provide an update when I have a better idea of whether this is a 2-week, or a 4-month recovery and rehab path, and when I know what my injury is called -- something more technical than "tenderized/smashed up soft bits inside shoulder area").


mob said...

Well, whatever it is called I hope you will get well soon. Bryon, you and me, the list of traffic accident related injuries this year is too long.

By the way, I got a MRI for my ellbow after the crash at Saiko - ridiculous and unneccessary.

Take it easy, relax and don' overdo it with yoru arm so that you are back in life and back on your bike soon.

Manfred von Holstein said...

David, I'm sorry to hear and wish you a sound and speedy recovery!

Hard to blame yourself especially if you were not fast. But the pavement/sidewalks are a dangerous spot for sure.

Glad to hear you got good, fast and cheap medical treatment. My experience with MOB was not so good.

BTW, the prophylactic prescription of mucoprotectants is typical in Japan, but not necessary if you are taking NSAIDS for only a short period of time and have no prior history of GERD/NERD (stomach pains due to inflamation of the stomach lining). Typical cocktail usage of drugs, which makes the docs feel good but serves little purpose or sometimes has even negative effects.

Also quite unlikely you would need an MRI (or CT) any time soon. Normal X-rays from a few angles should detect any fractures.

Hope you will recover soon and without any lasting effects! And let's hope the rest of us stay lucky and have no accidents.

Cheers, Ludwig

TOM said...

Get well soon David! I pray for you it isn't lasting.

On the topic of medicine cocktails, and since you asked the other day Ludawig, I received LOXONIN (pain killer) - MYONAL (muscle relaxant) and MUCOSTA (mucuos membrane of stomach protection)... My entire left arm still hurts during downhills. The doctor tells me to make a reservation for an MRI (this is really to detect herniation and other abnormalities with ones nerves) but I refuse; I'd rather suffer on downhills than undergo an operation to put some piece of plastic between 2 interverebral disks which will move with time anyways and necessitate another operation.

lovensprockets said...

In football the injury closely fitting your symptoms would be called a stinger. Although I would not give this name to your injury. What you need to do is go through the various planes of movement and see where you are limited in range of motion or feel the greatest amount of pain. Then you can use this information when seeing the doc for MRI. Checking online reference pages will provide all the relative muscles involved in the movements of the shoulder. If you know the names you can tell the doc to focus on the areas related to that muscle or area for a better determinate of damage.
Best of luck and follow the RICE treatment protocol as best as possible.

David L. said...

Thanks for the advice, and the pro and con MRI discussion.

"Stinger" sounds plausible, except this pain really does not get any closer to the neck than a few inches inside the shoulder on my back -- where it is tender -- but it sounds like these things are tricky. I will try the self-diagnosis for movement/pain this evening.

I go back to the orthopedist for the elderly at National Medical Center tomorrow morning and will see what he has to say, and then if I'm not happy with the diagnosis or plan of action I'll look for a better alternative -- one of my colleagues was happy with an orthopedist in the Midtown clinic.

I'm on Loxinin and Mucosta. I am always puzzled to see something like Loxinin -- an NSAID like (but different than) ibuprofen (advil/motrin) or acetaminophen (tylenol) or aspirin or VIOXX (withdrawn from the market) or various others -- that is a major drug in Japan (and is apparently also sold in Brazil and Mexico), but is not on the market in the U.S., and likewise never see major drugs like ibuprofen or acetaminophen here in Japan. Ludwig can probably explain since he is an expert on the Japanese healthcare system (though not on sports medicine) ... maybe a topic best left for a drink some Friday evening instead of the blog.

Jimmy Shinagawa said...

Condolences David, I hope it heals quickly.

Manfred von Holstein said...

Tom, I would recommend you do the MRI if only to know what is causing the pain. Actually, if you are right and it is a problem with your vertebral disks, your current medication makes no sense and in fact the muscle relaxant may just make things worse. Muscle relaxants may help with pain caused by the muscles. But if you relax muscles more than you should and have disk problems, they will just get worse.

Also, if you keep taking NSAIDs (Loxonin is one) for a longer time, it would be better to take a PPI rather than a mucoprotectant. The latter don't really work that well, and it is more important to reduce your stomach acid to avoid it attacking the weakened stomach linen. The problem is that many Japanese doctors still don't get this and there is no prophylactic indication for PPIs yet, so you may need to fake some stomach pain to get what you should get according to best global medical practice.

TOM said...

Thank you Ludwig; you confirm exactly what I was suspecting...the muscle relaxant and pain reliever are mere stopgap remedies. I stopped taking them (still have 10 days portion)a few days ago. X-rays show narrower than normal space between the 6th and 7th intervertebral disks in the neck and this is putting pressure on the nerve system...apparently the cause is known to my doctor (Sanno Hospital). The funny thing is that the pain now only occurs when I am braking with my left hand on downhills (my front brakes are left). The symptoms are slowly becoming milder lately. I will try to live with it for now.

Jimmy Shinagawa said...

You could debate the pros and cons of healthcare here versus the rest of the world until we are all very old and grey.

I know from experience how long rotator cuff injuries take to heal. For that reason, I am in the "get it looked at the asap" camp, so I am sure Tokyo Medical Centre in Komazawa will be absolutely fine.

Good luck, get well soon.

Manfred von Holstein said...

Wish you all the best for the treatment!

Hard to say whether this is the right place - there is just no data in Japan to judge!

You could ask them how often the team doing this on you is doing similar things, and go by that.

TOM said...

Praying this operation will be a minimally-invasive one. I'm sure they will do an excellent job though. O-daiji-ni David!

mob said...

Good to hear than you did not require more evasive surgery. I hope that everything will be as before eventually. Well, some three weeks lus of a break during the winter season are not sooooo bad. Hope to see you bak on the bike soon nevertheless.

Manfred von Holstein said...

I don't think David was intending to have surgery to become evasive of us or cycling...

But glad to know invasive surgery was not necessary, and I hope you will recover well.

Was this 10-20% of US cost based on your out-of-pocket contribution (30% of total cost) or total cost?