I am off the bike this week, except for commuting, due to what may be a broken big toe. I say “may be”, because the treatment for a break or a soft tissue injury is the same. Without x-ray vision, I don’t know which it is. I haven’t found a good reason to pay for a doctor’s visit and an x-ray. If broken, pain and tenderness to palpation say it may be in two places. (The bike had nothing to do with the injury. Many have asked.)
The usual treatment is “weight bearing as tolerated”, meaning you walk on it as long as you can stand the pain, and a “post-op shoe” or other hard-soled shoe to minimize the bending of your toe when you walk (since you naturally push off on your big toe, stressing it with every step). Walking hurts more than riding a bike.
I splint broken fingers and other body parts – why not a big toe? So I devised this toe splint, which seems to be working. It fits (snugly) in a shoe, but feels better barefoot – which is true of life in general. The second toe is taped to prevent abrasion from the casting material – a semi-rigid material called “Orficast”, which looks like a roll of tape and is moldable, hardening after being soaked in warm water. While I walk a little funny since the toe won’t bend, it hurts a lot less. I gave up the cane yesterday.
Since I’m not writing about biking, I offer this post-mortem on a remarkable institution which would have marked its tenth anniversary last summer, were it not for a pandemic.
A 15 year old musician wanted to be an orchestral conductor. He looked around and found that, in the US, there were no undergraduate conducting programs. To realize his dream he would not only have to finish high school, but also get an undergraduate degree – then he could try conducting if he could get one of the coveted spots in a Master’s program in conducting. He discerned there was another way. He could start an orchestra.
With no funds, and being too young to form a not-for-profit corporation with which to fund it, ingenuity was the only recourse. He recognized that there were no opportunities for young musicians to play chamber orchestra repertoire, so he formed a chamber orchestra. He recruited musicians from WYSO (the Wisconsin Youth Symphony Orchestra) and the University of Wisconsin School of Music. He envisioned it as a mentoring program, so paired college music majors with high school students as stand partners. Over the years, he added workshops in historically-informed performance practice with local professional musicians. He enlisted faculty members (including members of the Pro Arte Quartet, the world’s oldest consistently-performing string quartet) to appear as soloists, so the student musicians could have the experience of performing with professionals. He developed a conducting apprenticeship program so other young musicians could get podium time during rehearsals and performance before an audience. He mobilized conductors to mentor him, found summer training programs, and served an apprenticeship with the Madison Opera Company – their first-ever conducting apprentice. World premieres and supporting young composers were an integral part of MAYCO, with a newly-commissioned work nearly every year. (2015 saw the US premiere of British composer Cecilia McDowall’s “Rain, Steam, and Speed”.) Eventually he partnered with an arts funding organization to provide a means by which donors could help fund the orchestra.
Partnerships were negotiated with WYSO and the university (and later, churches and an art gallery) to secure rehearsal and performance spaces, as well as use of larger instruments (e.g. percussion and piano). The orchestra performed on the Sunday Afternoon Live at the Chazen performance series. (Scroll down to August 5, 2018 on the Chazen Facebook page to hear a few seconds of the sound check for the performance we listened to online in a Tim Horton’s in Niagara Falls on that date.)
A series of top-drawer university violinists served as concertmaster until the conductor married the last concertmaster and they became co-artistic directors.
Little did the founder know at the time, but starting musical organizations as a teen ran in the family. His aunt’s brother, George Shangrow, founded the Seattle Chamber Singers at 18 and directed them until his death at the age of 59. That was never the plan for MAYCO, which started as a program to run until he went off to college. Then he thought about how to run it virtually while away at school, returning for the summer performance season. Since it was conceived as an organization run entirely by and for youth, it was going to end some time unless the founder became Peter Pan. It did, in fact, hold a “Finale” performance in 2016, before returning for an “Encore” in 2017. Due to an offer he could not refuse, he stayed in town for his undergraduate music performance degree and continued the orchestra until it was struck down by the pandemic.
The late John Barker, classical music critic and Professor of Medieval Studies, gets the last word: “Hope for humanity is not always easy to conjure up these days. But last Friday night at Music Hall, on the University of Wisconsin-Madison campus, brought me a genuine dollop of it, thanks to the concert by the Madison Area Youth Chamber Orchestra…The MAYCO players brought it [Shostakovitch’s Ninth Symphony] off with real flair, under Utevsky’s amazingly expert direction. (And, by the way, he is a splendid writer as well, as his notes for the program booklet demonstrated.)…That our area alone could produce such talent is what has stirred my hope for humanity.” (Excerpted from The Well-Tempered Ear)
Bicycling magazine recently republished an article with the clickbait headline “It’s Okay If You Don’t Wear a Bike Helmet”. Clearly, the implication was that helmets are not really very useful.
The article went on to talk about safer bicycling infrastructure – but it doesn’t have to be an either/or situation. Should we stop designing crumple zones into cars because we shouldn’t crash them in the first place? Should we toss out airbags, seatbelts, and carseats for kids? None of those are useful when nothing goes wrong. We work for the best and plan for the worst.
What does the evidence say about helmets? And how good is that evidence? A quick review: when we look at evidence, we consider “levels of evidence”. Different authors define those differently but, generally speaking, the highest level of evidence is a systematic review of randomized controlled trials (Meaning, for the non-scientists among you: looking at not just one, but many studies of the same phenomenon; and not just observing what happens in retrospect, but planning a test, assigning people randomly to groups, and looking at what you are studying in relation to a control group. A few definitions: randomized – people are assigned to one of two or more groups randomly, so that the groups should look the same; double blind – neither the participant nor the observer knows which group the participant is in; placebo-controlled – the group that doesn’t get the test intervention gets something that looks the same but should have no direct effect on the condition studied.) Expert opinion is the other end of that scale.
Randomized controlled trials are not always possible. The article “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials” (Smith & Pell, British Medical Journal, 2003) points out the difficulty of testing some hypotheses. They concluded:
“As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.” (Smith & Pell 2003)
Further, Yeh, et al (BMJ,2018) in the PARACHUTE trial, conducted a randomized (but not blinded) study of parachute use in “Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial”. Their outcome measures were death and ISS (Injury Severity Score). Come to my workshop for an explanation of ISS. They concluded:
“Parachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.” (Yeh, et al, 2018)
We can extrapolate from the above studies that we cannot conduct an RCT (Randomized Controlled Trial) to truly test the efficacy of bike helmets. We can also conclude that careful reading is important, lest we draw the wrong conclusions, or accept the conclusions drawn in articles in the popular press about the study .
So what do we have? Olivier and Creighton, writing in the International Journal of Epidemiology (2016), reviewed thousands of studies. 40 met the inclusion criteria and were included in a meta-analysis, with data from >64,000 injured bicyclists. For those who only like to read abstracts, we’ll cut to the chase:
“Bicycle helmet use was associated with reduced odds of head injury, serious head injury, facial injury and fatal head injury. The reduction was greater for serious or fatal head injury. Neck injury was rare and not associated with helmet use. These re- sults support the use of strategies to increase the uptake of bicycle helmets as part of a comprehensive cycling safety plan.” (Olivier & Creighton, International journal of Epidemiology , 2016).
For a few nuggets from that study: “In a recent Australian study of linked police and hospital data for cyclists in motor vehicle collisions, 34% of hospital-admitted cyclists had a head injury and 15% had a serious head injury.2 In a coroner’s review of cycling fatalities in Canada, 55% of deaths were caused by head injuries.3” Also note that “neck injury was rare and not associated with helmet use.” One of the objections to helmets I have seen raised (by both bicyclists and motorcyclists) is that they think they increase the risk of neck injury. Olivier and Creighton found no such correlation.
Looking at individual studies cited, the risk reduction for head injury attributable to wearing a helmet was 85% in one study and about 30% in another (though 70% for severe injury as assessed by the AIS (Abbreviated Injury Scale). Come to my workshop for an explanation of the AIS.
The argument is often made (and is made in the Bicycling article) that wearing a helmet leads to riskier behavior. This is a phenomenon actually studied with all safety devices. Some studies assert “reduced cognitive control” while wearing a helmet. Several of these analyze the behaviors of subjects playing computer games, in which the “risk” is theoretical in the context of playing a game. One which did look at bicycling behaviors noted that male cyclists rode at a slightly higher speed when wearing a helmet. This was not true of female cyclists. It should be noted that the helmeted riders rode at 19.2 km/h (a whopping 11.9 mph) compared to 16.8 km/h (10.4 mph) and that anyone who had previously worn a bike helmet was excluded from the study.
Anecdotal evidence is at the bottom of most evidentiary scales, if included at all. Your author once crashed at about 1 mph (stopping at a stop sign, hitting a patch of ice with front wheel, and falling to the left side, striking the head). It happened so fast that I remember hearing my head bounce off the pavement at about the same time that I realized I was going down. The impact cracked the helmet but caused no ill effects. It was only after trying to get up (and slipping) that I was aware of the ice. The speed of travel did not appear to mitigate the effect. It might be noted that crashing at a higher speed could result in reducing the direct impact of head to pavement (as you could hit it sliding, rather than directly, and the head might not be the first body part to hit). Think about falling directly onto pavement on your head at zero speed. Does that sound harmless?
I grew up in the pre-helmet era. (Truth be told, I remember the first time we got a car with seat belts, and I also remember children’s car seats as being entertainment devices, not safety devices. Our car seats were made of aluminum, lightly padded and covered in vinyl. The belt was a ¾ inch wide vinyl strap. There was a steering wheel with a horn button.)
I moved to California as an adult in 1984. Some people wore helmets out there. Virtually no one did when I left Wisconsin, but they were widespread when I returned. (Let’s just agree to dispense with the “I didn’t have ‘x’ when I was a kid, and I survived…” argument. See paragraph two.)
The first helmets were essentially leather “hairnets” worn by some bike racers. The first consumer bike helmets were hot and heavy. They were worn only by nerds. The Bell V-1 Pro, introduced in the mid-80s, was the first helmet that offered protection and caught on widely (and note that it looks like a sturdier version of the leather hairnet – that was not an accident).
I was riding in the mountains when I came up on a downhill turn, sharper than it first appeared. My bike was in need of a headset at the time, so it chattered under hard braking. I scared myself on that turn and went straight to a bike shop. I dropped off the bike for a new headset and bought a Bell V-1 Pro. I have not ridden without a helmet since then.
Who am I to pontificate about helmet use? So far, I’d say there has been less pontificating and more reviewing evidence. That being said, it is probably clear by now that I come down in favor of helmets. (Especially if you read the title.) We have discussedinfrastructure and safety here before. (And will again in a post very soon – written before this one but awaiting final revisions.) Not crashing is better than crashing. Prevention beats mitigation; but we will never prevent 100% of crashes and if you’re the one crashing, despite your best efforts, you might want that mitigation. Very few of us expect to crash. But that’s how I make my living.
I have spent the past 20+ years working in a large teaching hospital. I have spent most of those in a Level 1 Trauma Center. While some people plan to be in a hospital (for elective surgeries) or spend a lot of time in them (for management of chronic conditions), most of the people I work with had no intention of winding up under my care. I have learned, over the years, what injuries are likely to result with and without lap belts, shoulder belts, and airbags. And I learned why school bus drivers used to yell at you to keep your hands inside the bus. I have seen the arms that got trapped under cars and dragged along the pavement, and helped those folks with their rehab. (I no longer rest my arm on the windowsill when I drive, but that’s just me.) I know what you’re likely to break falling from a ladder, the difference in what young and old people tend to break in similar falls. I also have seen that people without helmets tend to have worse head injuries than those with helmets, that other injuries are pretty similar (mostly clavicle and rib fractures), and that those with head injuries tend to fare worse in both the short- and long-term.
We can also look at it from a business perspective – a risk/benefit analysis. *Risk of not wearing a helmet – brain injury, death. Benefit of not wearing a helmet – better hair or the feeling of the breeze in your hair (probably not both). *Risk of wearing a helmet – matted hair or not looking cool. (Some would argue that you have a greater chance of doing something stupid, but I’d say alcohol is the hands-down winner for that risk.) Benefit of wearing a helmet – reduced chance of head injury, bigger reduction in the risk of serious head injury or death. You may consider other risks and benefits, but I think it would be hard to come to a different conclusion.
While we’re at it, how often do you see families out together; the kids are wearing helmets, the parents are not? What message does that send to the kids? The way I see it, you are telling your children “helmets are kids’ stuff.” We know most kids want to feel grown up and many want to be like their parents. You can bet that, as soon as possible, kids will ditch the helmet to feel grown up. I see many middle school kids using helmets as handlebar decorations. If you are a parent and ride a bike, think about helmets – are you putting helmets on your kids because other parents might yell at you if you don’t? Are you doing it because you think helmets will make them safer? If the latter, then why don’t helmets make you safer? If the former, why don’t you have the guts to stand up for your convictions? (And exactly what are those convictions? Do you think you are battling courageously the nanny state?)
So you can take my word for it as an expert, or as someone who has personally experienced crashing and hitting my head, or you can read the literature. In all cases, I think you’ll find that you’re better off with a helmet than without. (And maybe you’ll find one story of someone who was somehow injured by wearing a helmet. An early argument against seatbelts in cars was that you would get trapped in a burning car and die because you wore a seatbelt. Yes, that has happened; but less frequently than people have been thrown from cars – through the windshield, a window, the sunroof – and killed because they weren’t wearing a seatbelt; which is not to mention the multitude of injuries sustained by those flying around in a rolling car even if they don’t fly out through an opening.) Since most of you will not crash and hit your head, you can play the odds if you choose; but then we’d have to look at the public health consequences and the societal costs of your choice. That would be fodder for another post.
(Complete citations available on request – but you oughta be able to find the articles if you try, and have access to PubMed.)
The Dihedral just ran a post about their dream van. One of their friends and frequent commenters, Martha, added a comment about her 1972 VW bus breaking down and spewing oil. I added a bit about our bus breakdown and said the trip changed my life. The Dihedral wants the deets. So here goes…
It was late summer 1973. I had spent 4-5 days camping alone in my friend’s back 40, engrossed in activities such as drying herbs with binoculars. I returned to town to find my roommates gathered in the living room, packed for a trip of their own. They asked if they could use my tent. I handed it over. They asked about the stove, the cook kit, etc. One by one I pulled things out of my pack and handed them over. Then I stopped and asked where they were headed. They said, “John got a temporary layoff from work, so we’re headed to the American Legion State Forest to camp for a week.” I said, “Sounds like fun. Maybe I’ll join you.” They said, “Don’t you have to work tonight?” I said, “Yeah, but…”. They all got silly grins and started swapping knowing looks. They finally confessed that they were off to Colorado.
[By the way, I was planning a major trip to South America the following spring. The Rockies seemed like a good warmup for the Andes.]
[Also by the way, when I eventually made it back to where I had then been working, to pick up my last paycheck, they offered me my job back. I turned them down – more on that below.]
I jumped in the bus with them and off we went. After the trip, we all agreed that it was too short and began scraping money together for a longer trip. As fall came, we had enough to head for the Canadian Rockies. We got about 100 miles. I was in the back, over the engine. I suddenly heard an unpleasant sound and yelled to John, “Shut it down and pull over!” We pulled over and the engine died. We had it towed to LaCrosse, where we got the bad news.
VW buses of that era had an Achilles’ heel. The third cylinder exhaust valve was tucked into a spot where it tended to overheat. When the valve burned, it broke up and scattered bits of itself through the engine. A rebuild was in order. When we were ready to hit the road again, we didn’t have enough money to satisfy Canadian border agents that we could support ourselves in their country. (They had a per person minimum at the time.)
It was time for a new plan. We continued west, but in a more southerly direction – to Estes Park, Colorado. While there, we headed into Denver so I could get my shots for South America. After getting my Yellow Fever, Cholera, and Typhoid immunizations, the Public Health Nurse asked if I had any aspirin. She advised that I get some and take two immediately, two more before bed, and two more as soon as I woke up. I said, “I’m gonna be sick, eh?” She said “Sicker than you’ve ever been.” The next morning I was able to crawl out of the tent and sprawl on a picnic table in the sun. I stayed there all day, too sick to move. Twenty four hours after the shots, I was fine again. If that’s the prevention, I’d hate to have the disease(s).
We stayed in the area until a sudden squall. We dove for the tents, leaving our dinner dishes on the table. When we awoke, we had to break ice out of the dishes before we could put them away. We decided it was time to head south.
We drove to New Mexico and made camp in the Sandia Range, just outside of Albuquerque. There we were hit with a hailstorm that dropped six inches in a few minutes. It melted as quickly as it came. My friends decided they needed some city and I stayed behind. We agreed on a day and time they would return to rejoin me with fresh provisions.
When the time arrived, I headed down the trail and posted welcome signs for them. Jumping across the stream to post a sign, I landed badly and heard a loud crack. I stuck my foot in the stream and iced it down. I made my way back to camp to pack up, figuring they’d take me to the hospital rather than rejoining me to camp longer.
At the appointed time, only one of them arrived. He told me he brought food for three days and they would return to pick us up at the trailhead. He brought some steaks, which had spoiled on the hike back. We spent the next three days crawling off to the woods with diarrhea, digging holes as fast as we could. [The idea of packing out excrement was unknown to us back then, not to mention it would have been a difficult cargo to pack.] In my spare time, I fashioned a crutch.
At the newly-appointed time, we made our way back to the trailhead. We got in the bus and made it to the ER, where I was swaddled in what I now know as a “bulky Jones splint” and fitted with store-bought crutches. It was time to head back to Wisconsin.
As winter settled in, I realized there was something more wrong with my ankle than a bad sprain. My peroneal tendon had an unfortunate tendency to dislocate when I walked. It did not seem like a good thing to have happen on narrow Andean trails. It wasn’t altogether pleasant on sidewalks.
I paid a visit to my local community clinic. The doctor there had no clue what was going on, but referred me to an orthopedic surgeon who diagnosed the problem when I walked across his office. He said he could fix it Monday. I called Fred to tell him I couldn’t make it to the Andes and scheduled surgery.
While recuperating, I began volunteering at the clinic. I also heard about a new co-op trying to get off the ground. Having nothing better to do that winter, I began to go to organizing meetings. I worked at that co-op for the next ten years, which led to a continuing career in co-ops in California and Nicaragua, which led to where I am today (two careers removed from co-ops, but that’s another story for another time). P.S. Happy 45th birthday, Willy St Co-op; which opened 10/09/1974.
Also that winter, I had a roommate who went ice skating every day. Feeling sorry for myself that I couldn’t go with him, I started plotting for spring. When spring arrived, I bought a new bike. (That story earned a paragraph in the January 20, 2018 entry.) That bike took me on my first tours, which led to the transcontinental tour of 2018.
So that, Dihedral, is my story. And I’m sticking to it. How an injury leads to a career path and a new bike, then a 4400 mile bike trip 45 years later. Way more than you bargained for, eh?
Riding a bike isn’t the only thing we do. People who ride (and write about) bikes have jobs and families and friends who don’t ride bikes. (Duh.)
After a 14 mile ride for an appointment this morning, it seemed prudent to get out on the water and not spend the day inside working. A couple of hours in a kayak does wonders for changing one’s outlook, and the view from the middle of the lake is a nice change from the shoreline. Staring at a computer screen can wait.
Even the time at the keyboard required a break, as a sudden downpour hit before I put the kayak away – can’t let the boat get wet;) The sun remained shining as torrential rain fell for about ten minutes. It’s 80 degrees (27 degrees Celsius) and the sun is blindingly bright. If it weren’t for the fact that I just changed clothes and my hair is still dripping, I’d think I imagined it. Now to go bail out what got in before I closed the hatches and covered the cockpit.
So what else do we do? One of us trains Occupational and Physical Therapists (and Assistants) for the acute care of patients with multiple traumatic injuries. While the odds that one of you reading this fits that description are slim (unless a search engine brought you here), maybe you know someone that fits. Nurses and Speech and Language Pathologists may also find value. This is a two day course, offered in the Detroit area September 17-20 (two presentations in different locations), downtown Milwaukee September 27-28, Kansas City area October 28-31, and NYC area December 10-13.
This is a trial run. If these seminars are successful, the program will be offered nationally next year. There will be a live webcast of the Kansas City presentation (which will be available on DVD) but, in our humble opinion, a webcast of a hands-on seminar sorta defeats the purpose, or at least limits the opportunity.
If you have questions that aren’t answered here or in the links (one to UW-Milwaukee, the other to PESI Rehab; both with copies of course brochure available), the instructor can be reached at OTTrauma@gmail.com. Please help spread the word. Stay safe out there! We’d rather see you on the road than in the hospital.
We’re official! We just received a photo of our sign:
And one last word from the road via Charlie, who finished his eighth crossing of the continent by bike:
Nothin’ half-fast about Charlie. He didn’t even mention his partial crossing of the continent with us last year, ended early because he had a date to go climb a mountain.