Monday, January 18, 2010

The Amazing Race

To understand this next patient, you need to do me a favor. Ball your hand into a fist. Now, rotate your fist either way as far as you can. When you can't rotate any farther and your forearm muscles feel tense and strained, imagine that you are Stretch Armstrong and continue rotating your fist for a full rotation. Pretty amazing, yes? Now, do the impossible and imagine another full rotation. And then another.

This is exactly what happened to Javier's testicle. Javier, a handsome but frantic eight year-old, had presented to our ER around 10 a.m. just a few weeks back. He had been born with an undescended testicle and had been closely followed by our pediatric urologist, who most recently had seen him just a month prior. Because his testicle had finally decided to spontaneously show up for this life, Javier's doctor was debating whether to surgically anchor his testicle down to keep it in place. Yep, a suture from his testicle to his scrotum.

Unfortunately, on the morning Javier had presented to our ER, he had awoken at 2 a.m. with sudden and severe left-sided groin pain. He was comfortable lying perfectly still, but the minute he moved or someone approached him to palpate his groin area, he was beside himself. You couldn't help but feel sorry for the poor kid who, despite his pain, was trying his best to be courageous.

After some morphine and a brief exam, in which he wouldn't even let me get close enough to thoroughly examine his genitalia, we proceeded with a very quick workup to figure out where his pain originated from. His urinalysis came back clean, just as I expected. Good blood work. The test that I most needed was an ultrasound of his affected testicle. To complete this test, because he was in such intense pain, we needed to give Javier an additional generous dose of morphine. The ultrasound tech was then able to manipulate Javier's scrotum to view his left testicle.

Sure enough, the ultrasound revealed that he has no blood flow to his testicle--a diagnosis of "torsion" of the testicle. So, from above, your fist = Javier's testicle. All the vessels that lead to and from his testicle had been twisted and rotated to the point that they closed off and were no longer delivering significant blood to the testicle.

Javier was in danger of losing his boyhood. Cringe-worthy stuff, I must say. I'd cry, too. I could only hope someone would be kind enough to load me up on morphine. And lots of it.

Javier, by this time, had been in pain for approximately nine hours. Time was "of-the-essence," so to speak, to save his testicle (after 6-8 hours, we begin to seriously worry). There are several manipulations one can sometimes attempt in the ER to save the testicle but, again, I couldn't get near Javier's testicle to really palpate it, let alone manipulate it. I was very close to giving Javier some anesthesia in our ER in an attempt to urgently "unrotate" his testicle. Thankfully, though, his pediatric urologist was close-by (from our earlier alert to her) and arrived in just minutes to take Javier to the OR. The race was on to save his testicle.

After establishing the diagnosis, I had a chance to go spend some time with Javier and his family. Javier and his uncle were well-versed in English, but his father wasn't. Fortunately, his uncle did a fantastic job of translating and by the end of our conversation, Javier's father had given permission to surgically repair Javier's testicle.

Poor Javier, though, was crying inconsolably now, probably as much from the fear of the unknown as from the pain of his testicle. More morphine, please.

I should have saved my drawings explaining the testicular torsion from that day. If I may say so, they were beautiful. Stunning, actually...NOT. They were a complete mess, like most of my attempts at drawing are. I should probably spend more time at home practicing how to draw a realistic testicle, so I'll be ready the next time. I would just need to be very careful about where I leave these practice drawings lying around. And who knows, maybe with a little practice I'll become the male version of Georgia O'Keefe!

What explanation Javier and his family understood best, though, was my fist and my attempt to rotate it. They understood that this "was not good" for the testicle. Bad, actually. To reinforce the seriousness of the situation, I brought a medical book into the room and was able to show them a legitimate picture of the testicle and how it had rotated on itself.

I have great news to share with you, though. Javier still has two functioning testicles! Oh, he sure does! Yes, yes--of course I'll wait for the cheers to die down. After the pediatric urologist made her scrotal incision, she was able to unrotate Javier's testicle and it immediately "pinked-up," meaning blood-flow had been reestablished. She later shared that his testicle probably survived this long because of two reasons; 1) his testicle rotated only a couple times, and loosely at that, and 2) the rotations probably didn't completely cut off his blood supply and a trickle flow of blood may have sustained the testicle. Lucky ball! She tacked it down so that this would hopefully not happen again to brave Javier. Yep, a suture from his testicle to his scrotum (did I mention this already?).

Regardless, I'm just happy that Javier can still face his world with two functioning balls. Let's face it--there is a reason we call them "jewels," and, as any guy will testify, it's better to face the world with two of them instead of one.

If things hadn't worked out for Javier, though, he would still have had one functioning testicle and worse things than that exist. I'm just glad that, in a few years, he won't have to go pick out a life-like prosthesis. Hmmm--decisions, decisions. A steel ball? Wooden? Saline-filled? I personally would go for the steel ball, after living through residency. Come to think of it, though, imagine what a chick-magnet a ten-pound prosthetic testicle could have been for Javier, regardless of what it was made of!

Initially, I thought we had helped Javier win The Amazing Race, saving his testicle and all. But after thinking the prosthesis thing through, maybe not.

Sorry, buddy.

Hats off to Javier for being a brave little boy. As always, thanks for reading. The last round of comments were very cool. Next post will be Wednesday, January 20.

18 comments:

Chrysalis Angel said...

Good save for that poor little guy.

Bongi said...

some time ago i got a guy who had already lost one 'jewel' to tortion and his only remaining one was torted (is that a word?). the urologists were on leave so it fell to me to fix it. luckily it was still viable (that's a word) and he left the hospital with a smile, albeit a lobsided one.

rlbates said...

I hope you'll submit this to SurgeXperiences (http://surgexperiences.wordpress.com/schedule/). :)

Rositta said...

I knew someone once upon a time that only had one "jewel". It didn't slow him down much and it was certainly viable. He went on to become a father. As far as the steel prosthesis, can you imagine going through an airport scanner with one of those? I can just hear the chuckles of the guy watching the pictures...ciao

MLee said...

I do not even have those jewels.... but OUCH, dilaudid please!!!!

t. said...

Can a guy have a ball job, much like a woman might have a boob job? We guys have cup sizes of our own after all though our measurements are not exactly indicated by a numer-letter pairing... Maybe someday they'll have implants that are available that make the jewels like a Newton's Cradle. Wouldn't he be a hit at cocktail parties!!

SeaSpray said...

Chick magnet ..hahaha!can you just imagine magnetic powers so strong that..all things metal, belt buckles,rings and/or earrings stuck onto the jewel. Twister anyone? no I did not just say that! ;)

I'm glad it all worked out for the little man. He had to be to get through all of that.

Your job must be so rewarding. (most of the time :)

thecatsmeow said...

I don't even own any testicles, and this one made me cringe for the little guy....yeowch! And yet, your story also managed to have some humor in it, too. I like that in a physician, whether I'm their patient or just reading out in the blogosphere.

Bongi, the word you want is "torsed". I can't imagine that happening to the same person twice...

artdoctor said...

One morning in the elevator (yes, one of them ol' elevator stories) a guy stood beside me, looked me up and down and said, "giiirll, you hot." I probably blushed out of embarrassment from this random guy commenting about me, and looked at him like, "whatever buddy (didn't say that tho)."

The next thing he said when we got out (he followed me) was that he would like to go out with me sometime, but I should know in-advance that he only has one testicle because the other one was shot off when he was in a gang, and so he has a plastic replacement.

?

I graciously, and assertively told him, "Have a good day and kindly stop following me to work or I will have to call security."

Glad you were able to save Javier's twisted jewel to save him from feeling the need to explain his ten pound ball situation to future/ potential dates.

On a lighter note (pun of course intended), if you want images of anatomical and medical explanatory sketches, try the website URL that is also posted on my blog: www.thinkanatomy.com and you can download apps for your ipod touch/iphone etc. If you get one of these i-devices, you can be just like digital book lady except waaay-cooler because it's Apple~

(that was my blog post for the week~ whew)

Maha said...

All I've got to say is, OUCH!! That poor little boy! Good story and a great job.

PS: I think you should post some of your drawing attempts on your blog - testicular and otherwise!

Bongi said...

thecatsmeow, if it ok with you i prefer torted. sounds cool.

interestingly enough this is a condition that does tend to reccur on the contralateral side. during the operation the urologist is supposed to open the good side and tie the sucker down. in the case i mentioned he did so as he should have, but for a reason i can't explain the thing came loose and torted anyway. when i did the operation i tied it down so firmly and in so many ways that even if he turns around quickly his eyes are going to water.

Score One Art Gallery said...

My God! That sounds painful beyond belief.

Lockup Doc said...

Ouch! Glad to hear he's doing better (and glad be a psychiatrist...)!

Cal said...

Until this moment I did not know prosthetic testis existed! I hope they only come in the saline variety, and any other material sounds too awkward, particularly while engaged in ... pleasurable business!
Good save for this little boy, and now thanks to you he will not need to consider this option.
(Considering a prosthetic would serve an aesthetic function only, how many men who have lost a testicle will actually choose to have a replacement? It is not like you can see one's package through pants well enough to justify it for everyday life, I don't think I can tell by staring at men crotches how many balls they have, so it would be for the sake of intimate engagements only I am guessing. Is there data?)

Chrysalis Angel said...

I don't think people realize how devastating this can be for the males. I've been reading the comments and it isn't quite the same response as it might be for a female losing a breast.

I believe the implants are the same for a male - silicone. Am I correct?

Interesting door you've opened StorytellERdoc. Maybe the question goes to our plastic surgeons?

I remember a young man I had as a patient, when I was a young student nurse. He had testicular cancer. It was a serious issue with this man and my heart went out to him.

Chrysalis Angel said...

I see they do use silicone as well. I don't know which is preferred today.

Dr. Mongo Lloyd said...

That poor kid! Glad to hear he's doing well!

Anonymous said...

Believe it or not, here's the version for pets (wouldn't want fido to look like he lost his manhood now...)

http://www.neuticles.com/

"Thank you for your interest in patented Neuticles and the revolutionary testicular implant procedure for pets. Inside you will find the latest information and updates.
Over 325,000 caring pet owners Worldwide have selected Neuticles as a safe, practical and inexpensive option when neutering.

Neuticles allows your pet to retain his natural look, self esteem and aids in the trauma associated with neutering. "

Yep, for real.

Seriously, I'm glad the kid is ok.