The Saving Brother

I heard the patient's agonizing scream emanate from Room 31 just seconds before Nurse Carla ran up to me. "Dr. Jim," she said, grabbing me by my arm, "I need you in 31 right away." Her face was flushed, her voice edged with concern. Carla, usually calm and collected, had me worried with her nervousness.

As we hurried down the hallway toward the room, we were greeted by yet another gut-wrenching scream. Somebody was hurting. And hurting bad. We hear many types of screams in the ER--demented screams, angry screams, excited screams, drunken screams, etc.--but this primal scream from being in extreme pain was by far the worst.

"What's going on, Carla?" I asked her, intrigued as to what I was going to find when I walked through Room 31's doors.

"Bad burns," she said, "and trust me, your heart's going to drop over this one."

We walked into the room and I was surprised to find an eighteen year-old male patient sitting upright in his cot, completely naked. He was alone and crying. He was thinly-built with shoulder-length blond hair, his face painfully scrunched-up as a result of his despair. His hands were alternating between flailing and holding his genitals. The nauseating smell of burnt skin and hair permeated the room.

I rushed to his side while Carla assumed position on his other side, preparing to start an IV. On a quick, cursory exam, I saw that he had apparent burns to his lower abdomen, his inguinal areas, and his penis and scrotum. Poor kid.

I quickly introduced myself to him. Through abbreviated, gasping words, he told me his name was Matthew.

"Matthew," I said, "we are going to start an IV and give you some pain medication to make you more comfortable, okay?" He nodded his agreement while grimacing from his discomfort. I continued. "After we get you a little more comfortable, we'll talk about what happened. In the meantime, I need to perform a physical exam to see what the extent of your burns are."

Carla had an IV established before I was even done talking. "Morphine?" she asked. "Morphine," I answered, "and lots of it." After giving her some further orders for IV fluid hydration, she hurriedly left the room.

I looked closely at Matthew's head and face. He had no singed nasal hairs, no burnt eyebrows or lashes. I had him spit in a container. His sputum was clear. He had no stridor or difficulty breathing. All good findings to suggest his burns didn't affect his airway. His heart sounds were excellent. His lung sounds were clear. His abdomen, barring the lower skin burns, was soft and without pain. His extremities revealed him to have redness and blistering to the palms of both hands.

Next, as Carla administered the morphine, I focused on his burned privates. His entire penis was red and blistered but, thankfully, the burns were not circumferential. A band of burns that completely encircled the penis would have had potential to cut off the blood-supply to the distal part and that would have been very bad. Matthew's scrotum was also burned, red with significant blistering covering its entire surface. His groin area and proximal thighs on both sides were also a bright, angry red and blister-filled. His anus and rectal area had been spared.

Because of the location of his partial-thickness and potentially full-thickness burns, Matthew needed to be emergently transferred to a burn-unit with his injuries.

After making quick arrangements for his transfer, I returned to Room 31 to find a much more comfortable patient. Several nurses, including Carla, were bent over Matthew tending to his burns.

"Matthew," I said, "do you feel better." Groggy from the pain medications, he smiled a goofy grin at me. "I sure do, Doctor. Thank you."

He then went on to explain to me how he had received his burns. His younger ten year-old brother had been playing with fireworks when Matthew had happened upon him. His younger brother, Matthew continued, was holding an M-80 in his hands, lit, and was trying to slide it down a tube that wasn't wide enough. Matthew, watching with horror, saw the wick of the firework burn down to almost nothing and he decided to act.

"I ran up to my brother, Doctor, and grabbed the tube with the M-80 sticking out of it. I thought it was going to blow up in his face, so I snatched the tube and held it against my belly so it wouldn't hurt him."

As you can probably guess, the M-80 blew while Matthew was pressing it against himself. Although the force of the M-80 missed causing him significant injury, Matthew's clothes caught on fire, resulting in his burns. Matthew was a hero.

"Is your little brother okay?" I asked. "I think so," he answered, "he and my mom should be here soon."

I liked this young man. Here was a respectful, saving brother who risked his manhood, his life actually, to keep his younger brother out of harm's way. I had no doubt that if the exact scenario repeated itself, he would do the same thing.

Within minutes after our discussion, I greeted Matthew's mother and younger brother in the hallway outside of his room. They were both distraught and crying, their tear-stained faces looking expectantly at me for some good news. Especially the younger brother.

I put my arm around his trembling shoulders while I addressed them both. "Matthew is much more comfortable now," I reassured them, "but I have some concerns about how bad his burns may be. We're going to transfer him to the regional burn center so he will get the best available care possible for his burns."

The mother nodded. "Please do whatever you have to do to get Matthew better, Doctor."

I escorted them into Matthew's room, where the younger brother immediately bolted to Matthew's side, hugging him. "It's all my fault," he muttered between his free-flowing tears. "I'm sorry, Matt." The guilty weight of the younger brother was heartbreakingly evident. Matthew, as I knew he would, put his protective arm around his younger brother. "It's alright, bro. I'm just glad that you are okay." Mom came up then, wrapping her arms around both of her sons. Carla and I stepped out to give them some privacy.

We transferred Matthew to the burn unit without incident. Prior to his leaving, we wished him well and told his mother to please keep us posted as to his recovery. We all wanted Matthew to have the best of outcomes.

A few weeks later, waiting in my work mailbox, was an update letter from the receiving burn unit regarding Matthew's condition. I eagerly ripped it open, nervous about the news it contained. Thankfully, it held the best news possible. Matthew hadn't required any skin grafting and, although his burns were significant, they expected a full recovery without any permanent injury or damage.

Sometimes, things turn out just the way you hope they will. Cheers to Matthew.

As always, big thanks for reading. See you Friday...

Little Big Man

We are all familiar with the saying "Actions speak louder than words." It is most often used to connote something favorable and positive. Unfortunately, this quote was the first thing that popped into my head while treating a recent patient.

I had been walking down the main ER hallway, another crazy shift in bloom, when one of my favorite nurses poked her head out of a room.

"Doctor K," Carla asked, "are you free to help me out with this patient?" I didn't even need to give her an answer. When Carla beckons, I come running. Plain and simple, she is that amazing.

I walked into Carla's room to find a patient lying in bed, hands to his face, crying out for his mother. Heartbreaking. His mother was kneeling beside him, whispering quietly in her son's ear. Tears were streaming down her face, too.

The patient was seven. A sweet, scared little boy named Eddie. Eddie had been rushed to our ER to be treated for burns to his face and body. From the doorway, I could see several small blisters with surrounding redness on his bare torso.

What were the circumstances that resulted in these burns? Apparently, Eddie did not come from a good socioeconomic situation and, as a result, lived in a crowded apartment with his mother and several other family members.

The day Eddie was brought to the ER had been an especially cold one. While his family sat watching TV in a room off of the kitchen, Eddie, hoping to be useful, went alone into the kitchen. He had decided that he would warm up the apartment. He grabbed a cigarette lighter and successfully persevered in his struggle to flick the lighter's flame. With his free hand, he turned the oven's dial to "ON." Ready to be a big man and provide heat for his family, he opened the door to the gas oven. Slowly, while holding his arm stiffly in front of him, he advanced the flame into the oven.

Whoosh! A sudden flash of flame was born and jumped out at Eddie, surprising him. He instinctively yelled out as he backed away from the heat. The pain and redness to his skin was immediate. The family called 911 and, after shutting the oven door, turned off the dial. Their quick thinking stopped any further flames from spreading. Eddie, with his mother accompanying him, was brought urgently to us.

I was able to determine that Eddie's burns were "minor." His airway and breathing were stable and his burns were either first degree (superficial, like a sunburn) or second degree (partial thickness, or to the layers just below the skin surface). When you are seven and in pain, though, any burn is considered "major" in my book. Suffice it to say, Eddie's burns were significant but not life-threatening.

While giving him pain medicine, some IV hydration, and soaking his wounds, we discussed Eddie's case with our regional burn unit. They requested we transfer him to their facility for overnight observation. I agreed wholeheartedly. He was a child in pain. He deserved to be treated cautiously, tenderly.

"Eddie," I asked, after we had made him comfortable, "what made you decide to light the oven this way?"

"Mama and Aunt Pammie do it all the time," Eddie said, shyly looking over at his mother. She was now sitting in a chair, beside his cot, stroking his hand.

"To cook?" I asked, rubbing this brave little kid's shoulder.

"No. We light it and keep the door open so we can stay warm." With the colder weather, it turns out, Eddie's family supplemented their apartment's warmth this way. Eddie, after seeing his mother and aunt light the oven several times, thought that he could do it, too. My heart broke a little, in that moment, looking at this thoughtful little boy who sustained burns because he was trying to help his family. He gave his mother a feeble, lopsided grin, the morphine adding to his charm.

"Baby, it's okay," the mother said, stroking his hand. "Aunt Pammie and I should have never done that." She turned to me and continued. "I'm not going to get in trouble, am I?" Although the question seemed self-serving, I was genuinely impressed with her concern for Eddie. She handled her little man with appropriate and abundant love. She even insisted on helping Carla with Eddie's treatment. I felt only good energy with her, discerning nothing suspicious. Eddie, it seemed to me, had a mother that truly loved him.

"No, you're not," I assured her, "but let me have our social worker talk to you about your living conditions and see if there is any available help for your family. Maybe have them come out and check the place out for you."

"Thank you," she said, "We could use some help trying to get the landlord to fix some of them windows."

So, as it turns out, Eddie's injuries were not a result of being negligent or careless. They stemmed from imitating the adults in his life, who were completely unaware of the lessons they were teaching him.

Eddie's situation got me to thinking in that deep, reflective way. How many times through the day do I, as a parent, verbalize to my children what I feel are essential life lessons when, in actuality, my witnessed actions carry more weight than any of my words. Actions that can be both good or bad. Conscious or instinctive. Helpful or harmful. Deliberate or unplanned.

Witnessed or unwitnessed by young eyes. My kids' eyes. Your kids' eyes.

Eddie ended up recovering quite nicely from his injuries and his family was very appreciative for his treatment and good outcome. They could not, however, have been nearly as appreciative as I was of the important lesson they reminded me.

Thank you, Eddie, the little big man. It's not everyday I get a life-lesson from a seven year-old.

As always, thanks for reading. Next posting will be Wednesday, February 3. Thanks for your votes and support in the Medgadget Weblog Awards...much appreciated.

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.

Please Make Her Comfortable

During a recent shift, I was witness to a family's struggle and courage in facing their mother's illness.

Their mother, age 96, had broken her hip a week prior. Because of significant health and social issues, the family and patient concurred with the orthopedic team that it wouldn't be wise to operate.

The patient was sent to a local rehabilitation facility. Prior to the transfer, the patient and her family had discussed at length a living will and to what degree heroics were to be performed in the event of a medical emergency. They opted for no intervention whatsoever--no CPR, no medical testing, no antibiotics, no intubation, no resuscitation efforts. Basically, they wanted only comfort measures for pain and anxiety relief.

A very difficult decision, of course.

Within a week of being transferred to the rehabilitation facility, unfortunately, the patient started to have a cough. Soon after, she began to have a harder time breathing.

The facility, despite their best efforts, eventually sent the patient to our ER when it was discovered that she had very low oxygenation levels. They were not equipped for this.

I walked into this patient's room and after introducing myself to her and meeting her family, consisting of two sons, a daughter, and a daughter-in-law, I began to sort out what I could do to help this patient and her family.

On exam, this patient was obviously struggling and appeared to have pneumonia. She had a fever and very low oxygen levels. When I listened to her lungs with my stethoscope, she had classic findings for infection. She was starting to get very fatigued and was not as mentally alert as her family knew her to be.

Normally, with a patient in this situation, we are very aggressive. She would have been intubated and received three, sometimes four, antibiotics intravenously. She would have gotten a very thorough workup that would have included x-rays, blood work, and possibly a CT scan of her chest to make sure she didn't have a blood clot in her lungs, a possible consequence of her hip fracture.

However, upon review of the patient's paperwork sent from the rehab facility and the family's personal request at her bedside, we did none of this. We respected their wishes and this patient's living will.

I did order this patient some low doses of morphine and valium which made her more comfortable. The family was quite appreciative. Although the patient was critically ill, she was not yet near her end. After another discussion with the family, we came to a mutual decision to admit their mother to the hospital and continue her comfort care. The family was uncomfortable taking the patient home with her hip fracture. I called their family doctor and he graciously came in and handled the admission.

During the admission, I was stopped by the daughter in the hallway. She was very tearful, as any of us would be, and second-guessing their family decision of no heroics.

"Mom lead an amazing life. I know it's time...but this is so hard to watch. I feel like we should be doing something more."

I put my arm around her. "God Bless your family," I said.

"Well," she sighed, "this is how Mom wanted it, so I guess we have to respect her decision."

I nodded at her words. I have several times witnessed these decisions reversed, but it seemed that this family was not going to follow that route.

The daughter, though, still needed to reconcile the decision with her anguish.

"What would you do?" she asked me suddenly.

Her question caught me off-guard. It was a question that I couldn't possibly answer for her. Her family's decision was made after weighing many specific circumstances, circumstances that I knew nothing about. So no, I couldn't give her a direct answer.

I explained this to her. "But," I continued, "does the rest of your family still support this decision?"

"Yes," she said, "and I think I do, too."

I decided to open up to her. I shared with her how several years ago, my beautiful mother, after courageously fighting and beating back leukemia for several years, decided that it was time to stop. It had been an extremely difficult decision, fully supported by my father, my six siblings, and myself. Because Mom knew. And despite all the setbacks, her faith had never wavered and her spirit had remained unconquerable. She had fought the fight and had benefited from that fight. But, unfortunately, her disease had come back with a vengeance. After several failed attempts to reenter remission, she chose to stop all further treatments and go home to spend her remaining days enveloped in our love.

"So, yes," I said, "it was very hard to watch. But it was the right thing for Mom and our family."

Now, the daughter nodded at my words. After a moment or two, she spoke. "Mom did have an amazing life, but yes, it is time."

I squeezed her hand in support and she leaned in and gave me a hug.

"Thank you," she said as we parted.

No, I thought to myself as I walked away remembering my mother's beautiful spirit, thank you.