As I saw the fellow purposely manipulate her fractured ankle, I knew I was wrong in not stopping him.
Three hours earlier, Mr. Sanchez*, a past boxer, and soccer player, came in with a broken pinky. He was moving from Atlanta to Houston, and in the process of moving boxes, a rock smashed his finger against something. Odd story, but he was the nicest patient I ever talked to up to that point. He had surgery for his fracture and was happy the entire time. I thought to myself, “My shift is off to an awesome start!” Oh, so little I knew at the time.
The next patient was a homeless man who was run over by a pickup truck, and his arm was pinned underneath a tire. Miraculously, he had no evidence of radial or ulnar fracture, and all I did was stitch up his open wound and bandage him up. Bizarre case, but I was glad I could help.
Then, I met Ms. Ruiz. She was a 21-year-old who was riding her bike that night at a park without a helmet. She hit a curb, flew in the air, and landed on her right ankle. After the x-ray was taken and myself, the resident, and the orthopedic surgery fellow reviewed it, we all agreed she needed surgery tonight.
“We’ll need to mold her ankle and part of her leg into a cast before she goes into surgery,” said my enthusiastic fellow.
“But, won’t it just be taken off?” I said.
“Yes, but we need to immobilize her ankle, so the fracture doesn’t get worse. And also, try to realign her bones to make it easier on the surgeon,” said my fellow.
I went along with it, and so the family medicine resident, the fellow, and I went back to the ER.
“Ms. Ruiz, we’ll need to make a temporary cast around your ankle so that everything is stable before surgery tonight,” my fellow told her and her mother.
“Will it hurt? I don’t handle pain well …”
“It won’t take too long, and we’ll give you a pain med soon beforehand.”
As we slowly rolled Ms. Ruiz to the cast room, I saw how messy and out of place everything was. There was a giant x-ray machine that could visualize the fracture in question as you’re making the mold. You could also see different size molds, and all the materials needed to make it wet before applying it to the area you wanted to make a cast of.
“Alright, Ms. Ruiz, we’ll need to slowly turn you over onto your stomach. T.J. will be at the head of the table to let us know if you need anything.”
“OK …” said Ms. Ruiz timidly.
As the resident and fellow prepared the cast materials, Ms. Sanchez and I talked.
“So, I saw your shirt has Captain Marvel’s symbol. You’re a fan?” I asked.
“I am! I can’t wait for her movie to come out, just love Marvel so much. Who’s your favorite superhero?”
“Mine? Probably a tie between Iron Man or the Hulk,” I said, smiling.
“OK, Ms. Ruiz, John is going to press down on your left leg so that it doesn’t move while I slowly wrap this material around your ankle, and part of your leg. It will feel cold and wet,” said the fellow.
So far, so good. I thought this would be a quick cast, and Ms. Ruiz would be off to surgery. Oh, how incredibly wrong I was.
“OK, Ms. Ruiz, I am now going to move around your ankle to try to put the bones back together. This will hurt. If at any moment you want me to stop, I will,” said the fellow.
“OK,” said Ms. Ruiz
The moment I saw the fellow twist her ankle forcefully with both hands, her blood-curdling scream filled the entire ER hallway.
“John, pull the X-ray machine to cover the ankle, I need to see.”
After the fellow took an x-ray, his face said it all. He was displeased and wanted to try again. He asked Ms. Ruiz if it was OK with her, and she gave a slight nod.
Eventually, the fellow stopped asking her and kept manipulating her ankle several times. My body wanted to walk out of the room and take Ms. Ruiz out of the fellow’s hands, but I sat there as a compliant med student. Then, I saw a classmate and an attending walk by and asked us if the patient was doing OK because they heard the screaming.
“Everything is alright, just making a cast for her fractured ankle,” said the fellow as he waved his hand.
Disapproval was all I saw from my classmate, and at that moment, I told my fellow to stop.
He looked at me and shrugged his shoulders. All I could think about was how can someone keep inflicting pain onto another person? It was barbaric. It was sadistic.
When the shift ended, I ended up sleeping in the student lounge. The morning I woke up, I went to lecture, but all I could focus my mind on was what happened last night.
“I should have told the fellow to stop earlier instead of sitting there and watching him hurt her,” I said to myself repeatedly.
It’s all too easy for med students to fall in line, to accept the hierarchical structure of medicine. To not voice your opinions against those above you is a dangerous practice, especially when you have concerns regarding your patient’s care. Medicine, as much as other fields in life, is a team sport. Everyone should have the freedom to share unmitigated thoughts and feelings about the care patients are receiving (and not receiving). Sometimes, the med student does have something important to say.
* All names and events have been altered to protect confidentiality.
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