The surgeon's 
epic break

The kid in room 63 is a fighter with a soft punch. Now he is on the ropes. Last night, this boy punched a wall in his parents' house, fracturing his fourth and fifth metacarpal necks. He hit the wall again and again until his fist bled. Now, he is in the ER and we pick up the pieces. I ask him: "Why did you punch the wall? Were you frustrated? Were you acting tough?"


He tells me about his great suffering, his all-consuming rage, the temptation of the wall: "I wanted to hit a reset switch inside. My anger overwhelmed me. Better the wall than a human face." For a moment, he looks triumphant as if he has won a contest. The boy has the height and the muscle mass of a man; the cognition of a teen. He holds in his left hand a Nintendo DS that engages him far more than my words about the management of hand fractures. 


Mom sits at his bedside. She looks tired. Tears have long dried on her face, and her eyes are swollen and red. I want to ask the kid: "Did you make your momma cry? Are you proud of this too?"


I keep my silence. His mother does not need me to stir up trouble. She will pay for this break. She had to take time off work to bring him here. She works on a factory assembly line. Her husband works in construction. Their son has a fracture that will require surgery. He has a Nintendo DS and a smart phone, but no job and no insurance. Both parents will need to work overtime to cover his hospital bill. The mother called her employer whilst her son slept. This is not the first time she has called in for her son, picked up the pieces, whitewashed over the drama. I want to ask the mother: "When will your son miss the wall and connect with you?"


I have already examined the boy's hand. The knuckles of his fourth and fifth fingers are flattened, the surrounding tissues grossly swollen, the digits rotated. A linear laceration cuts a sharp line across his fifth metacarpal joint. The wound extends to the subcutaneous layer. I see no tendon involvement, foreign bodies, or bone fragments in the wound. 


I page the orthopaedic PA on call. I describe the patient. "It looks like he needs his fracture reducing," I say. "I think he will need surgery at some point. Can you come down to see him?"


The PA sighs; then asks me for the patient's name. He wants to look at the films. I sense he is irritated. I hear him sigh again when he pulls up the X-rays. He asks me a few questions; his tone is curt. Normally, the PA is an easygoing guy. He grumbles about kids who punch walls, then expect others to pick up the pieces. I take a deep breath and stare at a point on the wall. Eventually, the PA agrees my patient needs his fractures reduced and tells me he will come down to see my patient. 


An hour later, my patient's hand is in a much better position. The orthopaedic PA reduced his fractures and placed him in a splint. He will take antibiotics at home. I order postreduction films, then call the orthopaedic PA when they are done. I know the patient will need to be seen in a few days for a wound recheck and to schedule surgery. The PA informs me that the orthopaedic surgeon wishes the patient to follow up at another hospital. 


I am bewildered. I explain that the patient wishes to receive his care at our hospital. The PA explains that his attending is declining the patient. This catches me by surprise. Decline? This has not happened before. How will I explain this to the boy and his mother? I need to establish follow-up. The PA transfers me to his attending. I think he feels caught in the middle. 


The surgeon is angry. He does not want to treat this patient. He has caught me off guard. I try to ask him why but my questioning only irritates him more. He rages. Didn't this kid go to another hospital before? He already has an orthopedic surgeon. He is doctor shopping! I wonder if the surgeon is tired of kids who punch walls, tired of ER calls, too used to being in control. He has lost it now. He is on speaker phone in the OR. He screams down the phone: "Why, why, why am I obligated to treat this patient? Tell me why?" 


Punch, punch, punch—the surgeon hits the wall. I listen to his rant. I want to ask him: Why are you hitting the wall? Are you frustrated? Do you need to hit a reset switch? 


A week later I see the orthopaedic PA again. He apologizes for the previous week. He tells me that they took the boy to surgery. As for the surgeon, I saw him just yesterday. His manners were impeccable. He gave me a smile, shook my unbroken hand: "Good to meet you, Alexandra. Now, where is your patient?"


I smiled back at him, remembering his tantrum and thinking none of us are too far away from the boy. I am learning to roll with the punches. I am becoming more resilient, developing a degree of toughness. I hope in the process I do not forget my manners, or the tears on the face of the mother. JAAPA