Chapter Ten

December

I liked pediatric orthopedics. After the unrelenting intensity of the ERSS, it was nice to deal with mundane kids’ problems for a while. But peds ortho wasn’t all flat feet and pigeon toeing. This was the Mayo Clinic and we got our share of difficult cases, too.

Bobby Lang was a six-year-old kid transferred to us from Decorah, Iowa. He had ridden his bike down a hill, directly into the path of a bread truck. He was lucky, though. Except for a laceration on the back of his head, his injuries were confined to the left leg. He had fractured his femur, and had torn away much of the skin on the front of his lower leg. The guys on ERSS made sure there were no other injuries, stitched up the back of his head, and then turned Bobby over to us.

Jake Burg was the senior resident on Peds with me. We got a big basin and several thousand cc’s of antibiotic solution and spent over an hour irrigating and picking pieces of dirt and asphalt from Bobby’s leg. It was obvious he would eventually need skin grafting. While I finished dressing the wounds, Jake took the X-rays upstairs to Dr. Steinburg, our attending surgeon. When Jake got back I asked him how Steinburg wanted to treat the femur fracture.

“Ninety-ninety traction,” Jake replied. That meant Bobby would not have surgery, but would be put in traction for four to six weeks, lying on his back with both his hip and his knee bent to ninety degrees.

Traction is applied to a fractured leg by drilling a pin through the bone distal to the fracture site. Weights are then attached to the pin to pull the bone back into alignment.

When I told Jake I had never put in a femoral traction pin, he said it was time I learned. He asked the nurses to get a skeletal traction tray and then showed me the landmarks I would use to put in the pin.

“All right,” Jake said when the tray arrived. “Let’s do it.”

I looked at him in amazement. “Right here?” I said. “Aren’t we going to bring him to the OR and do it under general anesthesia?”

“Nope. We’re doing it right here, in the bed.”

Traction pins are put in with a hand drill. I knew that much. A small puncture wound is made in the skin. Then a threaded pin is poked through the hole, pushed up against the cortex of the bone, then drilled through and out the other side. I had never seen it done but I knew it must be incredibly painful. And we were going to do this to a six-year-old boy without anesthesia? He couldn’t be serious.

“Mike,” Jake told me, “it’s not that big a deal. We do it all the time. You don’t put someone under general anesthesia for a simple procedure that takes two minutes. The kid is already in a ton of pain. We’ll give him a shot of morphine, put the pin in, hang him up in traction, and within a day or two he’ll be feeling a hell of a lot better.”

That was well and good, but he sure wouldn’t be feeling “a hell of a lot better” when I drilled an eighth-inch Steinmann pin through his femur.

It reminded me of doing circumcisions. When I was on my OB rotation in med school the residents had let me do all the “circs.” At first I was thrilled, but I grew to hate it. There was no anesthesia, nothing. We just took the poor baby’s foreskin, stretched it out, and chopped it off. “Wiener whacking,” the residents called it. The poor baby would scream his guts out. The OB residents seemed not to mind. They were inured to it. Even the most compassionate of them would look at the screaming infant, shrug his shoulders, and say, “Poor little guy. Well, get used to it, junior. Life’s a bitch.” I think they had convinced themselves that little babies were like carrots: if they couldn’t articulate their pain, they must not have any.

 

Jake told Bobby’s parents we had to put a pin in his leg. He asked them to step out for a few minutes. When they were gone he put a blanket under Bobby’s knee to keep it bent. Despite the morphine, Bobby howled in pain. When Jake had the leg in the correct position he helped me prep the end of the femur.

“Couple things,” Jake said as he loaded the Steinmann pin into the chuck. “First of all, stay away from the growth plate. If you drill a traction pin through the growth plate his leg’ll wind up three inches shorter than the other one.”

I swallowed and nodded weakly.

“Second thing. Put the pin through the middle of the bone, okay? The exact middle. Walk the point of the pin up and down the cortex to be sure you are starting right in the middle. Then just crank the handle until the point of the pin goes through the bone and starts poking into the skin on the other side. Then I’ll make a small incision so it can poke through. Got it?”

I nodded again.

“All right, Doctor. Let’s go.”

I pulled on my sterile gloves and picked up the hand drill. Jake took an 11-blade scalpel and made a small puncture wound on the inside of the distal thigh. “There’s your starting point,” he said.

At the head of the bed, Bobby was whimpering and moaning. Trying to look like I had done this before, I approached the side of the bed and smiled reassuringly at Bobby. As I moved the drill toward his leg, Bobby began to tremble. Tears poured from his wide eyes. Fortunately, because of the fracture, he couldn’t move his leg. I brought the drill closer, the point hovering just outside the puncture wound Jake had made.

“Hold it,” Jake said. “You have to angle it more that way.” He pushed my elbow down a little. “Yeah, like that.”

Slowly I advanced the pin through Bobby’s muscle until I felt the tip of the drill jar against the femur.

“Now walk it up and down until you feel both the anterior and the posterior cortex,” Jake said. As I did, Bobby’s shaking sobs intensified.

“Okay?” Jake asked.

“Yeah,” I said. “I’m right in the middle.”

“All right, then drive it through.”

As I slowly turned the handle, the threaded pin began burrowing into the femur. I glanced at Bobby who was groaning and tossing his head back and forth. I kept turning the handle until I could feel the pin exit the bone. A few more cranks and I could see the pin begin to tent the skin on the opposite side.

“Good,” Jake said. “Now wait ’til I make an incision.” He picked up the scalpel and made another short incision. Bobby scarcely said a thing this time. After having someone drill a pin through his bone, a little stab wound didn’t seem to faze him.

Another twenty seconds and I had the pin centered through the thigh, about three inches sticking out on each side.

“I like it!” Jake said. “Now let’s slip on the traction bow, and hook up the weights.”

Fifteen minutes later we had the X-rays back. “Good job,” Jake said. “See how you’re a couple inches above the growth plate? That’s perfect. Now we have to get the leg lined up.”

We set up a series of pulleys to allow Bobby’s femur to be pulled straight up toward the ceiling. His knee was bent to ninety degrees, parallel to the bed, resting on a cloth sling. A series of weights dangled from the traction bar at the foot of the bed. This whole process must have been incredibly painful to Bobby, but by then he was so washed out, so despairing of our ever being done, that he just moaned constantly no matter what we did.

Finally, when it was all over, we dressed the pin sites and let Bobby’s parents come back in. When his mother bent over to kiss Bobby, his sobs intensified and he clung to her neck as though he would never let go.

But Bobby’s torment wasn’t over. Because of the damage to the skin on his lower leg, we had to change his dressings every day. Invariably the dressings would be stuck to the wound and no matter how gentle we tried to be, it was sheer torture to Bobby. Finally, one morning we took him to the operating room and took a skin graft from the front of his right thigh and applied it to the damaged area on his left leg.

I dreaded our visits to Bobby’s room even more than he did. If an adult had this injury it wouldn’t be so bad. He would understand that everything we did was for his own good. He had to have a pin drilled through his femur. He had to have dressings changed. He wouldn’t have liked it, but he would have understood the necessity of it.

Bobby understood nothing. All he knew was that big men came to his room every day to hurt him. They strapped him down, and drilled pins through his bones. They twisted his broken leg. They ripped the skin off one leg, and tore at the sores on the other.

For the month we had Bobby in the hospital I watched the look in his eyes change from anxiety to fear, to hatred, and finally, worst of all, to despair. Toward the end of the month he no longer whimpered when we came in the room. He just lay there staring at us out of empty, sunken eyes, never flinching as we did our work.

A month later, when Bobby’s skin graft had taken and his femur had started to heal, it was time to take him out of traction, put him in a cast, and let him go home. But first the traction pin had to be removed. Jake offered to let me do it, but I said no. I couldn’t bear to have that little boy’s eyes on me anymore.

“Jake,” I said, “I just can’t…” Jake looked at me strangely, shrugged, and said okay, he’d do it.

We slowly unhooked the traction and removed the traction bow from the pin. Then Jake got a big pin-cutter and cut one side of the pin flush with the skin. He attached the hand drill to the other side and backed the pin out. There was no crying or thrashing this time, just those haunted eyes staring out of the vacuum of his soul. It was unnerving, and it was Bobby’s revenge. You hurt me, those eyes said. Now remember what you did to a little child, and remember what these eyes have to tell you about the human condition.

There was knowledge in those eyes, knowledge no child should ever have to possess, knowledge no adult ever wants to possess.

We put Bobby in a cast and let him go home the next day. Everything was healing nicely. His femur was straight. His skin had healed. I hoped someday he would thank us. But the straight femur and the healed skin had come at a great cost. I wondered how long it would take the rest of Bobby to heal. I wondered if he would ever again be able to look at the world through the eyes of a little boy.

I spent a lot of time thinking about Bobby after he had gone, trying to analyze my feelings. I was gratified that things had turned out so well, but I also felt guilty about all the pain we had inflicted on him. I concluded that it was naive to think all Bobby’s problems could be completely and instantly and painlessly cured. We weren’t gods, we were just a bunch of guys trying to do the best we could for injured people. We did what we could to help Bobby. We didn’t break his femur, we mended it. We didn’t rip the skin off his leg, we grafted it. Yes, what we did was painful, but it was necessary. That boy would have been crippled for life if we hadn’t helped him.

I had changed a lot over the previous six months. I had learned to keep my emotions a little more in check. I was a little more hardened, a little more seasoned, but the suffering of a little boy still got to me. And yet I knew if I wanted to be a surgeon I was going to have to get used to some harsh realities. Mothers die. Kids get run over by trucks. And sometimes the things we do to help them cause pain. Yes, I needed to be compassionate, but I couldn’t let my compassion paralyze me. I had to believe in what I was doing. I had to believe in the essence of a surgeon’s art: that a scalpel can heal every bit as much as it can cut.