Case I: A thirteen year old select level football player ―rolls his ankle during a game. He hears a pop and there is instant pain and swelling. He is forced to stop playing because of a limp. The next day, his ankle is swollen and bruised. He limps into the doctor’s office and has pain on the outside (lateral) of the ankle. An x-ray is done because there is pain around the lateral malleolus, most of the pain is on the anterior talofibular ligament- not on the bone. The x-ray showed no fracture and no suggestion of a growth plate fracture compared with the x-ray of the uninjured ankle. The doctor diagnoses an ankle sprain, either grade I or II. Treatment would be considered safe and standard of care if the doctor recommended: Rest, ice, compression and elevation and two weeks off of sport with gradual reintroduction of walking, running, and ―cutting drills over the next three weeks is recommended. This five week return is safe and “textbook approach”. Another treatment is one to two days of (RICE) and then begin physical therapy with the therapist to monitor return to play recommendations. Often therapy begins in the pool- where gravity is removed, progressing to land exercises, and finally game type activity (functional exercises). This may or may not reduce time out of practice. This more aggressive approach may be more acceptable to a highly competitive athlete- with the assistance of a therapist judging strength and safety on a day by day basis- rather than ―waiting for things to hopefully improve on a chosen date. A third treatment is crutches and immobilization for two weeks and then begin physical therapy. While this treatment is appropriate for a grade III sprain, it is not standard of care practice for a grade I or II sprain and results in prolonged time off before return to play due to immobilization, loss of proprioception, and reduction of strength. Therefore, more protective treatment is not necessarily better treatment.
Case II: A premier level eleven year old soccer player rolls her ankle while attempting to dribble the ball around an opponent. The following day, after ice and ibuprofen, she goes to the doctor. Her foot hurts by her little toe and notes that there is a ―bump on each foot at the outer side, but the injured side is more swollen. X-ray reveals a fracture at the back (base) of the fifth metatarsal- lateral foot behind the little toe. This is a common injury to growing adolescents after an ankle type injury. This avulsion fracture has a couple of acceptable treatments. 1. a post op shoe (hard soled shoe) can be used for three weeks or until no pain or limp, allowing ankle movement but protecting the 5th metatarsal. While acceptable, this may not offer enough pain relief for some patients. It also doesn’t offer protection during relative restriction- as the injured area is exposed and can be re-injured. 2. A cam walker boot can be worn for three weeks or until no pain or limp. While a more protective treatment, it also immobilizes the ankle and may require some physical therapy for ankle strengthening after the 3 weeks due to lost proprioception. It can not be stressed enough- while mending and resting the injured area, a walking boot, cam walker, or cast also immobilizes muscles, connective tissue, and vital structures that are not injured and also become weakened. Exercises to regain strength, and muscle memory (proprioception) protects the area from a new injury. In this treatment, the injured area is better protected, but other structures in the foot are too- that don’t necessarily need to be protected and may lose strength and proprioception. An unacceptable treatment approach in this case: 3. No treatment at all may result in prolonged pain and limp. This is an unacceptable approach to this injury.
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Based on a true experience- names, locations, and dates have been changed
August 19, 2000
“Jordan, your blood pressure is pretty low again. Even with the dopamine,” I kept facing Jordan but took my eyes away for a moment to glance up at the monitor, “your pressure is only 83/55. You’ve been septic before, but you’ve responded better in the past.” Septic and dopamine were words I had become accustomed to using but would not expect the non-medical person to understand. Jordan though knew them as part of his eighteen year old vocabulary. Dopamine is a drug used to increase blood pressure when IV fluid alone is not enough. Sepsis is a word used to describe overwhelming infection that effects many organ systems.
Jordan’s face looked sunken compared to when I met him eleven months before. His color was a pasty yellow, dark circles under his eyes, bald, weak appearing lying in his bed. The tattoo on his arm, once a sign of rebellion and strength stood out now as one of the only familiar characteristics from when we first met. His eighteen year old body now older, his skin an outside sign of how weak he now was throughout, his sarcastic smile gone. As a third year pediatric resident, I had met several teenagers diagnosed with cancer, each of them come with tragic stories. Families overwhelmed with an enormous unpredicted burden. Getting your child to go to school, study for a test, come home before curfew- irrelevant now with his body consumed with a disease rearing its ugly face starting ten months ago with leg pain.
Jordan was a social giant. His friends called him a partier. He had a reputation he had to uphold at his high school in a little town in Northern Iowa. He skipped class, went out with the dangerous crowd, and talked tough. He drank a lot of beer, admitted to smoking a little marijuana, and unknown to his family, experimented with other recreational drugs. To Jordan though, it was his time to have fun. His parents took care of the important things, and he was going to college in two years. He would make his real goals then. The goals now were to have fun, remain popular, and push a few boundaries.
But in the winter of his junior year, Jordan complained of ankle pain. He was an active teenager and although he couldn’t remember injuring himself, any number of things could cause ankle pain. The basketball game during gym class, jumping over the fence at his friend’s farm over the weekend while drinking beer, or helping his dad carry boxes up from the storage room to the Hardware store retail floor that has been his family’s name sake in the town of eight thousand for at least five generations. Jordan may have started having pain in October or November but it didn’t change his activity and really hadn't become a daily nuisance until probably December. He mentioned it to his parents late December or January and because there was no event that started it, his parents told him to get some Advil, use some ice, “it is probably growing pains or something”. But by the end of February his mom noticed he was limping and they finally went to the doctor, as Advil was obviously not helping.
His family doctor took an x-ray of his ankle. Expecting to find nothing, the doctor’s face changed. His eyebrows turned down, his smile turned to a frown, his eyes stared at the x-ray. But most noticeable, sixty four year old Dr. Emerson, always making small talk about something, stopped talking. A mass in the bone. Probably a tumor. Jordan was sent to our hospital the next day for a biopsy. Ewing sarcoma. The goals Jordan had not yet made would now be put on hold. He was angry. His parents understood why- they were angry too. Jordan was always in trouble, but he didn’t deserve this.
Jordan was not a compliant patient. He often argued with the nurses. He rolled his eyes at the residents and students. And he snarled and agreed with the head doctors, the oncologists, but made fun of them when they left the room. He had to stay strong, keep his reputation, even now- as an inpatient in a new hospital, with new people, with a new challenge all different than the life he had become accustomed to living until a life changing blow less than a week before.
Jordan finished a round of chemotherapy and once his white count was high enough was allowed to return home until the next round of chemotherapy would bring him back to the hospital for several days. Both parents, and sometimes his sister would make the trip from their small town to the big city, a dreaded trip with expectations of bad hospital food, chemotherapy that sometimes caused vomiting, and hospital staff that acted as if they cared but couldn’t know him like his friends back home and hardly understood what he was going through now. Life had become completely out of control.
By the third month, only his mom joined him. Each time she had questions written down, things that had come up from the last round of chemotherapy. Dad usually stayed at home to run the store and his sister remained at home to go to school and continue a more normal teenage life. Jordan had evolved from a sarcastic, tough guy teenager to an angry, “dog in a corner”, beat down young man. The often bully at school looked as if he was being bullied. Bullied by a disease that was winning at every turn. No school, no drinking, no parties, no girls, nothing that even resembled the last seventeen years of the only life he knew.
Four months into his treatment, Jordan became very ill. His fever was out of control and his blood pressure fell rapidly. The blood cultures showed E. coli, a bacteria found in stool. How could this have happened? The nurses are well trained to keep the port that the chemotherapy enters as clean as possible. Even the two and three year old children with cancer never have this problem. The nurses were interrogated. The oncologists were near hostile at the thought of E. coli found in the port of one of their patients. It was like a chef at a fine restaurant hearing of hair found in the main course of a guest’s dinner. How was this allowed to make it to the plate?
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