Case 42: Justin Beaver

My back is stiff. Before my shift, I spent an hour digging through the roadblock of snow that the plow left at the bottom of my driveway. My wife thinks we should hire someone to do this – someone faster, someone stronger, someone conscientious enough to complete this task before she has to drive to work – but I refuse. Shoveling snow gives me a sense of accomplishment, something to look upon and say, “I did this. I made this better.” Clearing this path also fulfills my nationalistic instinct, just as my Canadian brother, the beaver, is compelled to build dams to provide habitat and protection for his young.

My shift is almost over. I look quickly at the triage note and decide there’s likely little I can do for this patient. He’s already been seen by a doctor today, he has a diagnosis, and he’s even taken his first dose of antibiotic. Sometimes, symptom resolution takes time. I can reassure him and offer him analgesia if he’s in pain, but that’s about it.

Juman* is home studying this weekend. It’s two weeks before Christmas and in a couple of days, he’ll be back at school, knee-deep in exams. Today, however, his mother has been driving him across town in search of relief. The pain in his left ear began a couple of days ago, but it was mild. It also wasn’t associated with the typical symptoms of the ear infections he’d had as a child – fever, congestion, cough. Overnight, however, his pain intensified. It woke him several times, and felt like some was jabbing a pencil into his ear. In the morning, his pain was so severe, his eyes watered. At 9am, he was the first patient waiting at the new local walk-in clinic.

He’s healthy and has no medical problems other than severe, unrelenting pain in his left ear. It goes deeper than his ear, he tells me. It goes half-way into his brain. I lift the otoscope from the wall, and his neck swivels. “Actually,” I say. “Let me look in the good one first.” I’ve done this for two decades – good ear, then bad. I can still see and hear the doctors who taught me in clinics and on hospital wards during medical school: Some people have tortuous ear canals, and it’s kind to use the painless ear as a roadmap for the painful one. Some eardrums are scarred from tubes placed in childhood so it’s helpful to see a patient’s normal drum before examining the abnormal one. Look in the good ear first. The last thing you want to do is transmit infection from an infected ear to a clean one.

The right ear is perfect. The eardrum is translucent and clear, like a tightly pulled sheet of Saran Wrap. Juman grimaces as he uncovers his left ear and begs me to be gentle. I move slowly, advancing the tip of the otoscope into the canal. Juman doesn’t move. At the end of this canal, it’s dark. I pull the light back and angle it up, then down. I slowly retract the light.

“The doctor told you that the ear was infected?”

He reaches into his coat pocket and shows me a pill bottle. “Yeah,” he says. “Gave me these antibiotic pills and an antibiotic drop as well.” I read the bottle. It’s Amoxicillin, five-hundred milligrams, three times a day, seven days. Good enough for an ear infection, but useless for Juman’s ailment. He’s about to say something but his mother interjects.

“Well, the doctor wasn’t actually at the clinic.”

“It was one of those virtual clinics,” Juman says. “A nurse put a camera in my ear and the doctor was somewhere else looking at a computer screen.”

Our group of emergency physicians tried this once. We sent a small group of patients with soft tissue infections to an outpatient clinic where they could receive a daily dose of IV antibiotic. A nurse at the clinic would point a camera toward the infected area so we could follow their progress. Although this was convenient for patients, the view wasn’t nearly as good as what we could see in person. Furthermore, in medical school, we’re taught to use all our senses (except taste, thanks to modern diagnostics**) to assess clinical conditions. We couldn’t feel the temperature of the infected skin, nor could we palpate the affected area to appreciate tenderness, or the fluctuance of a developing abscess. We also couldn’t breathe in the familiar scents of common bacterial pathogens such as pseudomonas (wet socks and corn chips). While virtual, video-assisted assessments are an alternative to live clinical assessments, they carry considerable risk, both to patients and clinicians.

“I’ll be right back,” I say, leaving Juman on the examining table. My assistant Osler finds the items I need within ninety seconds: a sixty cc syringe, a large-bore IV catheter, warm water, towels, and a kidney basin. I return and tell Juman to keep still – that I’m going to use this makeshift squirt gun to flush a stream of warm water into his ear. His ear isn’t infected. It’s impacted with wax. It’s a simple diagnosis, something the walk-in doctor wouldn’t have missed if she’d assessed him in person. I fire the stream into Juman’s ear. After three shots, he feels a pop along with a little relief.  Two shots later, a tiny, woolly ball flows out of his ear like the curdled clump from the bottom of an expired milk carton. And although it looks like the Canadian beaver’s malnourished distant cousin, Juman and I stare at it with joy and wonder.

“Oh my God,” he says, shaking his head like a soaked dog. “Thank you so much!”

“Is it better?” his mother says.

“One hundred percent.” He extends his arm. “You’re amazing.” I shake his hand, unaware that in a few months this gesture will be as forbidden as using one’s tongue as a diagnostic tool. As Juman and his mother leave, I name the rodent-like ball of wax after one of our famous countrymen, and then discard him along with the kidney basin in which he lives.

Screen Shot 2020-05-15 at 1.34.37 PM
Justin Beaver

As I drive home, I feel good because I’ve actually cured someone today. Procedures like this – ones that provide instant relief to the patient – reducing a dislocated joint, draining an abscess, removing a foreign body, shocking someone’s heart back to its normal rhythm – are sometimes few and far between in medicine.

The winter precipitation hasn’t let up and my driveway is covered again. I park on the street, grab my shovel, and an hour later, I feel satisfied for the third time today. I also feel patriotic, as I plant my shovel onto the concrete and rest my chin on its handle, re-creating the legendary pose of Ken Dryden***, who, along with the beaver, is a proud Canadian like me.

* not his real name

** “historic anecdote tells us that the midwife would lick the forehead of the newborn, and if the sweat tasted abnormally salty the infant was destined to die of pulmonary congestion and its side effects” – from The Basic Defect in Cystic Fibrosis, Science, 23 Jun 1989, vol 244 pp. 1423

Dryden
*** Ken Dryden (from hhof.com)

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5 comments

  1. I hesitate to share with friends the feeling of satisfaction I get from “instant relief procedures”. High on that list is inserting a Foley catheter men suffering from urinary retention. I know I haven’t solved their problem but seeing them going from writhing in discomfort to relaxed makes my day.

  2. My mom is a doctor and jokes that she feels like God whenever she gets to do this procedure because patients are always so elated and grateful afterward and it’s so easy for her. As a recipient of this “power wash” technique, I can say it basically was a highlight of my year. 🙂

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