Every ER doctor gets this question. “So, what’s the craziest thing you’ve ever seen?”
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I love to cook. I began cooking as a teenager, and the first recipe I learned was my mother’s chicken curry. By the time I was eighteen, I was having my own dinner parties, watching friends scrape the bottom of a ten-quart pot for the last drops of her savory, spicy curry. My teenage son can make scrambled eggs and avocado toast, but that’s about it. If I asked him to spend a day with me in the kitchen, he’d probably tell me that he’d rather watch a video online or, even better, use artificial intelligence to produce a custom recipe with all his favorite tastes.
My mother would buy chicken legs and thighs, and we’d skin them together. She showed me how to grip the slippery skin on the meaty part of a drumstick with a paper towel. I’d peel the skin down until it looked like a lone pant leg hanging off the ankle. One last satisfying yank and the drumstick would be skinned.
It’s a tough question. Craziest thing I’ve ever seen. I could write a hundred different case reports that would all qualify, from the grotesque (maggots festering inside a neglected wound) to the gruesome (family members murdering one another) to the bizarre (a string of Christmas lights shoved up someone’s butt). What usually comes to mind is the most recent unique case I’ve seen. Sometimes it’s a great medical mystery solved, and other times, it’s that one-in-a-million accident that one has to see to believe.
It’s mid-summer, Friday evening. The day starts as it usually does – an elderly patient from a nursing home in a hallway stretcher with a fractured hip. Several hours later, I see a young woman in handcuffs. At low speed, she crashed her car into a fence. I note that she lives close to me, and I ask the accompanying police officers where the accident had occurred. I know the spot. It’s just a few hundred meters from two elementary schools. When I ask what caused the crash, she says she doesn’t know and that she’s just not feeling well. She’s healthy, doesn’t take medication, and denies any drugs or alcohol. She has no injuries, and her neurological exam is normal, except for a slight slur when she speaks. An hour later, her blood alcohol level comes back well over twice the legal limit.
As my shift nears its end, I’m still angry and I hope the drunk driver is behind bars. I’m in Fast Track now, so my navigator is picking up one-touch patients – lacerations, injuries – ones that don’t need extensive testing, ones that I can see quickly and treat as I finish up my most complicated patients.
Riley Messier* was initially given a triage score of five, the lowest on our acuity scale, but the nurse used an override to upgrade him to three because of “parent/caregiver distress.” Although they may have appeared panicked at registration, Riley and his parents are calm and cool. I’ve read the triage note: “Riding bicycle over jump and lost control. Flipped over handlebars. No helmet. Denies head injury. Noted penile bleeding, states laceration to the shaft of his penis.”
When I ask Riley what’s hurt, he confirms that it’s only his penis and that he has no other injuries. I’ve seen many groin injuries involving bicycles, and most involve the rider falling onto the crossbar. “No,” his mother says. “He’s not sure how it happened, but he thinks the edge of his handlebar clipped his groin as he went over.”
Riley is sitting awkwardly in a wheelchair. His arms are pushing off the handrails, and his butt is hovering over the seat. I step toward him and tell him that I should have a look. “Can you get up onto the exam table?”
“I don’t think so,” he says.
“He can’t move,” his mother says.
He isn’t wincing and doesn’t seem distressed, so I tell him I can help him onto the stretcher.
“You don’t understand,” his mother says. “It’s not just a cut.”
Based on the triage note, I’m expecting to see a cut on the middle of his penis, and because of its sensitive location, I’m not surprised at Riley’s apprehension. But a cut is just a cut, and I’m expecting to be able to stitch it quickly.
“I need to see it,” I say. “So whatever’s easiest for Riley.” I ask him if I can pull his shorts forward and have a look.
“Okay,” Riley says. “Just be careful.”
I lean forward and grasp his shorts at the elastic waistband. I pull forward and peek inside. Oh my God. My kids won’t have to learn how to skin chicken thighs with a paper towel. They can buy boneless and skinless right from the grocery store. It’s so easy now that if they want chicken curry, they can tap on their phones and have it delivered within thirty minutes. I’m not sure how grocery stores skin chicken with such perfection, but if they need a new technique, I suddenly have one. They could teach chickens to ride bicycles and then turn their handlebars one-hundred and eighty degrees, ensuring that the edge of the handlebar catches some part of the chicken’s skin before they fly off the bike.
I carefully let go of the waistband and explain my findings to Riley and his parents. I’ve learned not to show alarm through my facial expressions. “It’s a complicated injury,” I tell them. “I’m going to have to get him a bed so we can sedate him, get him to lie flat, and have a good look so we can repair it.” Just as I’m about to leave, I wonder how I’ll describe this to the urologist. Although Emergency Physicians handle almost all lacerations without specialist backup, this injury is unique. I wouldn’t mind having another set of hands with me. “I’m just going to have one more look,” I tell Riley. “I have to take a picture, send it to the specialist, and get his opinion.”
I return to the doctor’s station and sit down. “Holy shit,” I say.
A colleague turns to me. “What?”
I show him my phone.
“What the f*$k is that?”
“Look closely,” I say. “What does it look like.”
He repeats my words. “Holy shit.”
I page the urologist and tell him the story. He seems unimpressed, so I tell him I’ll send a picture through the hospital’s secure messaging system. “Just call me back when you get it.”
My phone rings a minute later. “What in the actual f*$k is that!”
“It’s what I told you it is,” I say. “His penis and his balls are skinned. Everything is intact, just the skin is missing.”
“Jesus,” he says.
“Have you ever seen anything like this before?”
“Of course I’ve never seen anything like this before!”
I order morphine and antibiotics for Riley, and when the charge nurse asks why I need an acute bed for a kid with a cut, I show her the picture. She asks no other questions. Minutes later, he’s in acute room five, the urologist on one side, me on the other.
FIGURE 1: INTACT LEFT AND RIGHT TESTICLES WITH SHAFT OF PENIS IN BETWEEN.
The entire penis and both testicles are intact but skinless. They are covered by a thin membrane and dotted with globules of fat. Filament-like blood vessels are running through the membrane. It’s as if an anatomy professor has carefully reflected the skin to expose every detail. I push sedatives into the IV as the urologist explores the area. The skin appears to be gone, but as we lift the pink testicles, there is a clump of bunched-up tissue sitting on his perineum (between genitals and anus). As we gently stretch out this bundle of skin, we realize it’s what’s missing from the testicles and penis. Like the chicken drumstick with its pant leg pulled down, the skin simply needs to be pulled back up and secured into place.
With Riley awake but comfortably sedated, I use forceps to pull the skin upward. It fits like a three-toed sock over his penis and testicles. As I hold it in place, the urologist begins to secure it with stitches, as if sewing a sock onto the ankle so it doesn’t sag.
It takes about forty-five minutes, but when it’s finished, I can’t believe that his skin is all there and that his genitals are practically back to normal. Within minutes, Riley is awake, and shortly after, he’s discharged home with a prescription for analgesia and antibiotics.
A week later, Riley is doing well despite massive swelling and some discomfort. In the weeks following, the swelling subsides, and his midsection returns to normal.
A few weeks after meeting Riley, my mother and I are skinning a roasted eggplant. Peeling an eggplant isn’t as easy as skinning a chicken – it’s hard to ensure the flakes of charred skin don’t get mixed in with the guts. My mother asks if I’ve cooked anything interesting lately, and I tell her about the octopus. I boiled it, seared it in oil and garlic, and then finished it on the barbecue. My mother asks to see some photos, and I whip out my smartphone. It’s so smart that it automatically recognizes and arranges all my food pictures into one folder. However, when I open the folder, I realize why my kids should learn to cook with me and not rely on AI to conjure up custom recipes. My phone has decided that Riley’s skinned nuts belong with my octopus, my crispy golden oven fries, and my eggs Benedict.
“What’s that!” my mother says.
I quickly turn off my phone. “It’s chicken,” I say. “Just some organ meats I saw at the butcher.” I almost gag, then get back to picking bits of skin from the eggplant.
*Name changed
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Glad I don’t ride my bike anymore.