I’ve been a physician for three decades, and handling Friday-night call duty was always particularly stressful for me. Often it followed a busy week and involved trying to avoid problems over the ensuing 72 hours while covering my practice and my partners.' If Friday night was bad, the weekend would almost certainly be difficult. Problems came in multiples—and tended to go from bad to worse.
One such weekend began on a beautiful Chicago summer night. As usual for a call night, I went to bed around 10 p.m., hoping to get a reasonably good night's sleep. Often, that was difficult, not because of any specific call but because of the anticipation of the call. This particular weekend, my practice group was on emergency-room call, which meant that we were responsible for any "unassigned" patients, meaning those who presented to the ER without any previous patient-doctor relationship with a physician on staff. Many such patients had no insurance and limited if any previous medical care, and could therefore be the most challenging. There was no reference point for the treating physician, and the patients were often suspicious of us and of "the system." Usually they were brought in by ambulance to the closest emergency room.
On this night, I was awakened around 11:30 p.m. for a consultation. I could predict a long night ahead of me, along with a stressful remaining weekend, within 10 seconds of hearing the reason for the interruption of my REM sleep: A 43-year-old man had suffered a fracture of the testicle.
The testicle is surprisingly resistant to injury, despite its exposed location, front and center, and despite being shielded by very little. (Scrotal skin is quite thin, and there's no significant layer of muscle or fat for protection.) With a predilection for just hanging, the testicle would appear ripe for injury. But it is the very lack of resistance, the ability to be pushed aside in a compliant scrotal sac, that allows the testicle to avoid a significant injury when struck.
Most males who have gone through puberty have at one time or another felt the nauseating ache that comes with being hit firmly in the testicle. The pain, indescribably significant, causes one to bend over and drop to one's knees, barely able to utter a sound through the suffering. Embryologically, the testicle takes its origin in the vicinity of the kidneys, and throughout gestation (pregnancy) it gradually moves into the scrotum during normal fetal development. The nerves and blood supply to the testicle have their origin up high in the posterior aspect of the abdomen. An injury to the testicle, from a sudden kick or blow, can consequently cause the pain to be experienced by the poor victim where the nerves originate. So with this type of injury, not only is there the local pain from the scrotum and testicle being struck but also the excruciating abdominal pain.
I walked into the ER around midnight and discovered, among other things, that the patient with the testicular fracture, who was lying on a gurney, was also articulate, educated and insured. I had reviewed his scrotal ultrasound before examining him. The blow to the testicle had been so severe and sudden that the actual covering—the fibrous shell around the testicular components (responsible for sperm production and testosterone)—was split open, causing the contents to be expelled from inside the shell. It was sort of like a cracked-open egg. You can only imagine the type of discomfort this would have caused at impact.
I examined the patient, confirming the diagnosis, and discussed with him the need for surgical exploration to salvage the testicle, if possible. In some cases, the damage to a ruptured testicle is so severe that, without viable tissue to repair, the testicle needs to be removed.
Our conversation led to the man revealing how the injury had occurred: He was hitting golf balls at a local driving range.
A SLICE GONE HORRIBLY BAD
I'm an avid golfer. I love the game—the history, the architecture of courses, the physics of how a ball flies. I often find myself daydreaming about playing a good round and how satisfying it feels to hit a golf ball solidly. So how on earth did this golfer, hitting balls at a range, get here?
I knew the range quite well; I'd hit balls there hundreds of times. It was double-tiered, curved to allow balls to be aimed toward the middle. There were numerous light poles, for those of us who just can't get in enough practice during daylight. Apparently, the man practicing next to the patient hit a nasty slice with his driver. The man hit his ball so badly, with such force, that it ricocheted off a light pole and hit my patient smack in the scrotum.
THE VICTIM HAD BEEN HITTING GOLF BALLS AT THE RANGE WHEN HE WAS HURT. THEN HE FINISHED THE BUCKET.
The thought of the event—the sound of the impact, the pain involved—was dizzying. As I interviewed the patient before surgery, my heart sank that a fellow golf addict had suffered such injury while attempting to improve his swing.
But wait. According to my patient's story of woe, he'd been injured in the middle of the day, and it was now nearly midnight. I asked why it had taken him so long to go to the ER.
"I had to finish my bucket of balls," he replied.
I was unclear if I'd heard him properly. Had he really just said he pulled himself off the ground after suffering a testicular fracture and continued to hit balls? If so, I had a new hero!
He informed me that he'd limped back to his car after finishing his bucket, driven home, and stretched out on the couch. Not until later, after doing a Google search, had he learned that a "significant injury" might have occurred. He figured this must have explained the swelling and pain.
After hearing this, I wasn't so sure he was my hero anymore. If I had a scrotum that was starting to look like a pomegranate, and getting larger, I don't think I'd be at home deciding whether to seek treatment.
I took him to surgery and was able to salvage the majority of the testicle. He did well, and went home the next day. My weekend was still in its infancy. Another day on call.
Editor's Note: Excerpted with permission from The Illness of Medicine: Experiences of Clinical Practice, copyright © 2018 by Michael J. Young, M.D., GM Books, 263 pages, $30. For your copy, go to gmbooks.com and click on the bookstore.