The case was about a 7yr old Afghan boy he took care of immediately after an IED (improved explosive device, basically a makeshift bomb insurgent's plant all over town) went off in village market in the middle of the day. There was a large number of women and children hit and he happened to see this boy. This sort of thing happens unfortunately, pretty frequently. Kids are brought to Bagram all the time and taken care of. This boy, however, was not like any child routinely seen anywhere. On initial exam, before delving into his blast wounds, the doc noticed something strange about his fingers and toes. They looked something like this:
For non-medical people, it's called "clubbing" and the exact physiology of it isn't really known but it's hypothesized that it's caused by a process that allows for right to left shunting of blood in the heart and leading to the mixing of oxygenated and deoxygenated blood in the body. It has been seen in people with long standing COPD, lung cancer, TB, cystic fibrosis, etc, something basically affecting oxygen content in the blood. Anyway, so as the primary survey goes on they notice this clubbing, puncture wounds to his chest and abdomen, and some other minor cuts. So just from the clubbing alone, doc new something was not totally right. As things progress and they start the trauma series of xrays, labs, etc they quickly realize this child is incredibly unique. His chest x-ray looks something like this:
Notice anything wrong?? (I thought of scrubs at first and how they hang the xray backwards at the beginning of the show lol) But no technical error here...his "stuff" is on the wrong side! Heart and stomach, both on the right! This kid had what is called, Situs Inversus, basically where his organs are transposed to the opposite side of his body. He also had transposition of the great vessels of his heart, aka the main vessels of his heart were also reversed. Crazy right? How is this kid even alive?? It's crazy because transposition of the great vessels is a condition incompatible with life in 100 % of cases UNLESS, unless, unless, there is small hole in just the right spot in his heart. In other words, his heart is totally backwards and this small hole, a ventricular septal defect, is allowing this crazy rearrangement of blood vessels to adequately oxygenate his body. Holy crap right?? Mind you, this kid is 7yrs old!! Which means, for his entire life, from the day he was born, his little body has been working sooooo hard to compensate for this congenital heart abnormality. AMAZING.
So back to his resuscitation. After docs quickly figure out sort of what they're dealing with, they get some labs back. The only 2 real labs of importance to explaining this case are Oxygen saturation and Hematocrit. Oxygen saturation is around 81%, which is low, but not as low as expected for somebody who probably has a huge hole in their lung, normal is greater than 92. His hematocrit, just a measure of the actual red cells in a blood sample, was also 81%, normal is anywhere from 40-50%. So this kid's ox saturation and his hematocrit are the same!!! This basically means this kid's blood is incredibly thick, to the point where this level of Hct is never seen, like ever! It's another way that his body has coped with this heart disease that he has, that's one of the ways he gets more oxygen, is to make lots and lots of red blood cells to carry more oxygen. Again...amazing.
So now the docs realize that their previous knowledge of "normal" physiology has gone totally out the window. How can you even begin to try to treat/correct/maintain his physiology when you have no freaking idea what is his "normal" in the first place? All they really know is that he needs surgery to remove metal that is in his lung and abdomen making him bleed into his belly.
*Side note: My favorite part of this presentation was when the doc was telling how $hit was hitting the fan and he had to run back and forth between this kid and a few others. He described what I can only picture to be the extremes of emergency medicine, badass docs and nurses running around making things happen in mass chaos. (doesn't that sound incredible?) My next favorite part of the story is when the doc, after getting the kid somewhat stable, tries to get a pediatrician (since he is 7yrs old) to take over. The poor peds guy practically craps his pants at the thought and refuses! I'm sure he didn't refuse because he was a jerk, I just think he was too scared to take on the case. :-) Sorry to all my peds friends, but I had to throw this in there.
Anyway, to make a crazy awesome, but long story short, the doc ends up putting a chest tube in the kid and taking him to surgery to remove the shrapnel left in his chest and abdomen. He survived the surgery but sadly died from complications of pneumonia several days post-op :*(
It is really really sad that he didn't make it. My first thought was, poor guy, so unlucky, just caught in the wrong place. But after really thinking about it, turns out that he was actually incredibly lucky to even be in that market in the first place. He basically overcame all odds to even be breathing, let alone live for 7 years. He wasn't just lucky, he was a walking miracle. We'll never know how long he would've really lived had he not been hit with that IED, but it surely wasn't going to be very long. It's even more amazing that he survived surgery. There's so much that has to go right in his physiology to sustain him, his body has been perfecting this for years. Surgery is highly risky in "normal" people, let alone him. So all in all, the fact that he died in the end while really heartbreaking, it's just a testament to how big of a miracle his life was to begin with.
After/during this presentation I pretty much had chills. One of my dreams is to travel the world and practice medicine in places that doesn't have doctors really. To treat people, like this little kid, who have never seen a doctor in their lives. It's a huge reason i joined the Air Force. So although I sometimes have my doubts about how the AF will impact my life, hearing stories like this puts everything back in perspective for me. Stories like that are the exact reason why I'm here. Nothing pumps me up more than to know that I will be (hopefully!!) able to go around the world and have my own stories similar to this. Of course being a doctor alone is sweet, but being one of the few people who can handle crazy cases like this one, and help people that would otherwise NEVER see a doctor is incredibly exciting.
There's a lot to worry about right now in this stage of the game. Residency applications, board scores, what happens if I don't match, where will I live, what if I'm still single at age 50 (lol, jk), it's A LOT to think about. I do my best NOT to think about it too much and reassure myself that things will work out, they ALWAYS do. But that day, sitting there listening to the story about that miracle boy made me REALLY realize something. The feeling I got from it made me see that although i am unsure of LOTS of things, like where on earth I'll be next year, or what I'll be doing. One thing I DO know is that right now, pursuing this dream, (totally stressed and confused and scared) no matter what happens, I'm exactly where I belong and wouldn't have it any other way.
Thanks for sharing this story. It's pretty cool, even though it ends on a sad note. I found it by googling "wrong x-ray Scrubs." I hope the last two years have kept the promise you wrote of here.
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