Gunshot wounds and Lightning Strikes: The Long and Winding Road to Rheumatology

A bank of gray clouds rimmed the horizon. I turned onto a long gravel driveway leading to the medical clinic in Gray, Maine, and heard a distant rumble. After 2 years of basic science classwork at the Kansas City College of Osteopathic Medicine, I am traveling the country with my wife, Sandi, rotating through surgery, family practice, infectious disease, dermatology, ER, GI, cardiology and pulmonary medicine.

For the first twelve months, I was primarily an observer relegated to “skut” work—drawing lab work or performing histories and physicals. In the ER, for instance, I peered over the shoulder of a resident or was relegated to removing sutures. That changed 3 months ago when I traveled to Coffeeville, Kansas for my rural clinic. There, responsibilities were heaped on me like an overflowing bowl of grits.

The community hospital in Coffeyville, Kansas was so small, it didn’t employ an emergency room physician. Instead, a nurse signed the patient in and called the patients’ family doctor. For the unassigned patients, the family doc I was rotating with suggested that I hang out in the ER after-hours, see the patient, and give him a ring.  “You’ll learn a lot,” he assured me.  Yes, I did.

Of course, it helped that the ER nurse was an old pro and bypassed me—calling in the covering family practice physician or general surgeon for the true emergencies. For the less acute visits (and this comprised the majority of the patients), I worked through a history and physical, made a tentative diagnosis, ordered lab and x-ray, and formulated a plan. For the first month of my 3-month rotation, my supervising attending appeared out of nowhere as soon as I got off the phone to check my work. Over time, he pulled back, evidently satisfied with my judgement, and asked questions like, “So…is this laceration on the lower leg similar to the one I watched you suture last Saturday?” Or, “Why don’t you call when you’re ready to discharge the patient and I’ll check your work?”

On the weekend the rodeo was in town, I was sitting at the nurse’s station when a rodeo clown came in who had been kicked and run over by a bull. It was the most blood I had ever seen in a fully conscious human being. When I called my attending, he asked, “Have you ordered an x-ray to make sure he didn’t fracture his skull?

“Yes, the x-ray tech just took him over for a skull x-ray. He scrambled over a fence after the bull ran over him. No loss of consciousness. His neuro exam is normal. His buddy who brought him in said that it’s amazing but the only place he was kicked was in the head.”

I waited for the perfunctory, “I’ll be right over,” but instead the attending said, “Head injuries bleed like a stuck pig. Clean him up and if there’s no skull fracture, start suturing. I’ll be over as soon as I finish my meal.”  The x-ray of the rodeo clown’s skull was surprisingly normal, and after cleaning and recleaning the wound, what was left was a ragged starburst gash. He was surprisingly lucid and relaxed; this was not his first encounter with a bull. After I anaesthetized the wound edges, the ER nurse brought out a surgical tray and I methodically brought the edges together. An hour flew by. As I finished the last of 28 sutures, Dr. Smith arrived and silently watched by the door as I reviewed wound instructions. “Clyde,” he finally addressed the rodeo clown, “Will you be back in town next week for Frontier Days?” The clown nodded. “Dr. Radis will be here and can remove your sutures.”

One shift, after midnight, I was nearly out the door when there was a commotion in the parking lot and the waiting room flooded with people shouting, “He’s been shot! Give him room to breathe!” I froze in my tracks. Except for the sign-in clerk and the night nurse, I was alone. The crowd carried the young man into an empty exam room. The gunshot patient’s entire left arm was wrapped in a bulky rag. In the blink of an eye, the ER nurse cleared the room, inserted an IV into the crook of his elbow and hung a liter of lactated Ringer’s solution. I said, “Yes,” when she asked, “Do you want lab to type and cross-match 2 units of blood?”

Before turning my attention to the wound, I methodically ran my hands up and down my patient’s legs, assessed peripheral pulses, palpated his belly, and peppered him with questions, assessing him for additional injuries. Satisfied that, like the rodeo clown, his wound was a singular problem, I carefully loosened what looked to be a make-shift tourniquet above the elbow and held my breath as the ER nurse handed me a wad of sterile gauze. Beneath the tourniquet was a ragged handkerchief. I lifted one edge, then the other. Through the inner biceps was a pea-sized hole. On the outer biceps was another bloodless exit wound.  Neither wound was large enough to suture. Without a word, the ER nurse handed me 2 Band-Aids as she administered a tetanus shot. A police cruiser pulled up outside.   

That was 3 months ago. Goodbye Coffeeville, Kansas, hello Gray, Maine. A thunderclap boomed as the storm drew nearer. I pulled on my white coat, draped my stethoscope around my neck and smoothed down my cowlick. Opening the clinic door as the first drops fell, I felt in my left coat pocket for The Little Black Book of Primary Care, my reference for new or unusual clinical problems. Inside, the clinic staff was expecting me. Dr. Allen was in his office behind a towering stack of charts and magazines. He looked at his watch and announced it was time to get to work.

On our way down the hall to the first patient, he asked me about my surgical experience. Before I could answer he followed up with, “Ever assisted in a vasectomy?”

My eyes flared. I had no idea that family doctors performed vasectomies. “No, but I’ve had 3 months of surgical rotations.”

“That’s great.” We entered an exam room. A local farmer lay on a padded table, prepped for the vasectomy by the nursing staff. Dr. Allen sat on a swivel stool and directed me to an empty stool to his left. The permit was signed.  

“Hand me the 5-cc lidocaine syringe.” I handed the doctor the syringe. The farmer involuntarily flinched as the needle pricked the scrotum where our incision was planned. “That’s the worst of it,” Dr. Allen said. “The lidocaine stings. We’ll wait until the anesthetic takes hold and from there it’ll take only a few minutes.” As we waited with our hands folded, Dr. Allen half-turned and whispered, “I’ll make the incision here.” He nestled the scrotum and testicle in one hand and pointed towards an imaginary line. I held a retractor lightly in my left hand awaiting further instructions. Outside, rain pelted the glass and gusts of wind bent a clump of white birch bordering the parking lot.    

Dr. Allen reached overhead and focused the operating room light on our patient’s groin. Then he grasped the scalpel and made a flowing incision in the upper scrotum. He dabbed the edges of the wound with a sterile gauze pad before placing a gloved finger into the incision and identified the vas deferens through which sperm flows to the penis. I held the wound open with my retractor and leaned in for a closer look at the dull ivory tube.

It was at that exact moment lightning struck the Gray Medical Clinic. The intercom above our exam room door exploded in a rain of plastic. The direct hit knocked me off my stool and momentarily, like the pause between heart beats, there was silence, followed by the acrid odor of shorted wires and panicked voices flowing down the hallway. A wisp of smoke descended from the shattered intercom.  

Dr.  Allen remained upright on his stool. His scalpel clanged to the floor. The lightning strike seemed to slow time down. The farmer lay silent on the table, his chest slowly rising and falling. A calloused hand moved to his face and rubbed an eye. In slow-motion, the hand moved down to the sterile field and pulled the sterile drapes off to one side. The farmer lurched to his feet.

Dr. Allen stirred as if emerging from a dream. “Wait! Hold on! Lay down! I’m not done!” The farmer pulled up his trousers, a blood-tinged gauze extending out his zipper. As he turned, the last drape fell away. “Hold on! Lay down!” Dr. Allen repeated, but the man moved silently into the darkened hallway. He had received an unequivocal, powerful message. It was time to go. In another moment, he was out the front door into the pouring rain. I peeked through the blinds and watched as he opened the door of his truck and awkwardly pulled himself into the front seat. The windshield wipers flipped on. The truck pulled away.  

It’s no surprise I can recall little else about my outpatient family practice rotation in Gray, Maine in 1980. After all, that was more than 40 years ago. When friends ask me, what happened to the farmer? I have to say I honestly don’t know. I do know the experiences shaped my career decisions. After Coffeyville, I crossed emergency room medicine off my list. After Gray, Maine, I knew surgery held no interest for me. Eventually, and with a number of detours, I settled into rheumatology. It’s been a good fit. Gunshot wounds and lightning strikes guided me there; I just didn’t know it at the time.