"Man is the only animal that blushes. Or needs to."-Mark Twain
"YES," THE TALK SHOW HOST INSISTED, "WOMEN AND MEN are different." Wow. After 13 years of marriage, that didn't come as a great revelation to me. You could also say children and adults differ: Children are small, brutally honest little folks who say what's on their mind without pretense and will candidly answer any questions about their bodies or health. Adults, on the other hand, are more self-conscious.
As a rule, female adult patients I've interviewed over the years tend to honestly describe symptoms without spinning the history or exam. Women tend to give honest answers-even for an embarrassing problem.
But I've noticed that men hate giving embarrassing information-even to their physicians. In fact, until former presidential candidate Bob Dole admitted on national television that he had erectile dysfunction, men wouldn't talk with their doctors about it. Can fear of embarrassment create problems in the prehospital environment? Let's examine this month's case to find out.
Scenario
One summer evening you're working with your partner on an ALS ambulance. It's a nice night in the big city-low humidity and quiet enough to enjoy the sights and sounds. Dispatch shakes you from your reverie: "Medic 43X, respond for an adult male complaining of severe back pain, 1445 William Drive, off O'Connor Ave. Time out is 2002."
As your partner drives to the scene, you wonder out loud where the BLS units are and why you're getting their assignment. On scene, you find Larry Zach, a 33-year-old police officer. Between paroxysms of pain, he tells you he was lifting a heavy object into his police car and suddenly experienced severe back pain. He says he's felt this way for about seven hours, has vomited and has severe nausea. His wife says he's been sweating profusely since he came home, but he doesn't have a fever.
His vital signs: Blood pressure 146/88, pulse 110 and respirations 28. You administer oxygen via non-rebreather mask, initiate cardiac monitoring and establish an IV of normal saline. The patient's ECG reveals sinus tachycardia at a rate of 110.
When you ask about the intensity of his problem, Zach tells you he's never felt worse pain, and it's unrelieved by position or rest. He then asks his wife to leave the room. When she leaves, he tells you the pain is moving from his back to his scrotum. He says he was too embarrassed to mention it before.
You pull on your gloves and examine his scrotum, finding it swollen and tender to the touch. You place the patient on your stairchair and gently apply ice packs around his scrotum in an attempt to ease his pain. During transport, the patient admits he should have called earlier to report the problem. Because of his embarrassment and because he didn't want anyone touching his private parts, he tolerated the pain as long as possible.
At the hospital, physicians place a doppler on the scrotum and confirm there's no blood supply to the swollen testicle. They hustle the victim into surgery, but they can't save the testicle.
Testicular torsion
The next week your medical director conducts a continuing medical education class for your department, and Zach's case comes up. The doctor informs you that testicular torsion is a legitimate emergency caused by the testicle twisting on the spermatic cord, interrupting its blood supply. It can be caused by trauma or occur spontaneously.
Testicular torsion most often occurs at age one or during puberty, but any male between the ages of five months and 41 years old is at risk. The presentation: Sudden and unrelenting scrotal pain that often radiates to the back, accompanied by swelling, nausea and vomiting.
The patient must be treated with cold application and rapid transport in the first two to six hours after torsion occurs to prevent tissue death and have any hope of salvaging the testicle. Other conditions suggested by this presentation include kidney stones, epididymitis or musculoskeletal pain.
Discussion
We've all seen patients in obvious discomfort trying to be stoic. Myocardial infarction patients are famous for this. I've found countless chest-pain patients taking multiple stomach meds or topical pain relievers when they should have called 9-1-1. This case is no different.
Patients with testicular pain are almost always embarrassed and may insist the pain is in their back. In this case, embarrassment cost the patient dearly. Please remember it's our job to ask tough questions and insist on honest, complete answers.
Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.
To subscribe to Jems for only $28.97 per year, click here.
