John Monaco, M.D.
In pediatric hospital medicine, and even in most office practices, we spend the majority of our time dealing with illnesses and their prevention. There are times, during certain seasons, it seems as if infectious diseases ‚ and all that kids are exposed to ‚ are all we see. Easily forgotten sometimes is the fact that accidents and injuries are a major cause of morbidity and mortality in kids and adolescents. I was reminded of this reality one particularly busy day on the pediatric service when I was introduced to Julia.
Julia was in the emergency room when I met her and her parents. The neurosurgeon had called me and asked that I admit her to my service in preparation for reparative surgery set for the following morning. "She has a fractured spine," was all I was told, leaving my imagination to run wild with the possible scope of this particular injury.
Whenever I hear of spinal injuries, my mind immediately returns to my critical care training, where it was the responsibility of our team to care for adults and children paralyzed with spinal cord injuries. Their cases were invariably tragic and their outlooks, at least initially, grim. I was so overwhelmed by the plight of these previously healthy individuals ‚ mostly men ‚ left completely incapacitated by this injury that I made it the focus of my research during training.
I was fortunate, later in life, to become friends with a quadriplegic who taught me the absolute strength of the human spirit and the ability to overcome all odds through the power of will and perseverance. He became a successful and influential man only after his spinal cord injury. He was one of my heroes, and remains so over a year after his passing. It was these thoughts that swam around in my head when I met Julia.
As I walked into the examining room, I could sense my nervousness. I hoped Julia and her family could not! She was, from that very first moment, a polite and pleasant young lady of 17 years, who was neither an athlete nor the most popular girl at her school. She did, however, possess a certain kind-heartedness and emotional confidence that came through immediately. Why is it always the nice ones who get these kind of injuries, I thought to myself after meeting her.
I was happy to find, when examining her chart earlier, that her injury was only to the bones of her lumbar spine; in fact, two of them were broken into several pieces, so-called burst fractures. X-rays, CT scans and MRIs did not demonstrate any injury to the spinal cord itself. And the neurosurgeon's initial neurologic exam did not demonstrate any deficits that might indicate a cord lesion. Thank goodness, I thought. "Fix the bones and she'll be fine," I muttered to myself.
I knew this wasn't the end of the story, however. Like all injuries, there would be swelling for a couple of days, only in this case we were dealing with the spinal cord and the tissues surrounding it. If her cord swelled too much, pressure on the nerves might result, which could lead to nerve injury and neurologic deficits. It was for this reason that she would need to be in traction, with absolute bed rest, until her surgery to repair the fractures.
It was when we finally got around to discussing Julia's mechanism of injury (the method by which she became injured) that I was reminded of the fragility of adolescent health contrasted with the infallibility of the adolescent psyche. Adolescents feel nothing can ever go wrong with them, yet they are exposed to so much that can hurt them. This mindset is the fundamental paradox of the teenager facing the dangers of the outside world, a fact that keeps me awake many nights thinking about our own two teens!
In this regard, Julia's case was classic. She had awakened in her upstairs bedroom in the middle of the night needing to use the bathroom, which was across the hall. To cross the hall, she needed to walk past the stairway. In the darkness, she misjudged her footing, stumbled on the top step and fell the rest of the way down the stairs, essentially shattering two vertebra. She was lucky she hadn't been injured far more seriously.
When I asked her why she hadn't turned on the hallway light, she responded by saying that she had been afraid that she might wake up someone. I suggested that her parents might have preferred being awakened by a hall light rather than by horrible sound of their daughter tumbling down the stairs. She shrugged her shoulders and said, "I guess..." I wondered then if she knew how truly lucky she was. I, of course, reminded her of this every day that she was in the hospital.
Luckily, Julia recovered well. The first two nights were rough, however. Her asthma acted up, no doubt brought on by the stress of the injury, and she did develop mild pulmonary edema. At one point on the morning of the second day, she became concerned that one of her toes felt "numb." Thankfully, this sensation resolved after her spine was repaired.
Two weeks after her fall, Julia was ready to leave the hospital. She had received initial physical therapy and was regaining strength rapidly. She had become accustomed to the stainless steel rods that had been placed in her back for stabilization and she had even begun to walk.
Julia had also become accustomed to my teasing and continual references to her astounding luck. Much as my own children do when I overstress a point, she grew weary of my admonitions. But on the day she was discharged, after we said our good byes and she was being rolled down the hall to the exit, she suddenly stopped, turned in my direction and said, "Next time I'll remember to turn on the light!"
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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