Tales from the Trenches: A True Urologic Emergency

Luis Molinero Martnez/123RF.com

“Urology, stat to the ER.”

While I had had my share of overnight call as a trauma intern a few months back, as a newly minted urology resident, these were the last words I expected - or wanted - to hear blaring from the overhead speakers as I rounded. It was late afternoon, the other urology residents were finishing up OR cases or clinic, and I was alone.

For several moments, I froze in shock. However, my astute cat-like reflexes - fine-tuned over a year of surgical internship - soon sprang into action. As I sprinted down the two flights of stairs to the ER, I had no idea what to expect: what could inspire a stat overhead urology page? Testicular pain or infected, obstructed ureteral stones, the common urological emergencies, could easily be handled via a discreet “beep-beep-beep” to my pager. What was so urgent that the ER residents couldn’t waste time to check the on-call sheet to determine which of the urology residents were on call before taking such resolute action?

As a second-year resident with only a few weeks of urology experience, I was used to introducing myself whenever entering the ER, hoping to summon a façade of expertise and bravado that was not entirely familiar to me. However, on this occasion, as soon as I passed through the double doors of the ER, I was summoned urgently to the first trauma bays by a frantic looking ER attending. I walked by a very uncomfortable looking police officer standing just outside before entering the trauma bay to find the entire trauma team assembled next to the patient.

A young man, similar to me in age, lay on the cot, looking much better than the previous inhabitants that I had taken care of a few short weeks ago. He had no immediately apparent lacerations or bruises, no C-collar around his neck and had even been spared the trauma shears fashion makeover that was a hallmark of entry into the first trauma bay. As I approached, ER attending pulled me to the side and whispering urgently, “Its amputated, he amputated it!” As he pointed, none too discreetly, to the patient's midsection, covered with a standard issued hospital gown lightly stained with blood, understanding slowly dawned on me.

“It” meant the penis, and suddenly as a newly minted “urologist,” I was the expert in the room regarding the management of the amputated phallus. I had just done one or two distal hypospadias cases, no adult penile cases, and was not aware that there was a lecture on penile amputation protocol.

My veneer of bravado quickly crumbled as I listened to the details of the patient’s presenting complaint. By report, the patient had amputated his phallus in his apartment in a premeditated fashion. He had prefilled a Ziploc with ice and placed the severed part of himself there as he called the Emergency medical services. Once in the ER, an ingenious physician had placed a tourniquet around the base of the penis and cleaned the phallus, wrapping it before putting it on ice.

The patient was pale, due to the blood loss, but was coherent and awake. His vitals were stable, and he told me a similar version of what I had heard from the ER attending. On physical examination, he had made a clean cut (with a Butcher's knife), and the dorsal vein, urethra, and the corpora were level and appeared pink and healthy. I excused myself and ran all the way to the OR, where my chief was in the midst of a cystectomy - a case that we rarely interrupted. Donning my surgical bonnet and mask, I breathlessly relayed the history to him.

Unheard of for such a coveted case, he broke scrub- with the attending’s blessing and a promise for full details upon return and accompanied me to the ER. Things quickly began moving. The patient had already been typed and crossed and was alert and competent to give his consent for immediate surgery. By this time, our reconstructive specialist had joined us, and he elicited the aid of the plastic surgery team to reconstruct the vascular structures of the penis. The team secured an operating room, and the patient was whisked away in the race to save his penis.

As the junior resident, I was not able to scrub the case, but luckily, the floor activity calmed down enough that I could watch over my chief resident's shoulder as the surgery began. The requisite skill and surgical planning that went into the execution were both fascinating and inspiring, and I watched in rapture. The surgical and plastics team successfully re-attached the penis, and the patient recovered well, spending a few days on the urology service with plastic surgery following closely. He was eventually transferred to the psychiatry ward (appropriately) and left the hospital after a few weeks. In follow up, his urethra healed well, and he was able to urinate on his own and eventually had a spontaneous return of erections.

As a new resident, I was fortunate enough to see the collaboration of plastic surgery, urology, and eventually psychiatry work together so beautifully. It was inspiring to see the quickly coordinated care in which our health system is capable and can excel so early in my career.

Even though I initially went into urology thinking I would not be paged overhead and true emergencies would be few and far between, any time a hospital overhead page starts with "stat," my ears perk up just a little, in case a true urological emergency is underway!