Like any good detective, ER doctors
need to follow the evidence.
RUBY ROSE: Whether it's mysterious fragments
embedded in a wound.
I want to be like Nancy Drew.
Figure out what these are.
RUBY ROSE: A knee ravaged by an incurable disease.
Or an injury that seems to defy logic.
When we have questions--
Your answers--
RUBY ROSE: --just might save you--
--From an absolute nightmare.
[music playing]
First impressions in the ER can be deceiving,
whether it's someone who looks perfectly fine that's dealing
with a potentially life-threatening problem
or new information that sends us back to the drawing
board for a treatment plan.
That's why we ask so many questions about your ailment
and medical history, so we can get to the root of the problem
faster.
So let's talk about toys.
Today's toys are so freaking cute.
You just want to eat them up.
And for four-year-old Mavis at our Killeen facility,
that's exactly what she did.
And I need to get the scoop.
RUBY ROSE: Researchers have found that over the last 20
years, foreign body ingestion in children have actually doubled.
Most of these objects are harmless.
80% of them will just pass right through you.
But there are some things that kids swallow
that can be really dangerous.
Button batteries, for instance.
You know, the ones that are shaped like a coin?
If they get stuck inside, they can burn through tissue in just
two hours, which can be fatal.
If a child swallows more than one magnet,
they can cause serious damage to the stomach and intestines.
Basically, the magnetism pulls them together inside you,
messing with blood flow and possibly
creating puncture wounds.
So knowing exactly what your kid just swallowed
is important for us at the ER.
RUBY ROSE: I'm happy Mavis is moving and talking
and breathing so well.
If she did swallow something, it's not
currently causing a problem.
But you cannot be too careful when it comes to a potential
obstruction of the airway.
I have to find out if there's something in there.
So for Mavis, I want to make sure
that the foreign body isn't in her trachea or windpipe.
My first step is to put in an X-ray.
If the toy is radio opaque, we'll see it on the X-ray.
You can't judge a book by its cover,
know where a swallowed doll went without an X-ray,
and you can't judge a wound by its size.
At our South Austin location, 32-year-old Bailey sustained
what looks like a small injury.
It's only about a quarter of an inch,
but it's hiding a mystery.
Dr. Steven Elsbecker is already extracting
a bit of unidentified debris that was lodged inside.
And now, the question becomes, what other secrets
could this wound be hiding?
[music playing]
So basically the spring came loose,
snapped back, and hit her in the leg.
There was some debris in the wound itself.
And the injury happened so quickly
that she's not quite sure where it came from
or whether it was from the environment
or a piece of her own bone.
So there's already a little mystery building up with what
that debris might have been.
RUBY ROSE: Behind every ER doctor is a true detective.
And when Dr. Elsbecker is not tearing up
the streets of Austin on his beloved road bike,
he's glad to put his Sherlock Holmes
hat on in the name of medicine.
You see, when a good mystery hits the ER, everyone has
an opinion, including the Watson in this case, Townesend,
the radiology technologist.
Inspecting the wound, we pulled some fragments which,
to me, I thought it was bone.
But the person most interested in what came out of Bailey's
leg is, well, Bailey.
RUBY ROSE: While Doctor Elsbecker isn't exactly
sure what the foreign body is, he does
have an idea what it isn't.
So it seems like that spring carried something
into the wound, and then a little bit of a mystery
as far as what that is and how the heck that spring
carried it into your leg.
So even if that is just debris from the outside environment,
that was forceful enough to cause the wound
and embed the debris in her skin.
So we're going to get an X-ray.
That X-ray might show extra debris
and if there is, where it is.
All right.
Let's take a look at that leg.
The worst case scenario if we don't do our due diligence
and leave something behind is it could get really infected.
If that were the case, she could require additional treatment
in the ER or an operative intervention
to remove whatever was left behind.
RUBY ROSE: Ultimately, when a patient has a concern,
we have to take it seriously.
At SignatureCare Emergency Center in Austin, Texas,
our resident Sherlock Holmes, Dr. Steven Elsbecker
has pulled some mystery shards out of Bailey's leg,
and there could be more.
The X-ray might show us where that
debris or those extra bits are.
So Dr. Elsbecker ordered an X-ray to see if there are more
unidentified objects or even bone
fragments that broke off when her
leg was hit by an attic door.
And the results are in.
So you have tibia, the fibula.
The impact was mid-shaft.
And so what we're looking for is possible fracture,
possible foreign body.
From the looks of it, it looks clear.
The bone looks fine.
RUBY ROSE: With no more debris found in the wound,
Dr. Elsbecker is now confident he can repair the injury
without complications.
There's a little pinch and a little burn
with this medication, OK? - OK.
Just do your best not to kick me in the face.
After the wound is cleaned, the last step is closure.
RUBY ROSE: We've seen some pretty
wicked lacerations in the ER.
Woo.
RUBY ROSE: Some patients are intrigued
by seeing inside their body.
Others refuse to even look.
And sometimes just a small glance
at that 1/4-inch cut makes the patient almost pass out.
RUBY ROSE: It's not unusual for a patient to get
dizzy during a procedure.
The cause can be something as simple as low blood sugar.
RUBY ROSE: We give patients juice
because it has simple sugars that are absorbed quickly
to bring their blood sugar up.
So what was in the wound is still a little bit unclear.
But any time something with that velocity hits the bone,
it can cause a bony injury, whether it's
a fracture, a chip off the bone, or a contusion
to the bone itself.
The good news is that she's on the path to healing.
[music playing]
Back at our location in Killeen,
our little doll swallower, Mavis, is getting chest X-rays.
Despite the fact that she's not showing any real symptoms--
--We still need to be careful that the doll was not aspirated
or sucked down the windpipe.
And if it's stuck in her esophagus, you know,
the food tube, a toy can create tears in the tissue.
RUBY ROSE: For my next test, I need to evaluate
Mavis' swallow function.
And this candy seems like the best way in.
RUBY ROSE: I didn't see anything that
looked like a doll-sized foreign object in the X-ray,
but one of our radiologists needs to weigh in.
Radiologists specialize in diagnosing ailments
with medical imaging technology, like X-rays
MRIs, and ultrasounds.
They are specifically trained to interpret
those diagnostic images down to the pixel.
They will recommend treatment options and additional tests,
and sometimes they see what we don't.
I wish I could send all my patients
home skipping like Mavis.
But sometimes, even walking can be a challenge.
The average person walks about 110,000
miles in their lifetime.
That's like circling the Earth four times.
But at our Midland location, Josh, from Stanton, Texas,
has sustained a unique injury to his foot
while on the job that's not only going to affect his daily step
count, it could have a devastating effect on his life
forever.
Well I have concrete in this one.
They cleaned this one out a little bit.
It was covered in concrete.
I've got concrete that goes through these right
here, right up in here, and then in these two big ones
right here.
There's concrete splattered in them.
And the first question we had, obviously,
is how did Josh get hardened concrete inside
of his right foot?
Two days ago, while I was at work I was cleaning
out a 18-wheeler trailer.
It had dried concrete in it and liquid that
was in the bottom of the tank.
I was in the water for about 10, 15 minutes
trying to clean the concrete out,
hitting it with jackhammers, stuff like that.
And then I just started noticing my foot
started hurting real bad.
So when I went to go pull my foot out of the water,
I actually just pulled the top part of my boot
without the sole out of the liquid in the tank.
What I think was mixed with it would be acid or something
caustic, like a dissolvent.
Concrete got up into my shoe and, I guess,
collected on the already wounded spot
that I had that had been burned away.
It actually literally dried into the wounds on my feet.
[music playing]
RUBY ROSE: At the ER in Midland, Texas,
Josh has received multiple chemical burns
from a caustic liquid while cleaning
out the tank of an 18-wheeler.
And it's burned holes in his foot.
Add to that, the wounds have filled with hardened cement,
a combination that Dr. Mark Mauldin
has never seen before in his 34 years of practicing medicine.
I've certainly seen chemical burns before,
not where the concrete was still kind of in the wound,
almost burned into the top of the foot.
This was an unusual presentation.
RUBY ROSE: We see chemical burns pretty often in the ER
as a result of contact with drain cleaners, bleach,
and even acid.
Compared to receiving thermal burns,
you know, like the ones from fire or something hot,
amputation is three times more likely with a chemical burn.
So chemical burns are bad enough without being set in concrete.
Well right now, it's definitely infected.
It developed a little cellulitis.
And you add some swelling to the top of the foot.
It was quite painful.
We put an IV in.
We checked some labs, gave him some antibiotics,
and then gave him pain medicine through the IV.
RUBY ROSE: As the first line of defense
against worsening infection, Dr. Mauldin wants the wound
to be properly cleaned.
But with an injury of this magnitude,
Josh will need to be taken to a burn center for specialized
treatment as soon as possible.
OK.
The concern is that if the foreign body, the concrete,
the debris from the job site doesn't get cleaned off,
then the infection will just get worse.
And then he could end up, ultimately,
perhaps lose his foot.
MARK MAULDIN: We gave him pain medicine
through the IV in hopes that it would be enough to allow us
to debride the wound here in the emergency department,
but he just did not tolerate it.
So he needs to go to a burn center, where they can put him
to sleep and and then adequately clean it out and check
the depth of the burn to see if maybe he has
some third-degree burns also.
RUBY ROSE: While a first-degree burn only damages
the outer layer of skin or epidermis,
a third-degree burn destroys both the outer layer and
the dermis, the layer beneath.
All righty.
Sounds good.
Well, thank you, sir.
All right.
You take care.
As Josh heads immediately to a burn center for more
comprehensive treatment, another painful case has arrived
at our Killeen location.
I'm treating an older gentleman that has sustained a laceration
right on the kisser.
I was parked in the academy parking lot.
I come around in front of the car, and I just fell.
And next thing I know, I'm down on my face,
and I feel the blood dripping out of my lip.
Yeah.
The hunk of skin that's hanging is just painting a lip.
RUBY ROSE: In addition to his lacerated lip,
Noel used his hands to break his fall.
I can see a little bit of bruising there.
Does that hurt when I press on it, though?
And he's experiencing some swelling
and tenderness in his wrists.
So after I repair his lip, we'll need X-rays to make
sure he didn't break any bones.
RUBY ROSE: The lips have over a million nerve endings
and are easily one of the most sensitive parts of the body.
This is why babies put absolutely
everything in their mouth.
The lips provide a lot more information
than the other senses.
Even the fingertips are hundreds times
less sensitive than the lips.
So lip injuries can easily dial the pain up to 11.
So he had a pretty good laceration to his lip.
And lip lacerations can be pretty tricky
because when they're with the Vermillion border,
you have to line it up really well.
Is that OK like that?
Yeah.
OK, good.
You might feel some pulling.
OK.
I think he did really well.
I think it came together very nicely, so yeah.
So it's good.
RUBY ROSE: While the lip repair went well,
a funny thing happened before Noel went to get X-rays.
Noel up and disappeared.
You never know what mystery will hit the ER.
Because now it's the case of the vanishing patient.
[music playing]
RUBY ROSE: At the ER in Killeen, Texas,
after repairing his lacerated lip-- just a couple more,
and then we're almost done-- my patient Noel pulled a Houdini.
Uh-oh.
Where'd he go?
And disappeared before getting his wrist X-rayed.
Elopement is when a patient leaves a health care facility
unnoticed and unsupervised.
It happens in ERs, hospitals, and nursing homes
all over the US.
For patients with decreased mental capacity
due to medication, mental health issues,
or even traumatic injury, these people
are at risk for serious harm.
And there have been many cases that
have even resulted in death.
And Noel's whereabouts has us scratching our heads.
It happens.
NURSE 1: He's right here.
Oh, there he is.
There you are.
Phew, mystery solved.
NURSE 1: We thought you ran out on us.
I know.
Here, come on in.
Now we can take the X-rays to make sure Noel didn't fracture
any of the bones in his wrist.
He doesn't look like he has any fracture to the carpal bones.
His metacarpal bones and his radial bone
looks great, actually.
So he didn't break anything.
And the only thing he did was really cut up his lip,
and that was a good repair.
And I think it came together really nicely.
Three, four, five, six, seven, eight.
We did eight.
Eight.
We definitely did a lot.
It should heal just fine.
You might be a little sore tomorrow, though.
Yeah, that's what I was thinking.
On the face you have about 24 hours
to come in and get it repaired because there's so much
vasculature above the neck.
But some of these, they develop infections and abscesses.
And so if you wait too long, the complication rate's
a lot higher.
Well, it was so nice taking care of you.
And we'll get your paperwork--
I know.
And I hope I don't see you again in the emergency room.
But you know.
You're welcome.
OK.
Take care.
A lot of times we see patients that
are dealing with chronic issues that
manifest into painful emergencies
time and time again.
Like I said before, getting a detailed medical history
from our patients can kick start our treatment plan.
At our location in Killeen, Texas, a woman's painful battle
with lupus, a chronic inflammatory disease
where the immune system attacks the body,
has brought her to the ER.
And Doctor Mike Hasegawa will be fighting
it off on the front lines.
And I swear, the guy's always draining fluid.
Mary, from Copperas Cove, Texas has come in with a painfully
swollen knee.
RUBY ROSE: Lupus is a devious disease
that affects people of all ages, from newborns to grandmas.
It's kind of like your body is betraying you.
Your own immune system can't differentiate
between normal healthy cells or the bad stuff,
like viruses and bacteria.
So it attacks everything, from the joints and skin
to major organs, like the kidneys, heart,
lungs, and even the blood.
Having some fluid in there is one of the parts of it.
When the joint fills with fluid,
the pressure that builds on the nerves in the area
can become excruciatingly painful.
If this swelling and inflammation
sticks around for long enough, it can lead to muscle atrophy.
Essentially, the muscles will waste away.
About 25% of adults in the US have
an extreme fear of needles.
So if you're one of those people,
now's the time to look away.
RUBY ROSE: At SignatureCare Emergency Center in Killeen,
Texas, Doctor Mike Hasegawa is treating a patient who's
knee is painfully swollen as a result of her battle
with lupus, an inflammatory disease that
can wreak havoc on the joints.
Dr. Hasegawa has to reduce the edema, or swelling,
caused by the excess fluid.
MIKE HASEGAWA: OK.
1, 2, 3, poke.
NURSE 2: Oh, here it comes.
MARY: Oh, wow.
MIKE HASEGAWA: Yeah.
So overall, I like the color that's coming out of it.
OK?
MARY: OK.
MIKE HASEGAWA: This is kind of normal, not infected color.
MARY: Cool.
I like that.
Yeah, exactly.
I've had some knee taps where I'm
basically pulling out pure pus.
That's an extreme bad infection.
Hers looked pretty darn clear.
It was clear, straw-colored, yellow.
And that's pretty much a standard, healthy fluid.
MARY: That's a lot of fluid.
MIKE HASEGAWA: I can feel your knee shrinking.
MARY: Oh, yeah.
NURSE 2: Do you need another--
MIKE HASEGAWA: I need another one.
Yeah.
MARY: Geez.
MIKE HASEGAWA: Round two.
MIKE HASEGAWA: For this, we're going
to send to the laboratory.
While the fluid does look healthy,
it's always a good idea to get it analyzed at the lab
to confirm that the joint is not infected.
OK.
So let's see.
Officially that's like 30 cc's that came out of you.
MARY: Wow.
Yeah, right?
RUBY ROSE: 30 cc's, or cubic centimeters of fluid,
is only about an ounce, so it won't quite fill a shot glass.
But when that much excess fluid is in your joint,
just ask Mary.
It can be extremely painful.
Try to bend your knee.
I bet you feel a little bit better with it.
Look it there.
It even looks different.
Yeah, right?
That's a lot better.
Look at my knee now.
They almost look the same.
Yeah, that's a lot of fluid.
That is a lot. MARY: [inaudible].
Yeah.
So the worst case is really in terms of an infection.
Now if there is an infection in that joint,
it's really going to destroy that socket.
It's called septic arthritis.
And the treatment is almost always surgical.
Now if there is any glimpse of an infection there,
we'll catch it on the sample that we sent to the laboratory.
Bye, take care.
RUBY ROSE: Another satisfied customer walking out of the ER
on their own.
[music playing]
But for a few of the patients we saw, their road to recovery
is not yet complete.
Remember Josh, who sustained chemical burns?
Once he left the ER, he had to undergo surgery
to remove the concrete that hardened inside of his foot.
Well, I left signature care, escorted
out by ambulance to UMC Hospital to their burn unit.
I stayed there for a few days.
They skin grafted to cut the concrete out of it.
They used a laser to do it, and it cuts
just little layers of skin.
First, the specialist used a surgical laser
to remove the embedded cement and burnt tissue.
Then, artificial skin grafts were
placed over the surgical sites.
This artificial skin is made of collagen,
an essential protein found in the body that
helps new skin cells grow back.
The skin graft was pulling the minute pieces
of concrete, the rock, the hardened pieces
actually out of the skin.
And they did three of them consecutively on my foot
and then did scrubbing to clean the rest of it out.
I found out it was a third-degree burn on my foot
and did muscle and nerve damage on it.
So some of my nerves and my toes want to try to move my toes
and my whole entire foot like literally
locks up and everything.
The spots that are wide open right now,
that are still covered with my falsified skin,
are the spots where I have the nerve
and muscle damage in my foot.
[music playing]
The white stuff on here is a ointment
that I have to put on it to keep it moist at all times.
Because if I let it dry out, the skin, nerves, and muscles
will not heal right.
These white spots right here are third-degree burns through
all three layers of my skin.
If you can't tell, this black in the middle of these
are actually my muscle, nerves, and tendons that it ate into.
Been healing for about three weeks now.
RUBY ROSE: He still has a long road to recovery.
Josh avoided the worst possible outcome because he could
have easily lost his foot.
They told me I should be fully healed
up in three to six months.
RUBY ROSE: Now, there's another familiar patient back
at our facility in Killeen.
It's Mavis, the four-year-old with an appetite for dolls.
RUBY ROSE: And as she comes in, we're
already slammed with patients.
[music playing]
RUBY ROSE: At SignatureCare in Killeen,
it's the anticipated return of Mavis for her follow-up visit.
My colleague, Dr. Elsbecker, will be the lucky one
to get the Mavis experience because I'm already
bone deep in a wound sustained from a run-in
with a glass coffee table.
When I looked at my finger I was like, oh, oh.
Yeah, it's pretty deep.
I don't want my finger falling off.
Yeah.
RUBY ROSE: So unfortunately, I'm not going to be able to see
Mavis for her follow-up.
Dr. Mike Hasegawa is also busy.
And yeah, you guessed it.
RUBY ROSE: Yet again, Dr. Mike Hasegawa
is draining fluid and blood from a patient,
after he sustained an injury to his ear
while doing some Brazilian jiu jitsu.
MIKE HASEGAWA: It's an injury to the cartilage.
As part of the healing process, it bleeds everywhere.
So we're trying to drain that blood out of there.
See?
He loves it.
So for little Mavis, our resident Sherlock Holmes
is now on the case, Dr. Steven Elsbecker.
And for him, it'll be elementary.
So today Mavis came in for follow
up of a possible aspirated foreign body
or ingested foreign body.
And that's something that either went down into the lungs
or down into the GI tract.
We're going to let the doctor see you real quick,
and then we can go get your snacks, OK?
OK.
I'll come get you, OK?
OK.
I'll be right back.
OK.
Take a really deep breath.
Good.
Again.
Last time.
RUBY ROSE: If she did aspirate little dolly,
she most likely would have symptoms--
Choking, coughing, difficulty breathing.
And if it was stuck in her esophagus or bowels,
it's the same story.
She might be vomiting, drooling, develop a fever,
or have abdominal pain.
Look at that.
So since her first visit she's been doing really well,
and she hasn't had any symptoms.
Our suspicion for anything bad is a lot lower now that we've
had the luxury of time.
It's looking good for Mavis.
But the real proof will be in the X-rays.
So Dr. Rose, who saw the patient initially,
wanted her to come back for repeat
imaging, which we did today.
And fortunately, it didn't show anything in the lungs
or in the gut.
So we had quite a long talk with mom today
about what to expect going forward.
We didn't see anything obvious on X-ray, which doesn't
mean there's nothing there.
It just means it's unlikely that there's something there.
We did talk about what to expect if and when it passes.
But the good news is she'll be able to go home
today and follow up with her pediatrician,
and she should do really well.
RUBY ROSE: And just like that, little Mavis
heads back to resume life as a boisterous four-year-old.