Corinn Cross, MD (Host): Welcome to Peds Cast, a podcast brought to you by Children's Hospital of Alabama. I'm your host, Dr. Cori Cross. Today we're talking about testicular torsion. Testicular torsion is a serious medical emergency that requires immediate surgical intervention, but unfortunately, at times it can be challenging to diagnose.

To address this issue, Children's of Alabama created a new model for diagnosing testicular torsion promptly allowing doctors to act quickly and hopefully reducing the long-term consequences of the torsion. Today we are joined by the group that created this model, Pediatric Intensivist, Dr. Nick Rockwell, and Advanced Nurse Educator, Autumn Layton, both of who work with the Children's of Alabama Pediatric Simulation Center, along with Dr. Carmen Tong, who is a Pediatric Urologist at Children's of Alabama. Dr. Tong, let's start with you. Can you tell us a little bit about testicular torsion? What is testicular torsion and why is it so difficult to diagnose?

Carmen Tong, D.O.: Yes. Testicular torsion is a medical emergency. There really are not a lot of medical emergencies in urology, but this is one of those where time is of the essence. It describes a phenomenon where the testicle is twisted to the point that blood flow is cut off from the testicle. And typically the patient experiences significant, sudden onset of pain, swelling in the scrotum, often accompanied by nausea and vomiting.

And there's a common phrase that we use with testicular torsion, and that's time is testicle. Pretty much every minute counts. When it comes to testicular torsion, we can reasonably salvage a torsion or a testicle within several hours, of the initial inciting event. But after about six to eight hours, that window quickly closes to the point where it's difficult to salvage that testicle.

So, time is of the essence when it comes to torsion, and it can be challenging to diagnose in teenagers, which is the most common demographic that it can happen to. Primarily because as you can imagine, teenage boys are not always forthcoming about pain in their scrotum, and they may interpret that pain actually as abdominal pain.

And so as you can imagine, abdominal pain has a wide differential diagnosis. And if the acuity or the suspicion is not high for testicular torsion, it certainly can be missed during the initial physical exam.

Host: That makes a lot of sense. Can you tell me a little bit then, how you address this problem? You created this model. Can you take me through how that started from the initial idea to the actual creation?

Carmen Tong, D.O.: Yeah, this really started a little bit as a passion project because of our really great relationship and collaboration with the pediatric ER at Children's of Alabama. We wanted to streamline an algorithm and a pathway and kind of make this as easy as possible for the Peds ER doctors who are seeing so many children.

And this usually happens in the middle of the night when a teenage boy comes in with abdominal pain. This should always be on the list of differential diagnosis. And so we really started this because of several events that have occurred where there were near misses. And so we thought, well, you know, how can we help educate the residents particularly, but also the providers and the APPs on how to recognize testicular torsion and how to recognize it quickly. And so we hope that creating a model and an education simulation scenario can really drive the message home.

Host: No that makes sense. Now, Nurse Layton, you were the one who actually created this model, is that correct?

Autumn Layton, MSN, RN: Yes. So Nick and I worked together to create the model, that we eventually would use on our

Host: Tell me a little bit about how you created it.

Autumn Layton, MSN, RN: Yeah, so Nick and I knew we needed different types of materials to create like a torsed testicle and a nontorsed testicle. So we started off with just bringing items from home and around the sim center. And we started out with like an Easter egg, a walnut, um, styrofoam ball, stress balls, and some Play-Doh.

Host: So a lot of arts and crafts.

Autumn Layton, MSN, RN: Lots of arts and crafts. We had to get really creative. And so we just made various models using those different types of materials. And we really called in Dr. Tong, to be our content expert to figure out like which materials, would give us the most realistic feel in response to a testicular exam. And so Carmen came over and tested all of them and was like no, this one doesn't really feel exactly like it would, or, you know, yes, this one does, but the size is not realistic.

Let's fix the size. There was a lot of trial and error, with figuring out which material and which size. And so once we got the material and the size down, we, Nick and I decided that the stress ball is what we would use, for the non torsed testicle. And then the styrofoam ball is what we used for the torsed testicle.

And then to give it more of a realistic feel where you wouldn't feel that kind of material up under it. We used Play-Doh, and wrapped it around the stress ball and around the styrofoam ball. And then used Saran Wrap around that so that it had more of a it felt like it could move. And we used some lubricant and then like a skin colored balloon that matched the color of our mannequin and put that in there. And it created a testicle.

Host: That's amazing. So, Dr. Rockwell, once this model was created, how did you start using it? And did you see an improvement in diagnosis?

Nicholas Rockwell, M.D.: Yeah, so once we felt good about our model and about the scenario that we created, we brought our pediatric residents over to our simulation center and we have periods of time where they already come to practice scenarios and taking care of patients as well as other procedures. And so we worked this into their curriculum to be able to allow them to be exposed to a common thing that they would find on, say, morning rounds when they're going to go see their patient.

We developed a scenario where they had a teenager that had got admitted overnight for abdominal pain. And they were coming in to see the patient the next morning with complaints of increasing pain, worsening pain, and worsening nausea, and were asked to see the patient in their exam. And through that they were able to get the feel of what a torsed testicle feels like in addition to learning about something called a twist score where we were able to use this validated score to help them, help them better estimate the likelihood of a torsion. And so as they worked through that, we looked at their ability to do the correct exam, initially, and then after we did the teaching, we allowed them to do exams on, we created, Autumn and I created three other sets of testicles that were not necessarily a torsed testicle to allow them to do their exam and evaluation on those and kind of come up with a diagnosis as well for those and kind of better, assess and evaluate that, which has been a really, a really neat process because I think even when I was a resident in pediatrics, I don't know that I ever got the experience of being able to examine and palpate a torsed testicle that was truly in complete torsion, which was really neat.

Host: And then what have you found to be the response of the residents to the training? I'm assuming it's been great. But what, what have you found?

Nicholas Rockwell, M.D.: Yeah, the residents have been really excited about this. I think we got a lot of really great questions that came out of it. Looking about how to best move forward in this, what does Carmen and her urology colleagues need from the residents when they're in the emergency department or when they're on the wards, on like the general pediatric service?

How do we best approach this? How do we speak the same language? And so for them, they've been really excited to not only get some education, but also begin to learn how to best engage our surgical colleagues so that we can in a timely and efficient manner, get the care that our patient needs to the bedside for them.

And so they've been really excited and really enjoy this quite a lot. And actually it's been something that as people have talked about it, we have worked to translate this down to some of our other colleagues in the emergency department with some of our advanced practitioners and some of our attendings down in the emergency department.

Host: Yeah, I would imagine that the training would be something that other departments would like as well. Probably even your community pediatricians would probably benefit from being able to remember how to do that or if they haven't seen it in a while, I could see this being something that would be very popular at a conference.

Do you have plans to publish a study about the model or have you worked with other institutions to help them make their own?

Nicholas Rockwell, M.D.: So yeah, I'll answer a little bit of that and Carmen can help answer some of that as well. But, the short answer is yes. We've worked on presenting some of it, and so actually Autumn and I were able to present at one of our international simulation conferences, this past January to show off our model and to, it's really to bring some of it out into light, so to speak, in the public, which has been really fun. We got some great feedback there. Had some folks that were really excited and interested and got some contact information to potentially touch base in the future and to plan possible collaboration going forward.

The other fun thing, and Carmen can kinda speak a little bit more about this is we are working through analyzing the data that we gathered as we did this teaching with our residents, looking at some of the information that we gathered, analyzing some of that with some of our statisticians and are working to generate manuscript and be able to try to publish this.

But Carmen, you can speak a little more about kind of what we're hoping to do for next steps with that.

Carmen Tong, D.O.: Yeah. We're hoping to also roll it out to sort of our Advanced Practice Providers so that, you know, everyone in the ED gets essentially a refresher training session on testicular torsion, but I think Nick left out the most important part of all of the culmination of this work is that they, he and Autumn came up with this brilliant title for this project.

Autumn Layton, MSN, RN: Can I share it with them Nick and Autumn?

Please do.

Carmen Tong, D.O.: This is also going to be the title of our manuscript, and it's called Balling on a Budget, which I think summarizes the cleverness of this idea and the effectiveness also, of course, I mean, jokes aside on balling, but, uh, I think that one of the most brilliant parts of, of this project and also, uh, credit to the Simulation Center and to Autumn and Nick, is that they're able to create this very cost effective model that can be easily replicated at many other institutions.

I think often when we think about simulation and education, one of the biggest barriers is cost and time. And so by creating just this model that is very realistic with essentially household items or things that you can find at an arts and craft store, any program, any institution, any ER hospital can easily implement something like this for their providers just to have a refresher training on what a testicular torsion feels like.

Host: I think that's great. As we wrap up, is there anything else you'd like to share with our listeners?

Nicholas Rockwell, M.D.: I think, for me, one of the things that I've really learned with all of this is, how do we engage folks that we don't always work with? Which I think has been a lot of fun. As I know in simulation, urology is not one of the classic subspecialties that we talk about with simulation, whether it's, usually anesthesia or emergency medicine or intensive care medicine.

Those are the arenas that people classically think of. But I think it's been something that for us, we've learned how to better collaborate and include folks that can bring a lot to the table. I think that's one of the things that we've loved working with Carmen. There's actually been a couple spinoff projects that have begun to develop as well.

But I think for me it's been a, something that really anybody can do, like Carmen said, and if you engage and utilize the resources there in your institution; you can begin to really improve the education that you're bringing your learners, which therefore hopefully can improve and improve the care that you're providing to your patients, which I think is the ultimate goal of all of us, is really to provide excellent quality care. But it's been a really fun learning opportunity for me and a new person to work with and collaborate with, which has been great.

Host: Yeah. No, it sounds like it was a ton of fun and it, and you're right, that is the gold standard, right? In a few words, Nurse Layton, would you give us a take home message for today?

Autumn Layton, MSN, RN: So I would just say that, what seems like might be something that can't be done in simulation, like Nick was saying, we've been able to collaborate with urology to create something that is helping residents. And it can be done cost effectively when you don't have necessarily a budget to work off; you get creative and you learn to work with what you have to create something that can be used for education and just knowing that the education goes beyond just the model. There's more that can be said and learned through the simulation scenario and in the debriefing.

Host: Thank you so much, and thank you all for joining us. This has been an educational discussion on such an important topic. If you'd like more information or to refer patients at Children's of Alabama, go to insidepeds.org. That's insidepeds.org. That concludes this episode of Children's of Alabama Peds Cast.

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I'm your host, Dr. Cori Cross,