When I was just starting out, I learned an important rule in rapid trauma assessment at the bedside of a youngish, 20-something boy, all tattoos and pervasive armpit stink. The rule was “3 F U’s and you’re down.”
Dude had flown through his car’s windshield, owing to his lack of a seat belt, during sudden deceleration caused by striking a maple tree, according to the medic’s report.
Picture the scene: A scrawny guy in a mustard-yellow shirt, a matching mustardy tie, and a velour/soft-suede jacket, kind of retro-‘70s, tacky cool, but on the other hand the look may just as well have resulted from a lack of funds. The face, neck, and hands had a cherry-pink ruddiness, which, after the medic’s thick scissors chewed through the yellow shirt and jacket, was in stark contrast to his pallid, white, hairless and muscle-less chest. His torso flopped up and down like a fish, but his arms and legs were pinned down by the brown-shirted rent-a-cops he was swearing and biting at. The security guys were just as pink-faced from wrestling him to the stretcher, four on one. You’d think they would have had an easier time because he was losing steam moment by moment. He had them all riled up, calling them pussies and faggots, and seemed to be enjoying himself. I had to give him some credit; he lasted a lot longer than most of the PCP assholes who come in Friday or Saturday nights.
After a full-out 15 minute rodeo, he was down, down good, but still spitting, screaming, and scamming. Even hogtied, with leather restraints around the wrists and ankles, he continued to look for some way to get out. “C’mon, doc, just a little Ativan to get me to chill. Please? I ain’t gonna fuck with these beef monkeys no more. Promise.” He laughed like a lunatic.
Now, the only decision that an ER doc ever really has to make is simple: in or out. Hospital bed or street. But, given the nature of the crash, high-speed and ejection through the windshield, we had a long way to go to assess the extent of his injuries. Based on the prizefight he had just put everyone through, orthopedic injuries were ruled out. Ditto serious chest-cage damage. That left belly and head injuries. His head was bleeding but not obviously dented. Although he was speaking in clear, understandable sentences, we did not know if he had — physically as opposed to chemically — damaged his brain in the crash. As a result of his continued attempts to ward off the security guys, his rigid abdominal wall made attempts to assess stomach wounds useless.
We called the trauma team. The dude had already vocalized his opinions on the cops, the security guards, me, and all of the nurses except for this one blondish nurse. He would have been a lot happier, clearly, to be left alone. However, he really hated the trauma surgeon when he showed up. The trauma surgeon was too old-school to know how to communicate with the dude, and started out on the wrong foot.
“Stay still, young man, I need to examine you.”
The kid’s eyes narrowed in contempt and he lurched against his restraints as if he had already forgotten he couldn’t take a swat at him. “Yo, doc, gett da fock away.”
“All right, that’s one,” said the surgeon. “Now stay still. I need to examine you.”
“What da fock you counting, asshole? Fukkkc yy-”
“That’s three. Tube him.”
And that was that. The blondish nurse the kid liked had already drawn up a paralytic and a vial of etomidate, a fast-acting sedative nicknamed “Milk of Amnesia,” and a respiratory therapist had our airway-tube cart standing by. In a minute and a half, the kid was down, anesthetized and paralyzed in a pharmaceutically controlled way, and I gently and carefully slipped a translucent tube through his vocal cords.
There’s a lengthy mnemonic we learn about the causes of an altered mental status. Appropriately, for this situation, it’s “TIPS from the DUDE”:
Tumor — Not likely under the circumstances.
Injury — Top of the charts.
Psych — Possibly part of the mix.
Seizure — If he had injured himself badly enough, he could have had a seizure, too.
Drugs — Coming in tonight at number two, just below Injury.
Uremia — Renal failure. Nope, not this guy.
DKA — Diabetic ketoacidoses. Not this either.
Etoh — Ethanol. Like drugs, this guy might have been drinking but it wasn’t on his breath.
This boils down to getting a few simple labs — an alcohol level, tox screen, chemistries — and a CAT scan, and when a patient won’t or can’t cooperate enough even for that, we have to take charge of the situation. And if taking charge means intubating a patient against their will, it’s for their own good. As turned out to be the case with this dude.
The CAT scan showed that when he landed against the maple tree, the impact was directly to his temple, and he sheared the middle meningeal artery lying directly underneath. The resultant arterial bleeding produced a potentially lethal injury known as an epidural hematoma. The PCP and ampthetamines coursing through his blood kept him up and agitated when he otherwise might have lapsed into a semi- or fully comatose state. No alcohol on board.
We promptly called a neurosurgeon who evacuated the intracranial blood, thus saving the dude’s life. Delayed treatment of an epidural hematoma leaves the kind of permanent brain damage that, at the ripe age of 20 or so, would have haunted and ultimately burdened his family and friends for decades to come.
There was another lesson I learned from this guy: Don’t judge a brain-injured dude by his cover. A couple of days later, when he woke up, alert and in full command of all his arms and legs, he turned out to be a pretty nice guy. He had apologized to the security guards, asked that we send his regrets to the cops, and voluntarily agreed to enter a drug treatment program. “I know I was being a severe asshole and all,” he said, “but how did you know I was so messed up?”
Easy. We’re doctors and we’re here to help. Folks don’t tell us to fuck off unless something is seriously wrong.