Friday, October 10, 2008

Survival of the Fittest?

There is an old saying in medicine” “Your ability to survive major trauma is inversely proportional to your value to society.” Way too many times I have seem two ambulances arrive from the same scene—one with a dead 17-year-old high school Valedictorian (with a scholarship to Notre Dame) and the other with a combative 27-year-old plumber’s helper with 3 DUI convictions and a BAC of 0.280. His only injury—broken teeth from hitting the dashboard unrestrained (I have learned that unrestrained drunks often consider the dashboard a favorite food group). The old adage is true.

Several years ago, while working in a community hospital, one of the local cops walks in and says, “The ambulance is on the way in with a guy who was shot in the head—probably a drug deal gone bad.” We headed to the trauma room and waited. In comes one of our best EMS crews with a 26-year-old guy, strapped to a backboard, with an entrance wound on the right temple and an exit wound on the left temple. My visual assessment started to tell me that his future was going to be limited to being an organ donor or a politician. A quick mental status exam revealed him to be alert, but certainly intoxicated. I looked in his eyes and ears and he tracked what I was doing with his eyes. Then, I said to the nurses, “I know what is going on here. I have seen this before. It must have been a low-energy round and it hit the skull, was deflected around the head under the galea, and exited on the other side.” I had really seen that many years ago. So, to prove my theory I had Mongo, the x-ray tech (a big hulking man with a great sense of humor), get an AP and lateral skull film (I know, skull x-rays are taboo—but this was a few years ago and I was trying to see if there was intracranial trauma before I ordered a CT). Much to my surprise there were bullet and bone fragments as well as free air in the cranial vault. Holy shit! This guy appeared totally neurologically intact (but, I would not want him balancing a check book). So the work-up began.

The shooting victim had significant intracranial trauma. The hospital did not have neurosurgical care so we had to send him to the University hospital (people who get shot in the head NEVER have health care insurance. I understand the United States Association of Dope Sellers [USADS] has been negotiating with Humana for years to no avail). The transfer was arranged and we were waiting on an ambulance. I am sitting at the desk finishing a chart. I look up and there is the shooting victim (a gauze turban on his noggin) watching me. He politely says, “I got a headache.” I looked at him dumbfounded. I said, “Man, you’ve been shot in the head.” He replied, “Is that bad.” I said, “Yes. Real bad.” He says, “Oh. OK. Can I have a Tylenol.” I got up and gave him some Tylenol.

The ambulance came and off he went to University hospital so that some neurosurgical resident can improve his skills (collateral surgical damage in this case would be impossible). Later, as the sun was coming up, the nurses called me to the phone. On the phone was a second-year neurosurgical resident (with an Ivy League accent) who seemed totally flabbergasted. I asked, “What did you find about our friend.” Much to my surprise, he said, “Nothing.” I said, “Are you sure we’re talking about the same patient?” Something is wrong here. The CT looked like somebody put a stick in his brain and twisted it around like a chimp probing an ant mound. The resident said, “No doctor. You don’t understand. This guy got mad and walked out of the pit—with an IV in his arm and wearing nothing put a hospital gown. We can’t find him and he has air in his brain.” What can you say to something like that? (Of course, putting a Foley in a patient is the best way I know of to tether a patient to the bed). I said, “I’ll let you know if he shows up here.” Believe it or not, he was never found and assumed to be alive (they kept an eye on the Medical Examiner’s Office for several weeks). But, I think I know where he is. He’s working for A.C.O.R.N. signing up voters.

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