How Works in Rural America’s Emergency Rooms
I was a family doctor in a ridiculously small town for a while. Let’s call the town Blue Sky, USA. Blue Sky was far away from any city. It’s people were fine, hard-working, and conservative- a lot like you might expect in any rural community town in America.
As a family doctor in a small town, I on call every night for patients, the hospital, and the ER. This wasn’t a big deal since I rarely had patients in the hospital and the ER usually took care of itself. My patients hardly ever called me after hours. Since they all had my personal cell phone number, they could call me whenever they wanted, and I always answered my phone, they avoided bothering me after-hours unless it was really important.
Blue Sky had a tiny “Critical Access” hospital. The Federal Government heavily subsidizes these tiny hospitals so that Americans in rural areas access essential healthcare. Our hospital had a small ER which was staffed by one nurse and one doctor. Since us private doctors didn’t have the time or energy to take care of our private practices and staff the ER, the hospital had to cover most of the shifts with out-of-town physicians. The only doctors that they could afford were residents[1] from regional teaching hospitals. These residents were training in specialties other than Emergency Medicine.
The apprentice doctors who worked in our ER couldn’t handle issues that were much more serious that what is seen in an urgent care. If ‘worse’ than that came in, I expected a call from them to get some advice or go in to the ER. Serious trauma rarely made it to our doorstep; a helicopter picked seriously injured people at the scene and took them directly to designated Trauma Center. [2]
On occasion, these inexperienced doctors could get in “over their head” easily. Sometimes they called me too early. Sometimes they were too slow to call. Obviously, they couldn’t know what they didn’t know. Fortunately, there was usually a ‘solid’ nurse on duty in the ER who could coach the young ER doctors. The nurses sometimes gave ‘gentle suggestions’ to the residents when the case was easy. If a resident clearly wasn’t able to handle a patient, the nurses usually called me before the resident did. In the latter circumstance, all that I needed to hear from the nurses were the words “I need you here.” Those words required no further explanation or clarification. That’s when I got to the ER as soon as possible.
Mayhem in Mayberry[3]
One Saturday night, about two a.m., I got a text message from the ER. By itself, the simple fact that is was a text and not a call was unusual- the ER always called rather than messaged. It was immediately clear why. The text read “GSW[4] to the head. We need you in the ER now. Vonda.” That was the ultimate call to action. I covered my pajamas with scrubs and got to the ER in fifteen minutes.
As I was pulling in, the parking lot was pandemonium. The patient’s and the shooter’s families were everywhere and in various states of hysteria, screaming into the night air and at each other. Fights had already broken out. All available law enforcement, local police, sheriff’s deputies, and even a State Trooper were there, struggling to keep the unhappy clans apart and away from ER. I needed to get to the patient, so I hurried my way through the bedlam.
I walked through the sliding glass doors at the ER entrance and went straight to the “Trauma Bay.” That is what we jokingly called the oversized room with three beds where we took care of the sickest patients. I walked in there and saw the victim lying on the bed in his ‘street clothes’ with a “4 by 4”[5] gauze on his forehead. The resident stood next to him. He turned to me, with terror in his eyes, and formally announced the obvious; “It looks like he’s been shot in the head.” Without pausing to take a breath, he then said; “Would you prefer to handle this one Dr. Fish?” It wasn’t really a question. There isn’t much role for a second year OB-GYN resident to play in the care of a man who has just been shot in the head. Fortunately for me, I had residency experience in some of the roughest of rough trauma centers. Plus, I had worked as an ER doctor for several years.
Here’s a little background information
An emergency room doctor must never assume that the obvious cause for a patient’s “altered mental status (AMS)”[6] is the only reason. Injured brain and intoxication are often present at the same time. Although the workup[7] for drunk people with head injuries is detailed, it’s less complicated if the injury is a GSW to the head. Of course, the evaluation begins with a head to toe exam to find other injuries. X-rays are done on anything that seems tender at the same time as blood tests. While this is being done, the goal is still to identify correctable brain injury as soon as possible. The crucial test a CT scan[8] of the head and that gets done as soon as possible. If all the above are OK (they usually aren’t), then the patient gets “parked” in the hallway and see if they sober up. That is reality.
Back to the case at hand (head)
I walked over to the patient, leaned over him, and said hello. He was a fifty-year-old man who we will call “Larry.” Larry had on blue jeans with a white T-shirt which had a few drops of blood on it. The smell of alcohol was obvious. Larry was looking around for something, shifting around uncomfortably in his ER bed, and making gestures with his arms and legs. All of this pretty much provided me with the neurologic exam. He was even muttering (semi-coherently) “Give me something for my headache!” I thought that at least he was alive enough to be in a bad mood. It’s a good habit to tell trauma patients exactly what you’re going to do with them, so they don’t feel even more vulnerable than they already do. The little things count, so I let Larry know that I was going to take off his bandage and look.
With the gauze removed, I saw what was obviously a single bullet’s entrance wound. I searched all over the rest of his head for the projectile’s exit wound. I couldn’t find one. I reasonably concluded that the bullet had to be in his brain somewhere. Continuing the theme of frequent communication with the patient, I said to Larry “my goodness you’ve been shot right in the noggin.” Slurring every word, Larry replied, “Shit, my wife just wouldn’t give me no Tylenol.”
Most patients with gunshot wounds to the head are usually at death’s door- barely breathing if at all and lacking any purposeful communication or movement. At least at first glance, that was not the picture with Larry. Without the bullet in the brain, one might have thought that Larry was just a drunk guy with a headache.
Gunshot wounds to the head are dreaded because the bullet often wipes out whole swathes of the brain even if it doesn’t kill the patient. Also, once the damage is done to the brain or spinal cord (central nervous system), the injured tissue doesn’t grow back. If there is anything that can be done to enhance this kind of victim’s chance of survival or meaningful recovery, it needs to be done quickly. That means fixing bleeding around and inside the brain does that does its own damage. Therefore, a patient with a GSW to the head who has a correctable condition must get to a neurosurgeon at a trauma center ASAP. The closest neurotrauma center for us was an hour away by helicopter (if there was even one available). I also had enough experience to know that no neurosurgeon was going to take another GSW to the head case on Saturday night if they could avoid it.
Neurosurgeons make most of their decisions to operate/not operate on head trauma based on CT scans. In the past, many small hospitals didn’t have integral CT scanners.[9] In those the early days, private companies towed mobile home-encapsulated CT scanners from one rural hospital to another for a few days a month. In Larry’s lucky case, a CT scanner happened to be parked outside our hospital and the technologist was sleeping right down the hall. While we waited for the scanner to get ‘warmed up’, I had a chance to figure some things out, do some documentation, and come up with a good plan for keeping Larry calm in the CT scanner.
This last issue was important. Drunk people with head injuries sometimes go nuts in the closed space, loud noise, and isolation of a slow-moving CT scanner (they were very slow back then). Panic in a patient with a brain injury is bad because even the slightest extra pressure inside the injured brain can tip the balance between fixable and not-even-worth-trying. Since all of this is true, and it’s a bad idea to sedate a brain-injured patient, the best way of calming a brain-injured patient is usually to talk to them and hold their hand.
Practical life in a house filled with passionate people
While we were waiting, the paramedics finally had a chance to give me their report and the background story. Here’s the summary of what had happened: There were three people directly involved. Larry, the husband, Wanda, the wife, and Wanda’s Mom (Ms. Felicia). They lived together at Ms. Felicia ’s house for the last fifteen years. Larry was a skilled mechanic and made good money. Wanda was also a hard worker at the local nursing home. Ms. Felicia’s informal but full-time occupation was to ‘supervise’ the neighborhood’s ‘goings-on’ from the porch. Larry and Wanda, in their late forties now, were not legally married, but had been together for so long they might as well have been. Their relationship was not always blissful. The complexities swirling inside their house (and sometimes out on their front lawn) were well-known in the community and the police. In other words, this wasn’t the first time that Larry had been to the ER after a fight with Wanda.
Larry was a charismatic, easy-going, and affectionate man. Even though he was never in ‘good standing’ with Ms. Felicia, Wanda loved him very much as did many other women. The latter fact was the source of much friction in the household. Specifically, some nights Larry relished in Jim Beam scotch,[10] and on the weekends, he mixed whiskey with attention from his numerous female “admirers.” Sometimes, after wandering off to who knows where on a Friday or Saturday night, Larry carried with home with him both the scent of alcohol and perfume.
Wanda and her mother were keenly aware of Larry’s tendencies and weaknesses, and both had a good sense of smell. Animated by a rather violent temper and enhanced by Ms. Felicia’s righteous indignation, Wanda was not the sort to take things lightly- she was a “hit first and ask questions later” type of person. Wanda’s Mom was no ‘peach’ either. She usually kept her bat and .22 caliber Astra revolver[11] close at hand. In fact, if she couldn’t find a drama close which beckoned her vociferous opinions and implements, Larry was there to give her focus.
Usually, Larry could wiggle his way out of any serious injury. His method was well-practiced. He started by being profusely apologetic regarding his absences and “the possibility” that he might have been around a friend who was wearing a little perfume. He was skilled at loudly and sincerely declaring his eternal and unique love for Wanda. Besides all of that, and most importantly, Larry was also great about consistently paying the mortgage. As far as the real boss was concerned (Wanda’s mom), that was the ‘bottom line.’ All this maneuvering and his natural charisma were usually enough to keep Larry from serious injury even if he landed in the ER. Even though Larry, Wanda, and Ms. Felicia were a predictably volatile mix on the weekend nights, he had certainly never been shot.
A screen door doesn’t stop a bullet
However, the circumstances leading up to that night were unique. The previous weekend, Larry had deviated from his normal behavior and style, and crossed a line; Wanda caught him being “extra” friendly with another woman in their car in the alley next to their house. Wanda immediately ‘banned’ him from the house, disabled the car with a few strokes of a knife. She was harsh with Larry’s friend who barely made it out of the neighborhood in one piece and completely disrobed. When the police arrived, they helped Larry gather his belongings out of the street while simultaneously protecting him from more contact with Ms. Felicia’s bat. Larry ended up at the local church where he sobered up and slept on a cot in small room for the rest of the week. After this public humiliation, and the ‘splitting’ headache caused by contact to the head with a Louisville Slugger[12], Larry didn’t feel his normal remorse.
On the Saturday night in question, Larry finally decided to return to his house. Agitated, drunk and unusually unrepentant, an awful headache required some relief. The problem was that, although all his belongings ended up in the street the previous Saturday, the wallet remained with Ms. Felicia. He, therefore, didn’t have any money. Sometime after midnight, Larry walked up to the screen door[13] on the front porch and found that it was locked.
Larry banged on the screen door and shouted for some pills for his headache. Wanda opened the main door and smelled both the alcohol and the perfume through the screen. With her mother standing close behind, Wanda adamantly proclaimed that his eviction was complete and permanent. The ladies were determined to prevent his entrance. Larry was equally determined to get Tylenol or Goody[14] powder from the medicine cabinet. He started to force open the screen door.
During the ensuing scuffle, Ms. Felicia’s gun somehow got passed to Wanda. The gun ‘went off’. Larry was shot in the head. In the ensuing chaos, a neighbor called 911. The ambulance, police, and volunteer fire-department descended upon the house. Since everybody in town owned a ‘scanner’[15], numerous cars of every type followed close behind. The paramedics brought Larry to the ER.
As I was learning this backstory, I discovered that Wanda was in the Emergency Department, and trying to come back to speak with Larry. She was shrieking “I didn’t mean for it to go off! I just meant to scare him!” In the ER, the staff must always be aware that when the perpetrators of attempted murder learn that their victim might have survived, they sometimes come to finish the job. Wanda probably wasn’t interested in that, but she was at least making far too much trouble to be anywhere near Larry. He didn’t need any excess stimulation. I ‘politely’ asked the deputies to deal with Wanda. They finally restrained her and took her to jail for a while.
The CT scan- Inside Larry’s Brain
Within thirty minutes, everything was ready for the CT. I covered Larry’s wound with fresh sterile gauze. We plugged up the IV, put the bed rails up, and wheeled him down the hall in haste. I was dreading the results- the bullet likely had traversed the frontal cortex, which is the thinking part of the brain.
When we got to the CT room, Larry was more alert. His arm movements were more purposeful and emphatic. He still muttered “Doc, I got a fucking headache, gimme some god-damned Tylenol.” We helped us get him over to the CT scanner bed and he was mostly still during the twenty-minute test. I sat down in the control room to watch the images as they appeared. Although not a radiologist, I was able to identify big findings. I wanted to get some idea of the damage as soon as possible.
As each of the thirty or so brain images came onto the screen, I surveilled them. I could see the bruise underneath the scalp where the bullet struck it. There were also numerous small bright objects at the top of the head, but they appeared to be under the scalp but not inside the skull.
Figure 1- A CT scan of the brain after a gunshot wound to the side of the head. This CT shows devastating injury unlike what I was seeing on Larry’s CT.
The crazy thing was that I didn’t see any fragments inside Larry’s brain. I was shocked and perplexed. I told Vonda: “I don’t believe what I’m seeing. Let’s get the radiologist on the phone.” I called the local radiologist at home and woke him up. We sent the digital CT images to him. Fifteen minutes later, he called me back and confirmed that what I saw- there was no bullet in the brain tissue and no obvious brain damage. We got Larry back to the ER and I took a few moments to gather myself.
Sometimes a Q-tip is the most reliable test/tool of all
I was trained to rely first on what I see and sense from the patient in front of me. In high-pressure situations, I am deliberately skeptical of test results that don’t make sense. This is a good way to practice medicine, particularly when dealing with the sometimes medically confusing trauma. I also was keenly aware that I was responsible for Larry’s life, not the test. That’s the way I was trained to think until time, re-examination or the clinical situation changes a lot.
I went to Larry’s room and found some long sterile cotton-tipped probes from the gynecology exam kit. Needing to either prove my clinical opinion or disprove it, I stood next to Larry’s head with my foot-long Q-tip, and said, “Larry this is going to hurt, but it’s got to be done.” He didn’t like the idea at all, but I was determined.
After scrubbing the wound, I inserted a sterile Q-tip it into the hole in his head. As you might expect, I immediately ‘hit’ skull. I pressed around to find a hole in the skull, but I couldn’t find one. I then passed the probe around under the skin to try and follow its path. I found a tunnel of least resistance that went from the entrance wound to the top of the head. After applying some force, (unfortunately causing Larry some pain), I could feel the tip of the probe underneath the scalp with my fingertips. I pushed the probe from several angles and confirmed that there was no exit wound. I couldn’t believe it!
It was now clear what had happened. Most twenty-two caliber “long-rifle” cartridges are low velocity with a light lead bullet. Because the bullet is not propelled with much energy or momentum, their wounds are often taking irregular paths of least resistance through the body. I had seen this occur several times with GSW’s to the abdomen and chest, but never with a GSW to the head. In Larry’s case, that is exactly what had happened. Thinking about the mechanics of the struggle, the gun had gone off at Wanda’s hip and traveled upwards. It must have glanced off the extremely hard bone of Larry’s forehead. The bullet immediately shattered, and the fragments then passed in the plane between the tough skin of the scalp the skull. Except for the hole and bruising, Larry’s brain had literally “dodged a bullet.”
A bad way to get rid of a headache
I went to the corner of the room and sat down in a chair. My glee must have been obvious since Larry called out to me; “What’s so damn funny??” I went over to his bed and said:
“Larry, as Saturday nights go, this hasn’t been a good one for you, but it really is your lucky night. That bullet hit you smack in the head, but it didn’t go into your brain. It bounced off and sprinkled underneath your skin. That’s where it will all stay. You’re going to be OK if you can just control yourself and your affection for the ladies.”
Ever succinct, Larry replied, “Well that’s good, I guess. But really Doc, could I just get something for my headache?” I said, “Be careful what you wish for, last time you got a bullet in the head for your headache.”
[1] Residents are doctors who are training to become specialists. They are physicians but are still apprentices.
[2] Since the advent of designated Regional Trauma Centers (RTC’s), and the use of helicopters to directly transport injured patients from the accident site to the RTC, the survival of severely injured patients in isolated areas has improved dramatically. This system is one of the bright spots and laudable achievements of the American healthcare system.
[3] https://www.visitmayberry.com/
[4] GSW: gunshot wound.
[5] https://images.app.goo.gl/riC2g1GcV6gBg7rR7
[6] https://iem-student.org/altered-mental-status/
[7] https://www.dictionary.com/browse/workup
[8] https://www.radiologyinfo.org/en/info.cfm?pg=headct
[9] https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac-20393675
[11] https://en.wikipedia.org/wiki/Astra_680
[12] https://www.slugger.com/en-us
[13] https://www.ourstate.com/screen-doors/
[14] https://www.goodyspowder.com/products/goodys%C2%AE-extra-strength-headache-powder/
Hi there, just wanted to mention, I enjoyed this post.
It was practical. Keep on posting!
Thanks! JFMD