The Friendly Head-butter

The ambulance call came in shortly after 2 a.m. "We're bringing you a 27 y.o. unresponsive male with a head injury and alcohol on board." Despite the patient's unresponsive state, the prehospital team's vitals for this patient were stable.

We prepared a trauma room for this patient, unsure if we would need to intubate the patient to protect his airway and get an appropriate work-up. Alcohol ingestion with unresponsiveness can mean something very serious and, until we had a chance to thoroughly examine this patient, we would provide him with every cautionary medical measure available. Of course, flipping the coin, alcohol ingestion with unresponsiveness can also simply mean "passing out." And as anyone who has worked in an ER setting can tell you, the majority of patients who come in with these similar symptoms are usually just of the "passing out" variety.

Soon enough, the prehospital crew wheeled this patient through our ambulance bay doors and rushed him to Room 18, where we were waiting to greet them. The patient was disheveled, laying on his back, his head turned over his right shoulder. The smell of vomitus was overwhelming, a mixture of bile, soured alcohol, and undigested food. On closer inspection, that was not a designer graphic t-shirt he was wearing but rather a run-of-the-mill Hanes t-shirt sprinkled with the remnants of his puking. Corn kernals included. His cargo shorts were hanging halfway down his pelvis.

As we moved this patient from the transport cot to our hospital bed, the paramedics filled me in with a little history. "Einstein, here," the one paramedic started, "was out tonight with a bunch of buddies drinking and having a grand ol' time." He paused for a minute, chuckling to himself, before continuing. "Somewhere around his tenth drink, his buddies said he started head-butting anyone who would let him."

"You mean people actually let this guy come up to them and head-butt a 'hello' to them?" I asked, incredulous at the thought.

"They probably didn't see it coming," the paramedic answered. "Supposedly, he's real quick with the gesture," he continued, "like a head-butting champ or something."

How's that title for making your parents proud? "Champion Head-butter, 2010." I don't think I would have a prouder moment than if one of my children came home with that award. Especially if it came with some cash. Throw in a tiara and a sash, too.

"Anyway," the paramedic finished as we began hooking the patient up to our monitors, "he head-butted one too many people. He walked up to another drunk buddy of his, slammed heads with him, and literally dropped. Before he hit the floor, though, somebody standing next to him was able to catch him and ease him down. Witnesses said he was out like a light."

I yelled in this patient's ear and was happy to see him stir. I rubbed his chest and pinched his toes to make sure he was appropriately responsive, and he was, trying to swat away annoying me. I listened to this patient's heart and lungs. All clear. I reviewed his vitals. All stable. I looked closely at his pupils, happy to find them appropriately reactive. I was reassured that he was in no grave danger.

Now I had time to do a closer, more focused exam, starting with his head. Hardly surprising, this patient had a large, erythematous abrasion on his forehead, the skin tense from some localized swelling. I pushed on it to make sure his skull bones were stable underneath, expecting nothing less than a hard-head from this patient. He didn't disappoint. I looked in his ears and nose. No blood. I pushed on his facial bones and found no other abnormalities. The rest of his exam was also unremarkable.

In essence, this patient was a drunk with a big "goomba" on his forehead.

Prior to leaving his room and ordering his CT scans, the patient began stirring. His nurse, fresh out of nursing school, greeted him. "Hello, Mr. Sanders," she said, "I'm Chrissie and this here is Dr. Jim. We'll be taking care of you tonight." I said "hello" to him while I nodded my acknowledgement.

The patient must have liked what he saw in Nurse Chrissie, turning his attention back to her. In an artificially deep voice, slurred slightly, and with a lopsided grin, he said, "How you doin', Chrissie? You can call me Larry." He pulled his hands through his hair, trying to straighten-up a little. Unfortunate for him, though, there is a limit to how appealing you can make yourself when you are drunk, sitting in a hospital cot, covered in a gray, threadbare hospital gown. Oh, with a big "goomba" on your forehead.

"I'm good, Larry," Chrissie answered, enunciating 'Larry', "and how are you doing?" "I got a massive headache," he answered her. Then, turning to look at me, he said, "Hey dude, how about some medicine for this headache. Jesus H. Christ, already." I felt like head-butting him. In a nice, friendly way, of course.

A few minutes later, after this patient returned from the CT scanner and was waiting for his results, a call came back from the waiting room concierge. "Is it okay if Mr. Sanders has a few friends come back and wait with him?" "Are they sober or drunk?" the secretary rightfully asked before giving her permission. "They might have had a few drinks," the concierge said, "but they are really respectful and concerned."

I was walking down the hall, coming back from seeing another patient, when I saw Larry's friends coming from the opposite way. I wasn't aware of the concierge call, but none of that mattered. I knew who these two guys were the minute I saw them. I slowed my walking pace, wishing that the fluorescent hallway lights were just a little more brighter so I could better appreciate their appearances.

Both of the guys were wearing fashionable jeans with flip-flops that clucked with every step, graphic-Ts, and, barring the sprinkles of vomit that covered both of their fronts, looked quite hip. But these weren't the signs of their brotherhood, of best buddies out on a late Friday night having a great time, now bonding in our ER.

No, that sign would be the matching "goombas" they both wore on their foreheads. Bright pink, two inches in diameter, and glaringly obvious under their shaved heads, their warwounds looked almost identical to the injury of our patient, Larry. Their friend.

I stopped them as they walked by. "Hey guys," I said, having a little fun, "what happened to your heads?" The one remained silent, intently watching his pacing feet, while the other spoke. "You don't even want to know," he said, shaking his head in disappointment. "Well," I said, "if you guys want to be seen or get a bad headache, let us know, okay?"

Soon after, Larry's CT reports came back negative for any injury. Outside of a bad headache and a nice-sized contusion/abrasion, he was getting off quite nicely. I went to the room to explain his results to him, and caught my breath as I walked into Room 18. With these three buddies sitting close together with their matching injuries, how could I not think of The Three Muskateers?

Larry, thankful for not having any significant injuries, started crying (the gut-wrenching bawling brought on by a stiff drink) and throwing around his apologies to anyone who would accept one. A tech walking by his room even got one. "I'm so sorry, buddy," Larry said. "For what?" the tech asked. "I just am," he replied. The tech kindly went and got Larry a box of tissues.

Finally, a sober friend came to drive them home. A female. Long brown hair, very sophisticated-appearing, wearing a warm smile. Evidently, she also had a great sense of humor. She exhibited a hearty, genuine, gutteral laugh, I'm told, when she walked into Room 18 to gather her friends. And had a hard time stopping.

At least the patient was a gentleman. She wasn't sporting a matching forehead "goomba"...

As always, big thanks for reading. Trying to keep things light this week. See you Friday...

How Do You Sleep?

One of the more common, non-emergent complaints I hear in the ER is about sleeping, or the lack thereof. Although the patient is usually being seen for a more serious, emergent issue, if their sleep is not solid, they tend to skillfully bring it up regardless of what else is going on.

"Maam," I said, "it appears by your EKG that you are having a heart attack."

Despite chest pain so intense that my patient was clutching her chest, she still stammered, "But what can we do about my sleep?"

Or, imagine my elderly male patient in the midst of a stroke, with the left half of his face drooping, his speech slurred, and drool sliding down his chin. "I shant schweep adt nichte."

"Pardon me, sir, but what did you just say?" I asked.

Thankfully, the nurse starting his IV understood him. "He said, 'I can't sleep at night.'"

See what I mean? I've even had a patient share her insomnia issues during a pelvic exam. Maybe if she had slept more and fooled around less, I wouldn't have had to do this exam for her itchy, malodorous discharge in the first place.

Barring the situational, temporary reasons (for example, a death in the family), sleep disorders are typically viewed as chronic, long-term illnesses and, as such, should be treated by one's family doctor. Sleep studies may be necessary, and there are several options of treatment to prescribe, all requiring close follow-up. All reasons for me not to treat a patient for this disorder. I will, in a pinch, prescribe a few days worth of medication for a patient if their daily life is being severely affected, but that's about it.

Several years ago, after some prompting by my wife, I underwent a sleep study. It seems that I was having bouts of snoring and gasping for air in my sleep, per my wife. I'm not sure how she knew this, seeing that her head hits the pillow and a six-to-eight-hour coma immediately follows. But yes, she insisted, this was happening. So I took her word for it and pursued the testing.

I arrived at the sleep lab suite around 7:30 p.m, nervous and not sure what to expect. After checking in, I was shown to a huge bedroom, professionally decorated, with a queen-size, pillow-top bed beckoning for my company. "Come, Jim" it whispered to me, "come and let me wrap my big, down-filled arms around you." I think I heard the 40-inch TV calling, too, but I could have been imagining that.

After the tech showed me to my private bathroom, I changed into some appropriate sleepwear. You might be asking yourself--what's appropriate? I'm going to let your imagination answer that question. Just be aware, though, that they videotape you through the night as you sleep. And then post that video on YouTube. Just joking. Suffice it to say, I would suggest that one wear more than just the usual home sleepwear. And newer, too. Please, on behalf of all the sleep-lab techs in the world, don't show up in a stained, big-daddy Hanes t-shirt. Or tighty-whiteys. Or a moth-eaten thong. Or nothing at all. Especially nothing at all!

After changing, I climbed into bed. Soon, the tech came into the room. I was nervous, obviously, and likened this anxiety to how a 60 year-old fat, balding guy must feel while lying in his hotel bed, waiting for his prostitute to arrive.

The tech, a nonchalant, easy-going guy, explained the whole process to me. "First, we 'll attach these electrodes to your head, then your chest and finally your arms. After that, we'll leave you alone. You can do whatever you want--watch TV, read a book, whatever--until around 10 p.m. If you aren't sleeping by then, we'll ask you to turn off everything. Don't forget," he continued, "besides monitoring you, we'll be watching you on video." He pointed to the cameras in the upper corners of the room while he spoke. "Any questions?"

No questions, but just a silent prayer. "Dear God, I beg of you, keep me from scratching myself or making a fool of myself tonight. Amen." I added a bargain for good measure. "Oh, and if you do, God, I promise to give every ER patient a turkey sandwich, a warm blanket, and unlimited lemon pudding during the next week."

The tech left the room. I looked around, all this comfort surrounding me, and all I could do was think "How the hell am I going to sleep with all these wires hooked up to me?"

Well, I read a little, I flicked through the 1000 available TV channels, and finally, around 10 p.m., I turned off the lights. There's no way, I thought to myself, that I'm going to fall asleep. I pictured my wife at home, smiling, arms and legs spread out, sleeping soundly alone in our bed. I had the bad feeling that I had been set up.

Next thing I knew, though, I was being nudged in the shoulder. "Hey," I heard, "it's time to wake up." Through groggy, squinting eyes, I peered slowly around, clearing my mind's disorientation. That's right, I reminded myself, I was in the sleep-lab and, wouldn't you know, just had my best night's sleep in about ten years.

"You did great," the new male tech said. "Let's get you up and out of here." I got up, moved to the side of the bed, and he removed all of my electrodes. I got a quick shower, cleaning all the gel off of my head and body, brushed my teeth, got dressed, and headed home. I didn't need to hear the official results, I already knew--everything would come back normal.

Yeah, well, I'd like to call a penalty--the sleep-lab guys cheated. Unlimited channels, private room with bathroom included, big pillow-topped bed with down-filled comforter, the bed all to myself--who the heck couldn't sleep within those luxuries? The wires were but a mere distraction.

Have any of you had a sleep-lab study done? Similar experiences? Would you like to share how it went? What you wore? Let me lower my voice three octaves, like the great Barry White's, to a whisper and ask again. "Hey you, yeah you, how you doin'? What did you wear during your sleep lab?"

It took me some time, but I have my sleep all figured out now. Three, no four, things work for me. One, no alcohol. It's been shown to interrupt your sleep cycles, so I cut out my nightly glass of wine. Two, a great book. Three, Tylenol PM. Just one, occasionally. And four, in a pinch, 1/2 of a 10 mg Ambien tablet. I still have half of a thirty-day supply prescribed from last November. Take it on an empty stomach and within a half-hour, I'm a little woozy. Next thing I know, I wake up and it's morning time. And life is good. Bring on the day!

This isn't medical advice, just what works for me. Sometimes, though, it works too well. After taking a Tylenol PM several nights ago (I'm in the midst of several busy ER shifts), I woke up the next morning, horrified. On the ottoman beside our bed, my laptop computer sat with the top opened. Here, after taking my Tylenol PM, I had the brilliant idea to email a few people about their kind comments left on my blog. Rereading those emails this morning, I could only laugh and send those readers a follow-up email, apologizing for the ramblings. Forgive me if you got one.

Okay, I gotta run. I feel the Tylennnnnolll PPPPPMM kkickkkkkingggg innn aaagainnnnnnnn. Seriously. As we used to say when I was younger, "Good night, sleep tight. And don't let the bed bugs bite."

As always, big thanks for reading. Next post will be Wednesday, March 10. See you then...