At first he just laid on the backboard, stabilized. Two giant styrofoam logs on either side of his head helped keep him from moving.
Perhaps we should've left him there. He refused to tell his story. How did you get that 3 cm gash on the back of your head? Did someone jump you? No answers.
Try a bit of cajoling, which, of course, he doesn't respond to, being a young, drunk male. Where are you? What's your name? No response.
Normally, I suppose petulance works well to control your situation, but in an ER it's more likely to get you intubated, which I told him. He winked at me. Like, you understand, don't you? I can't tell the police what was happening.
Despite myself, my response at that point showed how old I really am. No, I don't understand you, genius. What the hell are you thinking exactly?
Restraints came next, eventually, as he got less and less cooperative and started to insult nurses, doctors, guards.
After we spun his head (CT) and found nothing, it was time to fix the laceration. It was a Y-shaped laceration with relatively clean lines that I could re-approximate well. Having done a few scalp repairs, I was hoping to try for a good result with a stitch at the Y that re-approximated the three angles loosely; Y-shaped lacs are notorious for losing blood flow at the middle of the Y since there is often a tearing force involved.
So that's where my head was. How can I technically approach this problem to get the best result for the patient, with regards to infection prevention and cosmesis?
His head wasn't at the same point. Just to get him turned over we had two security guards holding the limbs out of restraints. As soon as I started to irrigate, he started moving his head around, shaking it. To truly irrigate a wound the minimum amount is probably on the order of a 1/2 liter or so of tap water or saline. That didn't happen.
And my plans of stitching didn't happen, either. Once the wound was tolerably prepared, I asked him if he'd allow me to fix it, and he said, 'you do what you have to do, but as soon as you start, I'm going to go like this'--and he shook his head violently back and forth.
Now I'm less worried about him than us. There were four people in the room trying their best to help this genius, and the time it would take to suture him wasn't feasible. So he got staples. Less than 30 seconds, and his wound was closed. There was a touch of satisfaction that I would be lying to deny in stapling his head. 30 seconds was about all we had as someone had to hold his head down, and his free arm.
During the time we were screwing around trying to take care of genius no. 1, there were probably about 15 other patients that came into the ED and needed help, including a couple cardiac arrhythmias, a woman on the edge of sepsis, little kids that were really sick in the middle of the night.
Re-reading this post, I can see my writing is a bit choppy and odd. Probably because I'm still suffering from counter-transference--that is, strong feelings that arise in a provider in response to a patient that should, ideally, be put to the side. Not always so easy to do.
Perhaps I'm younger than I think, and still too close to the time in my life when I made my own stupid decisions. He certainly made it difficult to help him. Perhaps I'm not the most patient person by nature. Or, perhaps I was starting to be aware of everything going on in the ED that needed attention.
I'm still sorting this one through. What are the consequences of helping everyone? Can you make a judgment on how deserving someone is of help? If so, how?
In the meantime, I'll try to be less of an idiot, if only for the sake of others.