The other night, a woman rushed in asking for help getting her injured boyfriend out of the car. She said he had been drinking with friends when they called to say he had been stabbed and needed her help. When she got there, he was covered with blood, nearly unconscious and unable to stand. The friends helped her load him into her car and she rushed him to the hospital.
A nurse and a tech went with the woman to her car. There, they found a man slumped in the front seat. He had dried blood all over his face and soaked into his clothes. He moaned as they moved him into a wheelchair and pushed him into the emergency department.
When I entered the trauma room, I saw a tall, big-boned, muscular man covered in blood. His head was thrown back in the wheelchair and he was moaning. Though conscious, he did not respond to staff’s questions or instructions. His size and passive posture led to a quick conversation about how to best get him out of the wheelchair and onto the gurney. I bent over and, talking closely into his ear, firmly encouraged him to help us get him onto the bed. That was enough to get him to stand and move over to the gurney, where he fell back, moaning, his eyes closed the whole time.
I then stepped back against the wall at the foot of the bed while the nurses and techs got him undressed, placed him on a cardiac monitor, recorded some vital signs and started IVs.
Just then, the trauma surgeon walked in and asked me what was going on. I told her he had been stabbed, he seemed to be very drunk and we were in the process of evaluating him for possible serious injuries.
Suddenly, the man, who had hardly been able to hold his head up, leapt from the gurney, hollering loudly. He pulled the IVs out of his arms, yanked the monitor leads from his chest and tore off his gown. Throwing everything on the floor, he stood, naked, in the middle of the room, blood running down his muscular arms from where he had pulled out the IVs. Everyone was amazed at his miraculous transformation. He had suddenly gone from being a nearly unconscious rag doll to an erect, angry man who was hollering, swearing and waving his arms threateningly. Staff immediately stepped back away from him and pressed against the walls of the room, wondering what might happen next.
At first, his profanity-laden tirade was directed at no one in particular. Soon, he focused on me. Though his eyes had been closed and he had been acting incoherently, it became obvious he heard what I told the trauma surgeon and was very upset that I assumed him to be drunk.
He walked forward and got right up in front of me. Waving his arms wildly and pointing at his bloodied face, he screamed at me for saying he was drunk and not paying any attention to his stab wound.
I can’t say I was not afraid but I just stood, statue-still. I stared him straight in the eyes and did everything I could to not respond to him at all. Not getting a reaction from me, he turned and walked around the room, hollering at others who stood, lined against the walls. He picked out a nurse in the farthest corner, called her a “bitch” and gestured threateningly at her.
Recovering their wits somewhat, some of the staff tried to calmly talk him down. He paid no attention to them. He continued to pace the room, completely naked, with dried blood all over his face and fresh blood dripping down his arms. At times his ranting seemed incoherent. Then, he would say something like, “Look at me! Standing here buck-naked in fronta y’all. What the
f—?” All the time this was going on, his poor girlfriend was sobbing in the hallway outside the trauma room.
Eventually, he seemed to tire of it all and started looking for his clothes. Several of us encouraged him to let us evaluate him to make sure he was not seriously injured. This, he refused, demanding to be given his bloody clothes so he could leave.
This presented a difficult ethical question. When he came in, it seemed he was impaired. A person in that condition could not wisely refuse medical care. If he had tried to leave, it would have been appropriate to restrain him until we were sure he was either okay or competent to assume the risks of leaving against medical advice.
Now, I had a very different patient. He was alert, talking clearly in full sentences, and able to pick me out as the one who insinuated he was intoxicated. What was my responsibility? Did we need to tackle and restrain him to protect him from making a bad decision and leaving? Should staff be put at risk in order to make sure he didn’t leave until it was clear he was alright?
By then, security officers had arrived, waiting for my instructions on to how to deal with this man. I had to decide. He was big, strong, upset and covered with blood. I knew it would be a nightmare to try to take him down. Rather than put staff at higher risk, I told everyone to let him leave if he wanted to. It took him quite a while to get dressed as he kept getting distracted and continued hollering at people. Eventually, however, he walked out.
The next day, I got the following email from one of our physician assistants, referring to this same patient:
Hello Dr. Tad,
A patient presented to the ED today to apologize for his behavior during his most recent ER visit. He was very sincere, and wanted to apologize for his horrific behavior. He is very sorry and appalled at himself, stated he is not normally like that, and continued to profusely apologize, asking to please have me pass on how remorseful he was.
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