The other night, an overhead announcement in the emergency department caught my attention: “Dr. Tad to Room 11, STAT! Dr. Tad to Room 11, STAT!” Since I know my staff would not call me like this unless there was a real reason, I dropped everything and hustled to Room 11.

I got there just as the patient was being moved from a wheelchair onto the bed. I made my way through the crowd of staff filling the room, everyone hurrying to take her clothes off, get vital signs, put her on a heart monitor and start an IV.

When I got to the bedside, I saw a young woman who looked dead. She was pale as a sheet. She was unconscious and not breathing or moving. I could not feel a pulse.

I barked orders to make sure someone was doing each of the many things that needed to be done at once. In situations like this, we use the pneumonic “ABC” to prioritize our actions. “A” is for Airway. Before figuring out what her underlying medical problem was, we first took steps to protect and keep her airway open. I told the respiratory therapist to prepare to intubate her, pass a tube into her windpipe.

After Airway comes “B” for Breathing. Once the airway was open and protected, we would check to see if the patient was breathing well. If not, we would need to breathe for her by putting her on a ventilator.

“C” is for Circulation. Does she have a pulse? What is her blood pressure? Is she bleeding? What needs to be done so that blood is getting to her vital organs?

In Room 11 that night, I soon was able to stop worrying about “A” and “B” because, once she was out of the wheelchair and flat on the gurney, enough blood got to her head that she woke up. She started to complain of pain and asked for water. Airway and Breathing were good.

It was now obvious that Circulation was her problem. Along with the pallor I already described, her blood pressure was low and her pulse was fast. These are all signs of hemorrhagic shock. Since she was not bleeding on the outside, my assumption was that she was bleeding internally. I took a quick listen to her heart and lungs. I felt her abdomen, which was tender and distended. More orders were given in response to this new information.

As the rest of the team pressed to get IVs started and get blood work for the laboratory, I turned to find out who had brought her in. I went into the hall and found her concerned husband, a young Vietnamese man. His English was weak, but there was no time for a translator. I was able to learn that she had been complaining of abdominal pain and might be pregnant.

As soon as I heard that, I instructed a clerk to call the obstetricians and tell them to come to Room 11 immediately. I then ran an ultrasound probe over the patient’s belly and found just what I was expecting. Her abdomen was full of blood.

I called for Type O-negative blood to be rushed up from the blood bank so a transfusion could be started. This blood can be safely given to anyone if there is not time to check the patient’s blood type. The blood bank keeps some available for just this kind of situation.

About this time, the obstetricians came rushing into the room. I quickly told them what I had found and what we were doing. One stayed to help with the resuscitation and to try to get more information from the husband. The other called the operating room to say they were bringing the patient straight up.

The pregnancy test came back positive just as they pulled her gurney out of the room, headed for the operating room. There, they found her abdomen full of blood from a ruptured ectopic pregnancy.* She had a rough go of it but they were able to stabilize her by stopping the bleeding and giving her more fluids and blood. She left the hospital a few days later. She had a scar on her abdomen and was missing the fallopian tube in which the pregnancy had established itself. Otherwise, she was no worse for wear.

Reviewing this case fills me with gratitude. This lady was dying. It makes me glad I knew what was needed to keep that from happening. It also makes me glad we have the facilities to provide the care she needed. In times gone by and in many places in the world today, if this happened to a woman, she would be dead. I am really appreciative of my team. They did just what was needed when a life was on the line. I am also grateful for good luck. If the patient and her husband had delayed in coming to the hospital or gotten stuck in traffic or lost, we might not have had the chance to give her the services we trained hard to provide.

 

*If you are interested in reading more about ectopic pregnancy, here is a reference frpm my favorite medical resource: https://en.wikipedia.org/wiki/Ectopic_pregnancy

 

I recently went mountain biking in Moab, Utah. Unfortunately, I fell just as our ride was starting. It was soon apparent to me that I had broken some ribs on the left side of my chest. I painfully rode back to the trailhead and found a ride back into town, rather than trying to ride the rest of the 26 miles we had planned for that morning.

Since there is really no treatment for broken ribs, I knew there was no reason for me to seek medical care. I just set myself up on the couch of our rented condo and tried not to move around too much until I could head back home.

A week later, I was back at work, feeling better and was taking only ibuprofen for pain. “This has not been that bad,” I thought to myself. Little did I suspect that a surprise setback lay ahead.

I woke up on Saturday morning, eight days after my fall. As I got out of bed, I was surprised that I had more pain in my chest than I had been experiencing the previous few days.

While I was in the shower, the pain got a lot worse and any movement was now causing severe pain. Getting dressed was really tough but I pressed on, feeling sure it would soon pass.

As I started down the stairs into the living room, I was seized with a muscle spasm along my left spine that left me completely incapacitated. I hollered, stiffened and became unable to breath or move until the muscle spasm relaxed and the broken ends of my ribs were not being driven against each other.

The spectacle I presented on the stairs caused everyone in the house to come running. My wife, son and daughter-in-law rushed to my side, trying at the same time to understand what was wrong and wondering how they could help.

Several things went through my head as this was going on. I know enough about this sort of thing to understand, basically, what was going on. The pain from my broken rib was causing my back muscles to go into spasm. That was causing severe pain which was making the muscle spasms worse. Whenever I moved, I was caught in this terrible cycle and the only thing that helped was to not move, at all. Understanding this, I was not worried that I might have some terrible, life-threatening condition. I recognized that this understanding helped me a lot, compared to people without my training and experience who might be freaking out, wondering if they were dying or something.

I next thought that I always have to ask my patients to rate their pain on a scale from 0 to 10. In doing so, I sometimes wonder what pain I would rate at a level of 10, the most pain anyone could experience. “Now I know,” I thought.

After I was through with my clinical and analytic thoughts, my attention turned to how to get off the stairs. If I moved my trunk at all, like to take a step, the pain would come back and I couldn’t move. There was nothing I could do about it. With help from my wife and son, I forced myself down the stairs and collapsed on the couch, trying not to scream the whole time.

There I stayed the rest of the day, unable to move without triggering the same terrible pain. When it came time to try to take a nap, I needed help from my wife and son who moved me as if I were a piece of fragile furniture, trying to keep my spine from moving.

At bedtime, they helped me in the same way back up to my bed. The next day I still had pain and had to be careful but was some better. By the following day, I still had the rib pain but all of the spasms were gone. Today, I am almost pain free. I am back to riding my bike with no problems.

Now, I told you that story to tell you this one:

The next week at work, I introduced myself to my next patient. She was a lady about my age who told me a sad story about being attacked three days earlier by her mother, who suffered from Alzheimer’s Disease. She had been knocked to the ground and injured her chest. She told me she was pretty sure she had broken a rib and, knowing there was nothing to do for it, had just been taking ibuprofen and putting up with the pain.

What brought her in was that she had woken that morning with severe muscle spasms on the same side as her broken rib. The pain was so severe she was incapacitated by it and was worried about a complication of her chest injury.

As I listened to her, I had a hard time not smiling, which I knew would not be perceived well. As soon as she had a chance to tell me of her concerns, I briefly told her of my experience the weekend before. I explained what I thought had happened to both of us. I reassured her that what she was going through was completely understandable and she had nothing to fear. I also assured her that we would get her feeling better in a short time.

After some intravenous morphine and valium, she was feeling much better. She went home relieved to know she was going to be fine, happy to be out of pain and appreciative of a doctor who was able to empathize so distinctly with her suffering.

There is some irony in recognizing that she went to the emergency department and got some help while I just stayed at home and suffered.

One night this week, one of my physician assistants came to me frustrated that the patient he had gone to see had run him off, saying he wanted another doctor. Matt had addressed two complaints the patient had: difficulty urinating and a nagging cough. When the patient went on to more complaints, including shoulder pain he had been suffering with for over a year, Matt recommended he take up these more chronic problems with his primary care physician. That is when the patient ran Matt off.

It was now my turn. I found an elderly man asleep on a gurney wearing sunglasses and a beret pulled down over his face. I introduced myself and went over his first two problems. When I asked him if he had any other concerns, he told me about his shoulder pain, for which his primary care doctor usually gave him Vicodin. He then said all he wanted was to be treated with sympathy.

I asked him if he had come for sympathy or for Vicodin. He calmly answered, “Vicodin would be fine, thank you very much.”

This all took place in the hall right in the busiest part of the emergency department and as soon as he answered my question, I was surrounded by suppressed laughs. I had not intended my question to be comical. I’m sure he didn’t intend his answer to be funny either, but, together, they made everyone laugh. This was especially funny to staff surrounded every day by people looking for opioids for their chronic aches and pains.

 

A sixty-year-old woman came in by ambulance. The nurse entered “abdominal pain, flank pain” as the chief complaint. The nurse advised me that the patient was deaf and only spoke Spanish, so I grabbed some paper and a clipboard before going in the room.

I introduced myself and showed her my name badge so she would know my name. She motioned that she was deaf. I smiled, nodded, and pointed to my “Hablo Español” button as well. I then wrote on the paper, “Que pasa?” (What’s going on?)

She took the clipboard and started writing. “This isn’t going to be too bad,” I thought to myself.

When she returned the clipboard, I saw she had written, “Susana,” which was her name. That was about the best we did. With her reading my lips and using her sketchy Spanish, I was finally able to learn that she was, indeed, deaf. She only spoke Spanish and didn’t know any sign language. She also had never gone to school and didn’t read or write. On top of that, no family member had come in with her; someone who, I hoped, would be better able to communicate with her than I was.

Usually in medicine, we rely a lot on the history to start figuring out what is the matter with someone. In this case, through lip reading and pantomime, I was able to understand that she was having pain in her lower abdomen and flank. That was about the best we could do. I examined her and ordered tests, doing more tests than I might normally have to do since I didn’t want to miss something.

The tests all came back normal, her pain was controlled with the medicine I gave her and we were finally able to get hold of a family member who came in and helped get her discharged.

When it comes to communication challenges, it is hard to beat a non-English speaking patient who is deaf and doesn’t sign, read or write.

Some people really want their doctor to know the exact details of their symptoms. This often leads to extended written accounts of details patients believe will help with their diagnosis. Here is a reproduction of a written note a patient brought in to help outline his symptoms. If you have a hard time following it, I do to. In the end, we found nothing wrong and the patient left without a diagnosis. As I sent him off to follow up with his primary care doctor, feeling sure he had no emergency, I wondered if someone, someday, will find a strange medical condition to explain the symptoms or if it was all just mental. This is not an unusual thought as I discharge people. It seems mental to me but I don’t know everything.

 

Diabetic Type II
Off meds long time
#’s run in 200’s

Wed 7/6

3:30 AM

-woke up dizzy
-sat on edge of bed
-got online and video chat so people could watch me, make sure I was OK

4:00 PM

-eyesight got strange
-couldn’t see part of right side of vision. close one eye can see OK. close other eye see OK. both eyes – missing right side view

4:30 PM

-right side of lips (top + bottom) went numb for a little while. right arm and leg got weak and shaky
-only lasted a little while then lips ok again + arm/leg ok too (no shaky)

4:45 PM

-nauseas – didn’t throw up – just wretched

5:30 AM

-headache left front behind eye
-took Naprosyn Sodium (just one)

6:00 AM

-went to sleep
-eyesight still messed up

10:00 AM

-woke up feeling better
-no headache
-eyesight ok (but bright spots)

Wed

-bright spot/line in right eye fading but still there
afternoon       -small headache
-took Naprosyn – headache faded away

1 periods of dizziness

A young woman brought her brother in for psychiatric evaluation. She told me he had been acting strangely and gave me her written account of what had been going on. She was a bit compulsive in the way she documented things and, you can tell, was not primarily English-speaking. Still, if you can be patient enough to read through this, you will get an interesting insight into this man’s mental illness and the trouble it caused his family.

When the sister said she was comfortable that they were all safe with him at home, we discharged them with information on how to get him some psychiatric help.

Here is a re-creation of the “log” she kept and shared with me:

Log – JC (I am not using his real initials) – Summary

One Page Summary – August 2016

Patient Info:

Name:            JC

Age: 37

Phone:

Address:

Weight: 150 lbs.

Height: 5’8”

Education: BA degree Nuclear and Computer Engineering from UC Berkley in 20–

Career: Started working for S——— in 2016

Lives with: Wife, 4-year-old son, mom-in-law

Medications: none. Currently refuses to see any doctors.

Drugs or Alcohol uses: none. No history of drug or alcohol abuse

2013-2016

When he was working at a computer chip company, he said to the family that his boss taps his phone, knows where is was going, someone is watching and needs to close the blinds and install security cameras. Family had talked to him and lay out all the reasons why his boss would not do such thing. He was convinced at first. Family asked him to quit and he quitted, and stayed home with baby son and mom-in-law for about 2 years. He seemed fine most of the time but every few months, he will bring up issue of being watched and his phone being tapped.

June 2016

Started telling family that his in-laws are hurting-poisoning him and irritated that rich people controlling everyone and buying everyone’s mind, so everyone is scared to speak up. We talked to him but he cannot be convinced. He has these strong feelings about one week and increased to couple of times per week. He then said that it is his wife, B, who is hurting and poisoning.

July – August 2016

J has symptoms of bipolar disorder which includes: daily extreme mood changes, strong feelings of irritability and anger, avoid friends and social activities, decline sleep, having delusional thoughts, persecutory paranoia, episodes of hypomania daily and mania almost every other day. He refuses that there is anything wrong with him and everyone including doctors are all against him. He said he does not have paranoia because he is not that type of people. He now strongly feels that his wife is harming him, including poisoning him, throwing stuff to his head. He yells at her almost daily for hurting him and threatens to hurt her and the son if they try to hurt him.

6/6/2016 Sunday 12 PM

He held down P (the son) to put alcohol on his scraped knee. He insist that there are microwave length that controls all this. We argued very loud and he accused me of killing people, accused B of using atomic bombs and army trucks.

7/15/2016 Friday 10 PM

He took a picture of his scraped knee and insisted that it was serious, badly swollen, internal, microwave laser tissue penetration. Need to report to Obama. Everything is bought and everyone else is scared to say anything, everything is cover up including doctors. Everyone needs to be educated to a high-level and accessible. I don’t want to live a scared life like you all. You are all brainwashed.

7/16/2016 Saturday 8 AM

He posted on Facebook “Imagine life in a country that is constantly at war, surveillance, and creates artificial news. There’s gotta be a better way and I know I’m not the only one that feels this way.”

7/17/2016 Sunday 9:30 PM

He posted on Facebook “Thank you everyone for your care and kindness. I will keep a positive thinking going forward.”

7/18/2016 Monday 2 PM

Posted “Feeling cool about Usesome” which is an article about high-ranking intelligence officer making artificial news and destroying massive mankind.

7/20/2016 Wednesday 4 PM to 8 PM

He posted on Facebook “Got sick? Got resistors, capacitor, F T?”

7/23/2016 Saturday 12 AM to 3 AM

He and I talked for over two hours about various topics from “What do you think of B, rich people ruling everything, interviewing for the new job is beneficial because involve learning new thing, what if Mom and Dad and I were taken advantage, what would I do?” I told him that “That must be a scary feeling.” He said “Never mind” and changed subject. I asked him how his knee, what did the doctor say. He did not answer me.

7/24/2016 Sunday 12 AM

He posted on Facebook “<3ing.” Kicks bathroom door open and held up fist to B, eyes wide open. He said “You poisoned me, you and your coworker poisoned pool water and made me go into pool with P. My legs are handicap now. I don’t want to you.” B said violence is not going to help and sat down to talk to him. He calmed down and B was able to talk to him in a calm way. He listened and talked, lasted over an hour, then went to sleep.

7/25/2016 Monday 9 PM

He mixed cement and worked on the basketball hoop at 9 PM at night, shouting to B to help and asking mom-in-law to stay inside. At midnight, posted on Facebook a bunch of Chinese sentences that no one can make any sense. Like random Chinese words being put together to try to say something evil inside of someone.

8/2/2016 Tuesday throughout the day

P is sick. He said someone pressed button. J asked P to eat, P has no appetite and didn’t want to eat. He told P if he didn’t eat, he can die. He said at one point to P that P only needs to learn math and English and don’t need to learn anything else because he can teach him everything else.

8/4/2016 Thursday day

He said he was hypnotized, someone shot him. Caused by phone microwave. Felt that hair had blown by wind so he was hypnotized. Must be B who used pollen. She gets pollen everywhere. She is together with high school friends and large corporations like cops, FBI. He went out with P and Dad and ran into bad freeway traffic, he said someone messed with us. Someone messed with mom too because mom ran into traffic going home after work.

8/5/2016 Friday morning

He yell at B and said to sell the house, B caused T to pull wisdom teeth, she caused T to move away from San Francisco. He stopped after P started crying. I talked to him right after this episode and he acted normal. He asked me if I have already gotten my wisdom teeth off, I told him no because it was just a consultation. He said that they are getting ready to leave the house to bring P out.

8/6/2016 Saturday

He had a long talk with Mom mainly complaining about rich people ruling everyone else. There are smart people sifting all the stupid people out. Stupid people receive small incentive, so they comply and work like slaves. He was calm and had no episode.

8/7/2016 Sunday 9 PM

On the car ride home, he complained to B about her being a betrayed person. After arriving home he and P played and P accidentally poke J’s eyes. J said to P, you are trying to hurt me, I will kill you so you can’t hurt everyone in the society. He pulled B out of bed, dragged her down two flights of stairs and pulled her into the kitchen and pointed to a cockroach and accused her of poisoning him. After B tell him that it is not an issue when there are insects around, and Mom-in-law said a few positive things to calm him. They sat down and he saw her looking through her phone and he told her not to call 911. He asked if they are going to get a divorce and whether she is contacting a lawyer. He said “we can talk about it here and you don’t have to talk to lawyer.” Mom-in law-said it’s late and they should all go to sleep. He insisted to sleep with P in P’s room. She sleeps in their own master bedroom. Everyone went to bed. From 12:40 AM to 2 AM, he texted to a Family Group chat “Be careful, and evil is acting up again. My wife just put something in my drink. The family history going back hundreds of years are all traitor. Targeting all Chinese people, kissing ass to non-Chinese people, be careful, this 200-year-old issue still happens today, don’t fight within each other, needs to collaborate together. Is everyone around just sick for a long time?” When B was getting ready for work in the morning, he came to her room and said “I’m checking what the traitor is up to.”

8/10/2016 Wednesday morning

Mom called J and first he said “Don’t worry about me. Everything is fine.” He brought P out to the playground and museum and asked mom-in-law to join too, as if nothing happened last night.

8/10/2016 Wednesday 8:30 PM

I had an hour-long conversation with him. He said B together with other unknown people from high school poisoned him for years. He asked how we feel, he said he can’t explain it, it’s just feel different. He said she brings in drugs from somewhere/someone and dosage is not severe enough to kill him but enough to make you feel different and will last 20+ years. This all came from 200 to 5000 years ago that the tradition of poisoning continues to this day. There is a group of highly educated gangster related and rich people summoned people from China to come to the US and get citizenship and turn in people for them. B is brought into that group whose job is to turn J to the highly educated people. That’s why she poisoned him. He said he already reported to FBI and Obama. He said he wants to try to make B get out of it but she is too much in already. He said he is telling me and the family because he wants us to be careful. When asked if he feels angry or frustrated, he said some time but he can’t do anything about it so just let it be. When I asked he was sad, he said no because he smiles every day. He said he wants P to be highly educated so that he will know there are people around to hurt him.

8/12/2016 Friday 3 PM

I suggested he sees a marriage therapist because his current relationship with wife, he refused and said the root cause is that she needs to stop poisoning me. Then midnight he went to her room and said she is always awake, “every time I wake up in the middle of the night, this girl is awake.”

8/15/2016 Monday 5 PM

When he came home from work, he said someone throw stuff on his head, and he went to shower right away.

Said the same as yesterday about someone throw stuff on his head. When Mom-in-law was away from the house to get groceries, he started yelling at B that she is harming his family, harming his uncle, and said parents are scared of B. And then he said to P, “if you hurt my family, I will kill you.”

8/17/2016 Wednesday 8 AM

Wrote on family group chat that someone threw stuff on his head. He said he felt something that breaks/spread apart as it lands on his head.

A telephone call came into the emergency department and was transferred to the charge nurse. The caller said that a coach for the US Olympic Tennis Team was on the way to our emergency department and that he should be given VIP service when he arrived. She told me about the call and we both wondered what this might mean.

A while later, a middle-aged man arrived who was complaining of flank pain. As I talked with him, I realized this must be the person referenced in the mystery call. I couldn’t make any sense of this because the patient was not what you would picture an Olympic tennis coach to be. He was weird, pale, obese and dumpy. He gave a disjointed story of being diagnosed with kidney stones at various different hospitals around the country as he traveled with his coaching responsibilities. I had a hard time tying this all together in a way I was comfortable with. Nonetheless, I proceeded to make him comfortable and evaluate his flank pain.

Sometime later, a man arrived who identified himself as a limousine driver. He had a bemused police officer with him. They were looking for our Olympic tennis coach-patient. The driver said that the patient had contacted him in Pismo Beach and agreed to pay for a ride to our fair city, a distance of about 200 miles.

The patient pulled out a wallet, showed that driver it was full of cash then asked the driver to hold onto the wallet as the patient said he would be drinking in the back of the limo and would appreciate the driver keeping an eye on it. The patient jumped in and the driver headed off, happy to be paid for the nice, long trip.

When they got here, the driver was directed to the Fairmont Hotel. The patient asked the driver to wait for him while he ran inside to see if the people he was to meet were there yet. The patient went into the lobby and the driver patiently waited.

When the patient didn’t come back, the driver went inside and asked the staff if they had seen his customer. They said he had come in, asked where the nearest emergency room was and had exited out the back door. The driver pulled the wallet out of his pocket and found it was full of paper: no money. His customer had pulled a switch after showing him a wallet full of cash.

The driver then realized he had been had and called the police to help get some justice.

I was too busy to appreciate much of the interaction between the patient, the driver and the police officer. I understand the cop took a report and the driver left, angry and with no money.

I eventually figured out that the patient had no history of kidney stones and everything he told me was probably a lie. I have no idea where he went or what he did next after he left our emergency department.

 

My patient was a thirty-five-year-old man who came in by ambulance. He had a condition called tardive dyskinesia. It is a movement disorder that can develop in some people, often a side effect of some psychiatric medications. He had the most terrible case I have ever seen. Whenever he was awake, he had uncontrolled movements of his entire body. Not just wiggling but actually thrashing. Every single minute, he writhed in bed, throwing his arms and legs around so much that we had to put pads on the side rails of the bed to keep him from injuring himself.

He was a Kaiser member, and sees a neurologist who specializes in movement disorders. He is also a regular visitor to their emergency department. He ended up in our emergency department because, when the medics were called to his house, he told them he was so sick of his constant movement that he wanted to die. That prompted the police to put him on a psychiatric hold and all patients in our county that are on a psychiatric hold must come to our hospital.

I had never before seen anything so severe. I ordered laboratory tests and got some information from Kaiser before I was comfortable that he didn’t have anything new or dangerous going on. I then formed a plan to help control his movements enough that he could go to the psychiatric emergency room. We did this by giving him injections of medications. One medicine, benztropine, is used for various types of movement disorders. We also give him lorazepam, which is a tranquilizer.

When he got enough medicine, he finally quit moving and fell asleep. However, as soon as the medicine started to wear off, he started moving again. A little at first, then as soon as he was wide wake, the thrashing would start again.

When he was settled down to what he said was his baseline, I sent him over to psychiatry. However, in a few minutes, we got a call from them saying they were unable to deal with his constant movement and were sending him back to us. I eventually had to admit him to the hospital to be seen by a psychiatrist as an inpatient.

I looked on YouTube to see if I could help you get an idea of what this poor man was living with. Here is one example, which is similar to, though very much milder than what my patient had:

https://www.youtube.com/watch?v=Qf3I6t8fuA8

 

We frequently have to decide if an elderly patient has an altered mental status. This can be a bit tricky because the patient might be a little “off” at baseline so sometimes, we have to try a little bit harder to determine if the patient is altered or not.

The other night, the intern (doctor in training) told me an eighty-year-old woman was confused because she was not able to give the exact date. After meeting her, I asked her if she knew where she was and she named, exactly, our hospital.

I asked her if she knew the date. She said, “No,” without even trying. When I pressed her, she gave the year, off by only one.

I then asked her who was the President of the United States. “Obama,” she answered confidently.

“Who is going to be the president next year?” I then asked.

“I have no idea.”

Well, who are you going to vote for, Trump or Clinton?”

“Trump.” Again, with confidence.

“You are the first person I have ever met who supports Trump. Why do you think he would make a good president?”

“Because he is very rich and has a beautiful wife.”

Since my purpose was not to delve into her politics, I stopped the interview there. If she knew those two facts about the man running for president, it was hard for me to believe she might have any significant confusion.

 

A 23-year-old non-English-speaking Vietnamese man came in with a scalp injury. Through an interpreter, he said he was playing basketball earlier that evening when he ran, head-on, into the basketball standard. He careened off and ran into a nearby fence, which he also hit with his head before landing on the ground.

His friends took him home, shaved the area around the cut and made a compress of tobacco, which they placed in and around the wound. They then decided he should get it checked out and brought him to the emergency department.

When his laceration was numbed and explored, a piece of metal was felt in the wound. X-rays and a CT scan showed a bullet embedded in his skull. He also had underlying brain damage. I called a neurosurgeon to take him to the operating room to repair of his injury.

When confronted with evidence that he had actually been shot, he stuck firmly to his basketball story. I noted that he didn’t exactly fit the profile of a basketball player. He was just over five feet tall and was wearing flip-flops.

Could he have been shot while playing basketball and not realize it? More likely, he was involved in some sort of shady activity that resulted in his being shot and just didn’t want anyone to know about it.