Psycho

I was called to the trauma room in the middle of the night.  The medics were just moving a patient from their gurney onto ours. They reported he had been drinking and maybe doing other drugs at home. His family had seen him fall onto a glass table, breaking the glass and cutting his forehead.

During transport, the patient was excessively agitated and combative. Besides being strapped down to the spine board with the usual trauma straps and brace on his neck, he had leather restraints on all of his extremities and had been handcuffed to the board by police called to the scene.

He was a heavy, middle-aged man. His clothes, face, arms and bare feet were covered in blood. He was swearing and mocking everyone who was trying to help him. He spit in the face of one of the paramedics who was trying to stop the bleeding by pressing gauze against the large laceration in the middle of his forehead.

This sort of situation causes lots of problems in the emergency department. The patient may actually have serious injuries that might not be identified if he does not allow appropriate testing. Something has to be done to gain control of a very uncontrolled situation.

After calling out a list of instructions to the staff, I took his bloodied right arm, twisted it to keep it straight and held it to allow Fernando, the nurse, to start an IV. It was all I could do to keep him from pinching me with his bloodied hand while facilitating the catheter placement into his vein. Fernando then injected him with lorazepam, a potent tranquilizer.

The first dose had no effect. He was still thrashing and hollering. After the second dose, I was able to relax my hold on his arm. A third dose allowed us to start a more thorough, head-to-toe evaluation, looking for serious injuries. Though more relaxed, he continued to be uncooperative and demand to be let free.

Suddenly I noticed something changed. He went stiff, stopped breathing and started to turn purple. I told everyone to stop what they were doing so I could figure out what was going on. Everyone was immediately quiet with intense attention focused on his new condition.

I looked at the cardiac monitor and checked his blood pressure and pulse. No answer there. Next, I tried a “sternal rub.” This means making a fist and digging a knuckle into the front of the chest, purposefully causing pain. He did not respond. He was getting more purple.

As I quickly considered what to do next, the patient let out a huge breath, tried to sit up and screamed, “Psycho!” at the top of his lungs. He then fell back on the gurney and laughed hysterically.

I was almost frozen by the complex set of emotions that welled up inside of me. I was obviously relieved to know he was all right. I was filled with that indignation anyone feels when he recognizes he has been played the fool. I also could not help but see how funny it all was, in a sick and sad way. Drunks are profoundly sad yet they do and say things that are unavoidably perceived as funny. I found myself moved to laugh at something that was really very sad.

He continued to laugh and laugh, apparently enjoying the fact that he had played a very good trick on us all. He then allowed us to sew up his face and scan his head. He spent the rest of the night with us, mostly sleeping. By morning, he was sober enough to skulk out of the emergency department and head home.