It was a hot Saturday night and the ED was packed, as usual. All the histories seemed the same: “I was sittin’ on the stoop drinkin’ a few cool ones . . . then he said . . . then I said . . .” Countless cuts, bruises, and possible blow out fractures filled every room. The hallway was lined with several octogenarians who didn’t have air conditioning at home. Either they just wanted a couple nights of rest or the heat had almost killed them. In any event, they were cooling their jets on beds lining the walls watching all the commotion of the typical weekend night in the ED. It was a cheap boxing match and they had ringside seats.
I barely noticed when the ambulance doors flew open with the next unannounced arrival. But you couldn’t miss the profanity spewing out of the patient’s mouth.
“Take these f***ing things off me, or I’m going to kick your f***ing a**!” He was thrashing so wildly trying to get at his captors that he was about to turn over the ambulance cart. The arresting officer sauntered in slowly behind the ambulance crew, having obviously taken his time getting out of his squad car. His stooped shoulders and scowl told everyone he was tired and in no mood to deal with this patient any more. A quick glance at the patient told me nothing except that he was drunk, obnoxious, and would be dangerous if released. He had been wearing a mask that the ambulance crew had placed on him, a common move when the patient is intent on spitting on everyone. But now it was down around his chin. Despite being cuffed tightly to the gurney by all four extremities, he lunged at the nurse who walked toward him with a blood pressure cuff.
“Touch me, you f***ing c**t,” he said to a young nurse, “and I’ll tear your face off. I’ll find you!”
She froze, looking at me with the terror of uncertainty. His profanity was commonplace for the ED, but the look in his eyes made us take his threats seriously.
“I’ll take care of this asshole!” said Mike, one of the other nurses. He was in his twenties, heavily muscled, and had been in combat with the Marines as a corpsman.
“Take these cuffs off of me, you faggot.”
The look on Mike’s face as he strode to the bedside let me know that this could easily get out of control.
“Uh, let’s let him chill a little bit,” I said, trying to lower the temperature of the situation. “He doesn’t look like he’s too bad.” All I could see was a cut lip. “How did he get this?” I asked the cop.
“How do you think?” he replied somewhat menacingly. “Somebody got tired of his lip and busted it.”
“Doctor,” another nurse interrupted the conversation. “We’ve got an accidental gunshot wound coming in. They are wanting to know if we will hold the CT scanner open ‘til that one arrives.”
“Of course,” I replied without further questions. “Everyone, let’s get back to what you were doing. We’ll let Mr. Congeniality cool off here by the nurses’ station where we can keep an eye on him. Then when he’s burned off a little alcohol, maybe he’ll let us get close enough to examine him.”
Everyone had plenty to do and seemed happy not to have to deal with the drunk right at that moment. Everyone except Mike. He seemed disappointed.
Soon the GSW arrived and everyone got busy with that case. The drunk would still scream obscenities and threaten anyone who got close or dared to address him. But as we tried to ignore him, he started to settle down. After about two hours he seemed to settle into a quiet stupor.
Everyone tiptoed by the gurney hoping not to arouse him. When the paperwork and admission for the GSW was complete, I turned my attention back to “our little friend,” as the nurses started to refer to him.
“Billy, I need to talk to you,” I said, approaching his gurney. But he only snored more loudly. I noted that his chart was empty save for the name and police report. “Billy.” I raised my voice and gave him a moderate sternal rub. He groaned. “Billy!” I shouted as I pried open his eyes.
“Oh crap,” I moaned in frustration. One pupil was larger than the other. I quickly started palpating his head. Soon I found a tiny laceration buried in the thick, matted hair of his right temple. “I need a little help here,” I said with a crescendo, calling to the nurses. “Let’s get an IV started. Call the CT scanner and let them know that we’ll be down there shortly for a head CT. And call neurosurg. This guy is going to have to go to the OR.”
“Dr. Jennings is not going to like this,” warned the unit clerk. “Should I tell him the patient was drunk and in a fight?”
“Don’t tell him anything except that I have a head injury patient who will need surgery tonight. He won’t like it, but he’ll come in for me.”
The CT quickly found the epidural hematoma and an extremely pissy surgeon removed the clot. But the patient died the next day. No family could be found for three days. It seemed no one wanted to be responsible for the hospital bill or the funeral costs.
Eighteen months later I was sitting down to Thanksgiving dinner when the doorbell rang. A sheriff’s deputy stood at the door, looking embarrassed. “I’m sorry for the timing. This wasn’t my idea.” He handed me the letter from the attorneys and asked me to sign for it. I returned to the table with indigestion. “Who was that?” my wife asked cheerily.
I shook my head.
“Why didn’t you examine him to see that he was injured?” the plaintiff’s attorney asked me at deposition. “Was it because he was poor or drunk?”
“He didn’t give me permission to examine him,” I replied. “In fact, he threatened anyone who touched him.”
“But wasn’t the fact that he was in your ER enough to imply permission that you could examine him?”
“He wasn’t there by his own choice. He was brought there by the police.”
“Didn’t they give you permission to examine him?”
“They didn’t bring him to us for an examination. They dumped him on us because they no longer have a drunk tank. The only obvious injury he had was a split lip.”
“Our expert will testify that the standard of care is to sedate the patient and examine him. Why didn’t you do that?”
“We would have had to risk injuring him or possibly killing him just to examine him. That just didn’t make sense to me under the circumstances.”
“Now that you know that he died because you failed to take the simple step of examining him, does that change your mind as to whether you should have risked sedating him to get a good examination?”
“If I knew then what I know now, sure. But I didn’t. Isn’t it important that he was brought to the ER against his will and that he refused to be examined? Isn’t touching a patient against their protest an assault?”
“I’ll ask the questions,” was his only reply.
CDR Mark Plaster, MC, USN Founder & Executive Editor of Emergency Physicians Monthly