As I removed the layers of bandages that were wound around the man's head, it looked, at first, like a perfect dissection of the right carotid artery — the kind I had seen in radical neck procedures done for head and neck cancers. However, this was not a surgical field, nor was it done with surgical instruments. This man had chosen a 12-gauge shotgun to work on himself in his bathroom. This instrument was much faster but less accurate. While a radical neck dissection takes hours, in less than a second he managed to remove nearly every non-vital organ on the right side of his head down to the base of his skull -- which remained intact. Most of his right ear was gone, but his tongue was surprisingly intact. Why would anyone want to do this to themselves? It turns out that he didn't want this either, he simply missed.
Intending for the blast to travel out of the back of his skull, he put the muzzle of the shotgun into his mouth. When he bent over to pull the trigger, his head turned tilted off-target to the left and he missed his target. This changed the trajectory and, because he was shooting birdshot, the blast simply scoured away all of the soft tissues in its path. As is the case with many unsuccessful suicides, the results of the attempt were worse than if he had been successful. The small-town emergency room could not do much for his horrible head injury, so they intubated him, wrapped his head tightly with Kerlix gauze, and shipped him off in the middle of the night. The problem was that no one told us he was coming until he was crossing the bridge into St. Louis. The report was that a patient with a gunshot wound to the head and stable vital signs was coming and that the ETA was about five minutes. He had been traveling for over an hour and something was fishy. Someone said that the doctor didn’t call us he was coming, because he didn’t think the patient would make it more than a few miles. To everyone's surprise, he made it a few miles and then some.
I was the first to see this patient because, as the surgical resident in the Barnes Hospital Emergency Room, I owned everything that was bleeding -- and this man was bleeding. For about 20 minutes he was my patient. Then he was whisked away by Dr. Joseph Ogura’s team of world-class otolaryngologists. These were my friends. We teased each other about our specialty training. They told me that they thought of me every time they emptied their bladders and I told them to make a urology appointment if they were thinking about me too often. When they saw my patient that night, they teased me about my neck dissection skills -- inviting me to join their program so I could become more polished. They knew that I already had a position waiting for me in the urology department and were always kidding about my needing to see the light and come over from the dark side. As we pushed the gurney out of the ER and onto the elevator leading to the operating room, I told them that it was actually a urologic problem that had started this whole mess. They exchanged puzzled looks and were about to ask me if the cheese had slid off my cracker, but the elevator doors closed before I could tell them the rest of the story.
In their rush to get this man stabilized and off to the operating room, they had overlooked a fundamental and fascinating part of this man's medical history. In the papers from central Illinois, there was a handwritten note saying that he recently had a prostate biopsy and was told that he had prostate cancer. Somehow this was all that this man heard. He failed to understand that with a diagnosis of prostate cancer, he was actually nine times more likely to die from something else. Unlike self-inflicted gunshot wounds, prostate cancer is a disease most men die with rather than from. Had he clearly understood this, he might have reached for a good book instead of a 12-gauge and would have had a much better evening. This fact was not lost on Dr. Ogura’s team when I spoke with them again. Nor was it lost on any of my patients with prostate cancer for the next 40 years.
Ever vigilant,
RT
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