The ice-pick headache

Life is stranger than fiction. There is an entity known as the ‘ice-pick headache’ but this was different. 

I was a fourth year medical student doing a required Emergency Medicine rotation. Most of what presents to the ED,  even in a busy inner city ED, is routine. To avoid vein assigned only boring cases, I had learned to write my notes while sitting just to the side of the registration desk, where I could listen for patients with interesting problems or unusual presentations. This often allowed me to fill my shift with challenging problems. (I had not yet learned that fascinating patients often present with problems that do not seem challenging until the visit is underway, or that every patient becomes fascinating as one gets to know them.)

This particular night had already been interesting, educational, and tiring.  I did not even look up when the male voice told the receptionist he wanted to be seen about his headache. I was vaguely aware as she handed him a clipboard with instructions to fill out his name, date of birth, address and phone, and insurance information, and then bring the clipboard back to the desk..

Then I heard her gasp.

I looked up to see a young man from behind as he walked away, clipboard in hand. He appeared to be in his late 20s, with all the hallmarks of an inner city ED regular: poor hygiene and old clothes in poor repair. What caught my attention was the ice pick. It was buried to the hilt, neatly centered in the back of his skull.

 

The receptionist stat paged the nurse and the trauma resident. The young man was quickly placed in a room and neurosurgery notified, while I started taking a history. He had been drinking heavily with his girlfriend and they had had an argument. He didn’t remember what it was about. He remembered that she refused to have sex and that he was sitting on a couch watching TV. “I must have passed out. I do that a lot, mostly when I drink the hard stuff. I can handle the beer pretty good.”  When he awoke, he was alone in the apartment, the TV was still on, and he had the worst hangover he had ever had. “I’ve never had a headache like this. It doesn’t feel like a hangover. It feels like there’s something inside, eating my brain.”

It required the use of two mirrors to show him the ice pick, it was so perfectly placed, which probably explained why he hadn’t seen it in his mirror. I wondered how many people had seen it while he was walking the 8 blocks to the ED, what they had thought, and whether they had tried to say anything.

After some brief lab and a chest and skull X-ray (I’m old - this was before CT scans), he was given IV antibiotics (to prevent infection) and steroids (to reduce the risk of swelling) and taken to the OR, where the pick was removed from his skull (and brain) and he was observed for bleeding. He was discharged the next day with a prescription for antibiotics. The girl friend was charged with attempted murder but not convicted due to lack of a witness or adequate evidence. (Apparently, the betadine prep used before surgery is not good for preserving fingerprints on a weapon.)

 



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