Timeless advice: don’t run with scissors, don’t swim after eating, don’t drunkenly stagger out of a pawn shop and onto an interstate feeder road.  Especially if it lands you squarely in the crosshairs of a barreling tow truck.

To the driver who had glanced down at his radio, it was as if he had materialized out of thin air.  The story almost ended here, someguy to share the same fate as the flattened critters on the truck’s grille.  Only in retrospect was it clear that he was far too mean to die so easily.  Instead, the driver instinctively smashed the brake and yanked on the wheel, the front end seemingly just whistling by, but the side mirror smacking him flush on the shoulder, spinning him around, then the passing rear bumper catching him just below the knee.

Undeterred, someguy got up and resumed his staggering, although this time minus a chunk of his leg.  Police and EMS quickly arrived on scene, and someguy wanted no part of an ER evaluation but he was in no position to refuse, being drunk and high and whatever else, and so our paths crossed.

I examined him, cautiously, unsettled by his lability: he was laughing hysterically one minute, sobbing the next, then vicious the next.  The exam was about as revealing as a nun-of-the-month calendar — all I took away from it was that this guy was hit by a freaking tow truck and needed to be CAT scanned from head to pelvis.

But then the blood pressure cuff started inflating, and it was as if the cuff had become white-hot too.  Someguy, in an impressive burst of insanity, sat bolt upright, screamed, ripped off the cuff, ripped off his neck brace, ripped off his gown, and ripped out his IV, splattering drops of blood across the wall.

Clearly he needed to be restrained, for his safety and ours.  We did the usual thing, one person for each extremity, and I took my place at the head of the bed to keep his neck bones immobilized.  He fought the leather restraints, thrashing dangerously, so I slipped my fingers under his jaw and applied upward pressure, a move that typically elicits submission.  Not this time though, it was as if he was impervious to pain.  And then, suddenly, he managed to wrench an arm free and pow/pow punched me twice in the face.

I felt no pain, it didn’t hurt until later.  Instead shock and a primal rage that spread internally like a reservoir through a crumbling dam pleading and empowering me to retaliate but I didn’t, fortunately, I just grimly dug deeper into his jaw until finally that arm like the rest of him was tied up.

I went back to reassess a few minutes later, composed, since I am scary good at setting aside emotions to deal with the task at hand.  The nurse stood by with the haldol and ativan as I explained to someguy how important it was to get the scans, that he could have life threatening injuries for all I knew.  He looked at me wild-eyed and said as crudely as you can imagine that he’d never allow it to happen.  Immediately, I saw in my mind’s eye an image of the CT scanner, with the tech and nurses struggling to hold him down, and then returning to reality I looked at the nurse and asked her to put the haldol and ativan away.

Enough was enough.  I decided to sedate him far deeper, to a level that would require intubation and mechanical ventilation.  Reflecting on the decision while getting things ready I found myself more apprehensive than usual: there is always risk involved in taking over someone’s airway and here I didn’t have a “hard” indication like being unable to adequately breathe or clear secretions.  But here we were an hour and a half into his ER visit and I had yet to even be able to assess if he had any sort of internal injury, not to mention he was consuming the majority of resources available in the ER, so that he was compromising not just his care but the rest of the patients as well.

We gave him the intubating meds and his oxygen levels almost immediately plummeted.  Normally they’ll hold steady for 3-5 minutes or so, but his metabolic rate was ramped up so crazy high from all the stuff he was on that his body was chewing through oxygen like crop-deprived locusts through a field.  I hastily stuck the laryngoscope in his mouth and his vocal cords politely dropped into view.  ”Gimme that tube” I said, quickly easing it down his throat, the monitor voicing approval with some happier-pitched beeping.  Finally, blissfully, his care became routine, he went quietly through the scanner, and in fact he did have some internal injuries that were treated without incident.

Sometimes alcohol turns people into a-holes, and sometimes a-holes just happen to be drunk; this guy went on to reveal himself as the latter.  Not that it matters.  No matter how base, or irresponsible, or dangerous you might be I’m stuck with you.  How I feel about being the nation’s safety net is a whole other post, for this one it is suffice to say that holding the rope at times can literally leave a mark.