Shooting the Driver

There are as many ways to get oneself admitted to the brain injury service as there are methamphetamine labs in Iowa. It’s amazingly random for the most part, but there are also certain predictable sets of circumstances that lead to that end more often than you might think.  There was the woman who was driving under a bridge when a forklift fell from the overpass onto her car, and the guy who chased his valium with half a bottle of Maker’s Mark then walked in front of a snow plow (a waste of perfectly good Bourbon notwithstanding).  And then there was the lady who was smoking crack when she heard a gunshot she assumed was destined for her, so she jumped out of the third floor window. 

There’s the surprisingly common combination of ecstasy and bridges and of Canadian whiskey and shotguns (also skateboards and stair rails, ATVs and creek beds, and the extremely problematic Viagra and autoerotic asphyxiation). It is generally considered a bad idea to climb onto your roof to hang the Christmas lights when you have already been diagnosed with vertigo and sick sinus syndrome, or to get drunk and fall out of your deer blind when you are alone and no one will find you for a few days.  I confess that I have never really understood the phenomenon of being hit by a train, as it seems that the most likely way for this to occur is to be loitering (or sleeping) on the train tracks, and so the corollary implies that staying off the tracks might ensure that this would not happen. 

But the situation that remains the example of the most ill-planned, lacking-in-strategy and all-around preventable injury is the story of a man I admitted one sunny Friday afternoon.  This guy’s lucky to be alive, I thought, diving into his chart.  He had a terrible brain injury– intracranial blood, nerve shear, skull fracture, GCS=3, coma for greater than two weeks, tracheostomy, gastrostomy tube, the whole enchilada.  I went in to see him: he had been in the hospital for over six weeks, and still had blood caked behind his ear– his trach was filled with mucous, his G-tube had green discharge and granulation tissue around it.  He had what is referred to as the “Neurosurgery Mullet,” which is the hairdo you get when you come in as a trauma and the brain surgeon (or more accurately the OR staff/resident) takes the clippers to the site designated for the incision, leaving the rest of your hair intact.  After several weeks in the ICU, the unshaved hair grows to a raggedy wig of greasy mess, and by the time you reach the rehabilitation unit, your hair is a fright, your memory is returning in fits and starts, and there is the smallest glimmer of realization that things will never be the same.  I talked to this particular patient for quite a while, and found him to be “alert and oriented x 1,” that is, he knew who he was, and not much else. The most oriented you can be is to person (your name), place (where you are), time (the date, including the day of the week), and to situation (why you are in the hospital in the first place), that is, oriented x four.  Our patient could only come up with his name several weeks after his injury, which is all things considered, pretty bad. After a long talk with him which revealed numerous serious deficits, I returned to his chart to fill in the gaps in the story.  The EMS and ER records gave a fairly detailed accounting of the injury.  He was the sole passenger in a late model sedan, driving down an interstate highway within the city limits.  His girlfriend was driving, a little over the speed limit, but not what anyone might call recklessly. They were arguing when they got into the car, about something which no one will ever be able to detail, and several miles down the road, he drew a handgun and shot her in the head.  The car swerved, and spun across the highway and into a barrier. She was dead at the scene, as one might expect to find anyone shot in the temple at a two foot range, and he was thrown from the car and critically injured, as one might expect to find an unrestrained passenger in a high-speed collision. Most of the situation was familiar; the impact, the extraction, the transport, the emergency department record, the acute hospitalization, the usual infections/complications/delays.  But the thing that struck me most about the story was the knowledge that there was a single, blurry, poorly considered moment where he decided to shoot the driver of the car in which he was a passenger; where he considered, at least briefly, his options and chose to pull the trigger.  Did he realize that if she was injured no one would control the car, and that he would be in danger?  Was he feeling passively suicidal?  Was he so lacking in problem-solving ability that he didn’t consider the consequences?  Did he have any inkling that he would end up here, on my service in the brain injury unit, sucking pureed pork chop for dinner and spending his days re-learning how to walk?  Would he ever understand that he had killed someone he loved out of anger? 

I spent a lot of time with this guy, and many more in similar situations, and it only caused me to wonder a lot of things:  Why are humans so dumb?  Why don’t we learn to be smarter, more peaceful, less crazy?  Why do random horrific things happen to people who are doing what they are ‘supposed’ to do?  Why do we continue to do the most ridiculous shit and then act surprised that the outcome is undesirable? What will ever make us stop being hateful and ignorant and difficult and mean?  Unfortunately, I don’t know the answer; I have enough optimism left to still hope, but it is balanced by a wild and deep skepicism, and this is the result of musing over these points.

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