A little story for your weekend coffee... allow me to paint a picture for ya.
*****
0030 on a weekday night, in a usually busy (but not tonight) Level 1 ER. You're doing your thing, got 4 patients and are keeping up with them. In comes patient number five, and you know the drill: head bandaged, blood on the shirt and stretcher, malodorous chemical smell (is that beer or Jager Bombs I smell?) and the patient is, how shall we say, obstreperous towards EMS and staff. The patient won't cooperate with allowing vital signs, isn't forthcoming with answers to the triage nurse question, and is in general, acting like the drunken twit you've seen so many times before. The patient has no idea how they came to be bleeding from the occipital region of their head. Tetorifice is up to date, and the BAT (breath alcohol test) shows a 0.234. (Note bene: in our neck of the woods, we call someone who puffs a 0.234 a "pantywaist"). Triage accomplished, the patient (who I'll now call Bogan for the purposes of brevity) is shoveled off to your empty urgent care area for some emergent laceration irrigation and stapling coupled with some vigorous post-event sleeping in order to metabolize all that alcohol.
You only notice this from out of the corner of your eye, as you don't know Bogan is going to be assigned to you.... yet.
"Can you take the drunk head lac?"
Sooo.... you head over to assess Bogan. Well dressed, well groomed, expensive shoes. No puke that you can see or smell... more importantly, no urine, either. A irregular, poorly approximated 3cm v-shaped laceration graces Bogan's head. Bleeding is controlled. No other obvious injuries noted, and all of Bogan's clothing is intact and clean. Bogan denies pain elsewhere. Bogan scores a GCS of 13 (Eye 3 Verbal 4 Motor 6). Bogan cannot tell you how this trauma came to pass. Bogan can tell you that "My head hurts", primarily near the injury, but Bogan also says "I have a headache". Tsk, tsk, you cover Bogan with a sheet and search out any compadres who can illuminate the darkness.
Bogan's friends are in the waiting room. After telling them for the fifth time that you are *not* the physician, you get the rest of the story. Bogan was leaving a drinking establishment and got shoved down a set of stairs, unknown number. Bogan's head got cracked on the cold, unforgiving sidewark, and Bogan "was probably out for a good few minutes: we couldn't wake (Bogan) up, and when we did wake (Bogan) up, (Bogan) said 'my head hurts' and we laughed about it". I encourage Bogan's friends to stay here and wait in the waiting room, they reply 'nah, we need to go bail our other friend out of jail; (Bogan) can catch a taxi back to the hotel'.
You obtain their contact info and bid them so long. You inform the attending, and a CT brain and CT cervical spine are ordered. You dutifully apply a cervical collar to Bogan, and are met with no resistance from Bogan.
Hallelujah! Something easy! You head off to attend to your 4 other patients.
30 minutes later, you check on Bogan: sleeping blissfully, c-collar in a heap on the bed. C-collar reapplied (again, without any resistance), you call CT and ask when can the irradiating commence? Bring 'em down, they say.
You wheel Bogan down to CT, notify CT that Bogan is waiting and walk back out to where Bogan is: sitting on the edge of the bed, c-collar in a heap on the bed, Bogan looking at you, saying the following:
"Whaats goin' on?"
"Bogan, you hit your head, and we need x-rays to make sure everything's all right"
"Nah, evrythinnnngsh allright. Besides, I'd rather not."
"Sorry Bogan, we really need these x-rays; it'll be quick and all you have to do is lie there. It won't hurt a bit. Here's a blanket, get back in bed and get some rest."
Bogan complies; c-collar reapplied (no resistance!), and you go back to check on your other patients.
You check on Bogan's progress in CT a little bit later; stretcher empty, c-collar in a heap on the bed, and the voice of the CT tech staying, "Please stop moving!" coming from behind the door. Bogan, you assume, has begun receiving a large dose of radiation. You check in on the CT progress..... and realize the person being scanned in no way bears any resemblance to Bogan.
Bogan is missing. Gone. Into the ether.
Drat! Actually, the words running thru your head would make a Scotsman blush, but 'drat' suffices for this internet forum. You gather some help and quickly recon the entire Radiology Dept. Every stone turned, unlocked door opened.
No Bogan.
Dutifully, you notify your charge nurse & attending- "oh boy, better let security know"
Dutifully, you notify Security - "no one matching that description left this hospital; Bogan must still be here; we'll put out an all-points."
Dutifully, you notify the house supervisor - "I'll notify the floors to keep an eye out."
(dutifully, you also kick yourself for letting Bogan out of your site: in retrospect Bogan showed no inclination to try to walk away previously)
You spend a good 40 minutes looking for Bogan. No dice. Bubkis.
55 minutes after Bogan eloped, Bogan is found wandering the same dammned hallway in front of CT that you so thoroughly searched less than an hour ago!!!
"Bogan! Where did you go?!"
"I hadda pissh."
:devil:
You leave Bogan in the company of your ED tech to await CT. C-collar applied (no resistance!).
Dutifully, you notify the charge nurse & attending - "Oh good. Are the CT scan results back yet??" grrrr.....
Dutifully, you notify Security - "Thanks for letting us know."
Dutifully, you notify the house supervisor - "(laughter) Glad you found your patient!"
Twenty minutes later, you receive a stat call from CT scan:
"Your patient has a positive CT scan."
You hoof it down to CT scan to check on Bogan. You walk into CT juuust as the images flash by on the monitor. Bogan has one of the most beautiful right fronto-temporal subarachnoid hemorrhages you ever did see. A classic contra-coup injury: large scalp hematoma over the left occiput and the aforementioned bleed up front on the right.
BTW, Bogan's c-collar is in a heap on the bed. :angryfire:
You wheel Bogan back to the ER after applying the c-collar (no resistance!) and tell the charge nurse the following:
"I need a room. The patient has a bleed"
"From the head?"
"No, in the head. Subarachnoid."
Room given, you wheel Bogan in. You then begin the process of making Bogan look like a real, proper, sick patient. IVs (large bore x2, yay!), hospital gown, cardiac monitor, the works. Plus, the requisite neurosurgery/trauma consult, replete with 3 or 4 shortcoat Doc-lings milling about, eyes like saucers, watching the beautiful choreography of a focused secondary assessment. Your shift rapidly coming to a close, you follow up on your other patients (remember those four?), discharge one, medicate the other, and emotionally support the third. Since Bogan now has quite the crowd surrounding, you are able to do these other things without worrying that you will re-enter Bogan's room and find the c-collar. In a heap. On the bed.
*****
Lessons learned: 
-All drunks with an obvious mechanism of injury have a head injury until proven otherwise by CT scan.
-Get your drunks undressed, into a hospital gown; they are less likely to take a walk if unclothed or partially clothed.
-What is drunken, drowsy slurring to you just may be drunken slurring by way of increasing intracranial pressure.
-Always keep your drunks in plain sight so you don't play 'hide-and-go-drunk' like I did.
-Breath alcohol counts can be notoriously inaccurate if the technique is poor. Bogan's blood alcohol level was 0.299 a full five hours after the 0.234 blown in triage. Which means Bogan had a blood alcohol hovering near 0.38 upon arrival. In our neck of the woods, we call a 0.38 BAC, "pretty sporty"
-Lastly, when that little voice inside your head goes 'yay! the drunk a-hole walked out, steady gate, AMA! No longer my responsibility!', learn to stifle it and go get your drunk back in the ER until they are sober. :trout:
Hope you all enjoyed my little story.
-Craig
RN, BSN, and others.
