Don’t Get Nailed

The patient, a 34-year-old construction worker, presented to the ED with a chief complaint of headache—always a challenging presentation. Headaches have many potential causes, ranging from minor to fatal. Sorting it out in the ED can be daunting, while the consequences of an error in judgment can end a life, or an emergency physician’s career.

In the early days of the specialty, we didn’t have a plethora of diagnostic aids to help us resolve the dilemma of sudden onset of headache in an otherwise healthy young male (i.e., no CT scanner). We had to rely on our training and experience to lead us to the correct diagnosis and treatment decision; and we had rules and protocols, such as, “Plain skull x-rays are useless in the evaluation of patients with headache and no history or signs of trauma.”

A colleague evaluated this patient, who had waited awhile to be seen because triage prioritized potentially more serious maladies ahead of him. By the time the ED physician got to him, the headache had decreased in intensity and the man wanted to go home. He had been working on a construction site, wearing a hard hat, and felt a sudden pain in the top of his head. He finished his shift, then came to the ED. The rest of his history was unremarkable and his physical and neurological exams were normal. A doctor might be tempted to send this guy home based on the non-contributory history and physical examination, but something about the gestalt worried my colleague. He wanted to a spinal tap to look for bloody fluid, which would indicate a brain hemorrhage, but the patient refused. He insisted on going home where a cold Bud awaited him.

The emergency physician talked the patient into a simple, non-invasive skull x-ray series. “Call it a hunch,” he later told me. “I had no idea what I was looking for.” The doc got pushback from the staff about deviating from protocol, but he held fast and the patient went off to radiology.

The patient survived, but the actual x-ray is no longer with us. Here’s a reasonable facsimile, courtesy of Reddit:

Five-centimeter nail impaled through skull at forehead

Our patient’s x-ray was almost identical, except the nail entered at the top of the his head. After seeing the x-ray, our ER doc examined the patient’s scalp and found a small puncture wound that corresponded with a new crack in the man’s construction hard hat. A co-worker some distance away had discharged a nail gun, but didn’t see where the nail went. A neurosurgeon took the patient to the OR and removed the nail. After a brief recovery, he went home with no neurological deficit.

A brief review of the medical literature reveals that this type of injury is relatively common around nail guns—most often self-inflicted by accident.

The takeaway from this case, as stated by my ED colleague: “Trust your clinical judgment, even if it means going off protocol. Otherwise you could get nailed.”