FUCKING HEADACHE | Kenneth Weinberg
Deep into a tumultuous Saturday night, two men from the town’s volunteer ambulance crew burst through the doors of our Emergency Department. They whizzed their stretcher through the background pandemonium, passed a barking, croupy three-year-old boy on Bed 5, neatly avoided the vomit from a 40-year-old pancreatitic woman on Bed 3, and screeched to a halt at the side of the last empty bed, number 6. As they began unbuckling the straps securing their patient to the stretcher, they told me about the man they'd just brought in. Offhandedly, the older of the two crew members (wearing a green John Deere cap) tossed out a brief report to me:
"Yeah, doc, this guy called us complaining of a headache. Sounds like he did a little bit too much drinking tonight."
“By the way,” his younger partner allowed, “it seems like he doesn’t speak our language.”
“What language does he speak?” I asked.
”I think he speaks Korean if that's any help," the younger one replied as he and his partner turned quickly to go.
"Any family with him or anyone who can translate?" I shouted at their now retreating figures through the din, "How about his vital signs?"
"Nah, no one came with him," John Deere shouted back, and then, apologetically, he added, "Look, we've gotta go, got another call to get to!”
On that note, he and his partner quickened their pace, and, with the squawks of their walkie-talkies and the clicking of their stretcher wheels fading off down the hall, they were gone.
Apart from the nurse's aide now quickly taking his vital signs, my new patient sat unattended on Bed 6 for the better part of the next hour while I ran over to Bed 8 to suture a nasty scalp wound an 18-year-old kid had incurred in a street fight, and then went off to the Quiet Room. In that location, generally used to isolate and evaluate psychiatric patients, I found a delusional, agitated, 39-year-old homeless man whom the police had brought in because they'd found him walking down the street kicking over every garbage can he'd come in contact with on his travels through town.
Finally, I got around to my patient in Bed 6. I walked into his cubicle, its lights dimmed by the aide because of his headache, and got a good look at him for the first time. He was a middle-aged Asian man, dressed casually in a brown crew-neck sweater and jeans, with a thick shock of straight, short, gray-flecked black hair. While he seemed to be comfortable as he sat on the gurney, eyes open, arms folded across his chest, I was struck by what seemed to be the contortion of his round face. Its features appeared all tightened up, and I immediately wondered if this was from the discomfort of the headache that had allegedly brought him in.
“Hi, I’m Doctor Weinberg,” I said, “Sorry it took so long to get to see you.”
He stared at the curtain I’d pulled closed when I entered the room.
“Can you tell me your name?” I asked, wondering if he understood me.
Same blank stare.
Having seen many Koreans in the ER during my years there, I decided to use the one phrase I had learned and ask his name in that language.
“Kim,” he said and then began a long, incomprehensible monologue in Korean to me.
Now, it was my turn to stare blankly at him.
“Can you tell me what happened to you tonight?” I asked, shifting back to my native tongue.
No response.
I moved closer to his bedside and looked more attentively at him. I thought about what the ambulance crew had said and tried to sense if he had the typical wasted appearance and flat affect of someone who’d just spent the night drinking.
“Can you close your eyes?”
He did.
“Now, can you open your eyes and follow my fingers?”.
He quickly reopened his eyes but continued to stare at the curtain.
“Could you try to squeeze my fingers?” I said as I put my hands by his, my index fingers extended for him.
No response.
“Can you tell me why you’re here?”
Nothing.
“What’s bothering you?” I finally blurted out.
“Fucking headache. Fucking headache.”
This disconcerted me a bit, and all I could think to ask next was:
“Have you been drinking?”
“Fucking headache. Fucking headache.”
The words were said in a deep, angry monotone, clearly enunciated, but with a heavy Korean accent that made them nearly unintelligible.
“Oy, now what?” I thought, feeling stymied and uneasy.
I looked over at his chart, sitting on the bedside table where I'd placed it when I entered the room. I glanced at his name, saw it actually was Kim, and then quickly scanned down to the vital signs obtained earlier by the aide.
“No high blood pressure, no fever,” I noted.
“No stiff neck," I felt as I tried to examine him as best as I could, taking his head in my hands and gently moving it backward and forward, "Unlikely he has meningitis or a bleed in his brain."
“No bruises or swelling on his face or head. No signs of trauma anywhere. No alcohol smell, no smell of anything strange he might have ingested,” I thought, getting up close to him, discreetly sniffing and anxiously scrutinizing my brain as I tried to find any clue that could help me decide what was causing Mr. Kim's headache.
“What do I do? He needs a CAT scan. Should I call in the radiologist from home now and do it as an emergency? Or maybe, since I can't find anything really critical going on, I can give him pain medications, and if he feels better, scan him first thing in the morning when the weekend radiologist comes in.”
(This was at a time in the mid-1990s when, in the typical community hospital, to get a CAT scan in the middle of the night meant waking the on-call radiologist and having them come in to supervise the shooting and interpretation of the scan. There was a delicate process involved: knowing when to push this for someone who really needed an emergent scan and when to hold off for medical and political reasons, and wait till seven or so in the morning when the daytime radiologist would typically come in and do the scan first thing as they arrived for their shift.)
Here it was, four o'clock on a Sunday morning, and I was stuck. I'd been a full-time ER doctor for about ten years, used to working independently, trusting my clinical judgment, making decisions, and moving on to the next case. I wanted to do what was best for this man, but the language barrier made me feel like I was dealing with a black box. I thought about how critical words were in getting a flavor about someone's illness; I was grateful for my fluency in Spanish and French, but at that moment, I wished I knew so many more.
I started feeling even more stuck, ruminating about how unnerving Headache Patients could be. Fearing an unneeded headache about to descend on me, I decided to get another opinion.
“Lissa,” I called to his nurse, “Mr. Kim in Bed 6 seems to have a pretty bad headache, but I can't find anything wrong when I examine him. He understands so little English, and, my Korean being what it is, I can't get a good sense of how serious this is.”
Lissa walked to the bedside. She had grown up riding on the ambulance crew and had worked in the ER for several years. I respected her judgment.
“How about giving him some pain meds,” she asked as she looked closely at him, “ and seeing how he responds? You can always wake the radiologist up to come in and scan him if he doesn’t get better.”
“That’s funny. I was thinking the same thing,” I concurred, smiling.
I wrote an order for IV pain medication, Lissa administered it, and he seemed to feel much better.
Within minutes, he stopped repeating what I'd come to think of as his mantra; his face seemed to loosen up, and he fell asleep. Feeling much better myself now, I went off to see the new patients who'd arrived and, just before 7 A.M., called the tech and radiologist to ensure they'd scan Mr. Kim as soon as they got to the hospital. Before I left the ER, I told the physician coming in to work the day shift my concerns about this case and went home feeling I'd done the right thing and Mr. Kim would be taken care of appropriately.
Twenty-four hours later, I came in to do the Monday day shift and, before I'd even had a chance to take the lid off my coffee cup, Charlie S., one of the staff radiologists, called me.
“Kenny, I’m reviewing the CAT scans from yesterday,” Charlie told me in a panicked voice, “There was a patient who had a scan first thing Sunday morning that was read as normal. It was not a normal study!”
The CAT scan he was talking about was Mr. Kim's. It turned out that the part-time weekend radiologist had missed something critical on the images that showed abnormal blood in his brain, a subarachnoid hemorrhage.
“A subarachnoid. We missed a fucking subarachnoid!” I thought and immediately went into a panic myself. The words reverberated in my brain as the nurses and I raced to find Mr. Kim's chart to see what had happened to him on Sunday and, more importantly, to see if there was a way we could locate him immediately. We knew we had a time bomb on our hands, that two-thirds of all patients don't survive a bleed like this, and that he required emergency neurosurgery to save his life. As we searched, I kept thinking about how missing a “subarachnoid” was an ER doc's worst nightmare.
We quickly found the chart and saw that Mr. Kim had been feeling fine when he returned from his scan and had been sent home with our usual "Headache Precautions" Discharge Sheet (in English, of course.) As Charlie now showed me on the scan he brought over, Mr. Kim did not have a usual headache at all but instead had burst an aneurysm in his head and bled into his brain, the elusive cause of his expletive headache.
Surveying this chart again, all of its data appearing in such a different light to me now than when I'd last seen it early Sunday morning, I found, to my surprise, that the ambulance crew had left a phone number for Mr. Kim. I dialed the number in a frenzy, my heart racing, not knowing if anyone would answer, not knowing if they'd speak English, not knowing if Mr. Kim was still alive.
A woman answered, and I explained how serious the situation was and how Mr. Kim needed to return to the ER immediately. I hung up the phone, hoping she understood what I was saying. We immediately called for a Korean translator, and I began a wait that was one of my life's longest and most agonizing half hours.
Thirty minutes later, the doors to the ER opened and once more let in Mr. Kim, now with his family of three.
“Dr. Weinberg?” Mr. Kim asked, smiling as the group approached me.
I nodded.
“You called and spoke to my wife a little while ago, said something serious was going on with me?” all of this spoken in English that contained only the barest hint of an accent.
Trying to hide my shock, I yelled to the charge nurse: “Eileen, Mr. Kim is back. Notify the OR, and please call the doc who's on for Neurosurgery. Tell them it's urgent!” All this was said while I guided Mr. Kim and his family to the now-empty Quiet Room so we could quickly prepare him for surgery.
“Mr. Kim, I'm so happy to see you, so happy you seem to be OK, so happy to be able to talk with you.” The words and feelings seemed to burst out of my mouth all at once as we walked into the room.
As he put on the hospital gown I'd handed him, Mr. Kim turned and told his family in Korean what I'd been saying.
We sat together as the nurse came in to chart his vital signs and draw blood.
“Mr. Kim,” I said, “when you came in Saturday night with your headache, you had had a very serious event occur. A blood vessel had burst and leaked blood into your brain. From how you seem now, the bleeding has at least temporarily stopped, but it could bleed again at any minute, and you need surgery as quickly as possible to prevent that from happening.”
Mr. Kim seemed incredibly poised and dignified to me now as he listened to me as we prepped him for the OR for the daunting, prolonged surgery he would completely recover from. I sat next to him and thought back to Saturday night, to the ambulance crew, to my frustrations at my inability to penetrate the “black box .”
I thought about the complexity of the brain's language center and how the tidal quality of the ebb and flow of blood through it had caused the damage I'd seen evidence of on Saturday night. Now, because of the incredible resiliency of Mr. Kim's brain, the language center's function had been at least tempo-rarily restored, giving him a lexicon of much more than the two words of our language I'd last heard him use. And, I thought about the black box of my own language and cultural barriers and how they had so nearly cost this man his life.
Kenneth R. Weinberg MD has had a 40+ year career as a researcher in psychoneuroimmunology, ER, urgent care and house call MD. Weinberg has been involved with Physicians For a National Health Program, advocating for Single Payer, Universal health coverage, as well as a participant in the Program in Narrative Medicine and a published author, including in The New York Times. For the past eight years he has been a registered cannabis clinician in New York State and advocate to educate legislators, colleagues and the public on the benefits of the plant. He is finishing work on a memoir of stories and reflections on the interface between literature and medicine. A recent article titled “The Books They Carry” was just published in Psychology Today.