The first rule of emergency medicine is this...all patients fabricate (at least) and pointblank lie (at worst) about part-, or all-, of the reasons and events which have resulted in their needing medical help.
ALL patients lie.
And that's okay really...we know that...we factor it into the consultation...its why we ask the same questions in different form...and keep asking them...and frankly,we'll lie right back to you..."no of course this isn't going to hurt you!"
The difficulty with 'head injury' patients is this though...what is their "normal level of stupidity" and what may be caused by an actual brain injury?
And what percentage of their inability to name the Prime Minister is due to indifference and what part is due to alcohol and/or drugs?
The patient was a 24 year old fisherman who had allegedly been assaulted in some local hostelry by some complete strangers whilst waiting to start a Bible study class.
He was completely oriented to the "time/place/person/prime minister/monarch" questions;his cranial nerves were all grossly intact;his pupils were 'equal,reactive and accommodating'...but he couldn't tell me the name of the pub he had been in when he was allegedly assaulted...well...I knew then he was lying.
If you're smart enough not to want your girlfriend to know where you were when you were assaulted , then your excuse-for-a-brain is probably working just fine.
He was a lanky young man with a stack of gelled hair , sticky-out ears ,and a chipped front tooth...apparently from another bar fight.
He was dressed in the ubiquitous tracksuit...and smelt of dried sweat,working sweat,stale sweat,sleeping sweat,old sweat,sexual sweat,Christmas sweat,New Year sweat..even Halloween sweat.
(I had to put on a mask to examine him he smelt so bad...I told him it was because I had a cold...)
(You see...we do lie!)
He was accompanied by his girlfriend...a pretty if grubby young woman dressed in electric blue jeans,-about 2 sizes too small-,and a grey woollen top covered with what looked like glitter.
She was clearly worried about him and was sitting holding his hand (with her right hand) and texting with her left hand.
Apart from various bumps and bruises, (and with no real concern for a brain injury),his main injuries were 2 lacerations that needed to be sutured:-the first was a 1,5 cm long laceration to the top of his head...it was deep and bleeding profusely.
The second cut was 'T-shaped' with the top of the 'T' just below his hairline and the vertical arm,-about 2cm long-,extending down his forehead towards the middle of his left eyebrow.
"Right Sir...I'm going to stitch the top of your head first, to stop the bleeding and to get it out of the way..."
"I'll pop in about 3 deep sutures which should stop the bleeding...it'll take about 3 minutes..."
His girlfriend looked anxious...Will it hurt?
"Well...the local anaesthetic can sting a little bit...but it could be worse..."
How could it be worse...?
"Well...it could be my head needing the stitches..."
She looked anxious.
"And then I'll have a look at your facial laceration...that's going to take about 10 minutes...I want to get a good cosmetic effect on your forehead..."
What do you mean...'cosmetic effect'...?
"Well...the laceration is deep and is going to be visible...and I don't want you to have a scar like Harry Potter...so its going to take some careful apposition of the wound edges..and some small fine sutures...."
Don't bother mate...just stitch me up...
His girlfriend winced....Please take your time...
"Of course I will..."
No really mate...just stitch me up...why do you have to worry about the cosmetic thingy...?
"Well....I only know one way to suture a face...'mate'...and that's the Johannesburg Hospital way...the correct way...so if it's all the same with you,that's what I'll do..."
Okay then...well if you fancy you're a plastic surgeon,what about doing something to my nose...?
"No time tonight..."
and he pointed at his girlfriend...
...have you got time to do something about her tits?
Its a wonderful thing.
I gave her my phone number...listen...I may be older, but I'd be very grateful.