All Bleeding Stops: Eventually

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Crozet Annals of Medicine
by Dr. Robert Reiser

It was not clear to me whether he had won or lost the machete fight, but it was clear to me that he was about to lose the gunfight. He was standing in the center of the ER waiting room, still clutching his machete, surrounded by five cops with their guns drawn. With their guns all pointed essentially at each other, in a waiting room full of patients, there were actually going to be a lot of losers.

The patient was completely covered head to toe in bright red blood. The blood was dripping down his limbs and off the machete. There was too much blood; it couldn’t all be his. Sheets of blood coursed down his long hair and obscured his face. A gaping scalp wound cleaved his head front to back, in its way ghastly mimicking parted hair.

He was mumbling in incomprehensible Spanish, swaying and lurching drunkenly, halfheartedly swinging the machete in the direction of the officers. Their circle expanded and contracted as he moved to and fro, a deadly sort of danse macabre.

Perhaps it was a measure of the desperation of the waiting patients in this blighted inner city ER where I was working, but none of the waiting room patients left. They had retreated to the walls and corners, watching the drama expectantly.

I was admiring the restraint of the police and the inertia of the other patients, but it was obvious that the situation was unstable, and one slip would be disastrous. As a clinician and not a cop, I saw the scenario through different eyes and felt compelled to intervene. I approached the sergeant, whom I knew well. Without taking his eyes off of the patient he asked me “Whatta ya think, doc?”

“All bleeding stops eventually,” I reminded him. “Give him a minute or two and some space. Oh—and get some gloves on.”

The sergeant indicated to his men to move back and they complied slightly. This seemed to confuse the patient, and he did a slow lumbering pirouette, checking out the new deployment. Like the dying swan in Swan Lake, the pirouette devolved into a gentle collapse into a deep unconsciousness from blood loss, and the police moved in to restrain the patient and deliver him to us for resuscitation.

The resuscitation was relatively straightforward. He had lost nearly all his blood volume, and so we transfused him with multiple units of blood and repaired his scalp wound with giant thick silk sutures. His skull was fractured by the blow but his brain was not visible and no intervention was required for the fracture. No witnesses to the event could be found and the patient was not forthcoming with any information. Upon discharge he actually asked for his bloody machete back. The police kept it on the off chance that they ever found out what had happened, but they never did.

Scalp wounds are quite common and over the years I have treated many. The scalp is very vascular and bleeds copiously. Small lacerations can look like catastrophes. Pro wrestlers capitalize on this, using tiny razor blades to make surreptitious cuts in their own scalps to simulate significant injury.

On the other hand scalp wounds can be life threatening due to severe blood loss, as in the patient above. The most dramatic examples of this are the “scalping” wounds we see in the ER occasionally. The mechanism is the same as the scalping practiced by Native Americans and many others before them. A single deep cut to the bone across the forehead at the hairline followed by a sharp tug will dislodge the scalp in its entirety from the skull.

The scalping injuries we see are usually not from frontier warfare but mostly from patients ejected face first through automobile windshields. The amount of bleeding from these can be unnerving to the uninitiated, and I frequently have to remind the new residents of a central truth of the ER: All bleeding stops eventually.

P.S. Put a stop to the scalpings! Always wear your seatbelt.

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