“I Have This Pain In My Back”

Knife Wound

When I graduated from The University of Arkansas Medical School in 1964, I was certain that I wanted to pursue a career in the field of surgery. My Dad (Pop) was a general practitioner that was experienced in many areas of medical care, but he especially loved performing surgical procedures and the associated drama of the operating room. In looking back through trained and experienced eyes at the procedures he was able to do then, he was an excellent surgeon with superior judgment and skills.

The Medical Center hospital in Little Rock offered the best and most up to date care in the state at that time, but was relatively small in size, and the bed-side experience of the individual physicians training there was limited. I wanted to further my training in a larger metropolitan area hospital where there was no limit to training opportunities. In deciding on an internship, I had visited the city hospitals of Chicago, Minneapolis, New Orleans and Atlanta. I was especially interested in Cook County Hospital in Chicago, but unfortunately, I visited there in December prior to my graduation, and the icy weather I endured during my 2 day visit convinced me that was not the place for me. I opted for Atlanta and the best hospital for me was Grady Memorial Hospital. Grady is one of the largest teaching hospitals in the country, and I experienced things there I had never before seen.

The emergency room was an exciting place to serve as a young and eager doctor. There was a constant stream of patients; particularly on weekends, with injuries ranging from simple lacerations to major trauma involving gunshot wounds, stabbings, and auto accidents. The work schedule of the interns was 36 hours on duty and 12 hours off duty. That was a gruelling schedule, but we not only survived but thrived in an atmosphere where each of us was given great responsibilities and got to perform lots of procedures. When a patient came to the emergency room for a problem such as pneumonia, or a severe asthmatic attack, he was sent to an urgent care unit where the pace was a little slower. The truly urgent problems were treated immediately while the less urgent were asked to wait until a physician was available. The same doctors that covered the emergency unit also covered the urgent care unit. A triage nurse was designated to determine the urgency of any particular problem.

I was assigned to the emergency room during the month of December in 1964, and the weather that year in Atlanta was unusually cold, with several extended days of icy weather. One particular night near 11 PM a man wearing a large, dark overcoat walked to the triage desk and was asked about his complaint, to which he responded, ” I have this pain in my back.” The nurse asked him how long he had that pain, and he said that he developed it that night. Assuming he had sprained his back in some way, she handed him the usual paperwork to complete, and asked if he would take a seat in one of the waiting room chairs, and he would be called into a room as soon as one was available. He indicated he was willing to wait his turn. That night was busier than usual, and there were more than the average number of trauma cases. The man in the overcoat had to wait for about an hour and a half. When the emergency room pace slowed a bit, one of the nurses escorted him into a treatment room and asked him to remove his overcoat so that he could be examined. When I entered the room, he was sitting in a chair facing me, and seemed to be in no great distress. The nurse had just seated him and had not taken his vital signs when I approached him. He said he had the pain in his back since being a witness to a bar-room fight earlier in the evening. I asked where in his back he was hurting, and he turned slightly and pointed to his mid-upper back. I was shocked to see what appeared to be a butcher knife protruding from his chest wall and it was so deeply embedded that only the handle of the knife was visible. The handle was in such a position that the man couldn’t reach it, so he was not aware there was a knife protruding from his back. Needless to say, the intensity level of his treatment escalated, and I called a more experienced surgical resident to assume his care. An x-ray was immediately done and he only had a minimal collapse of his lung, thus no shortness of breath.

The man did well; recovering quickly, and was able to go home in a few days. I learned several important lessons from this emergency room experience that night at Grady. First, never assume that the complaint from an unknown patient coming to an emergency room is a minor condition until proven otherwise. Secondly, get a more detailed history of a person’s complaint before having him seated in a waiting room for more than a few minutes. And finally, when you see a butcher knife protruding from a person’s back, don’t assume that the problem is minor back pain, despite what the patient tells you.

Dr. John

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