It was well into my third year. Because I lived a distance from the medical center and shared cars with a group of other medical students, it was not unusual that I would spend the night at the hospital. When this happened, I would split my time between the library (or some other place to read and study) or sitting near the front desk of the emergency department, watching for interesting cases that I might follow and learn from during the course of the evening. I still remember ‘cluster night.’
A young man, well-dressed and in his early 20s, whom I later learned was a graduate student at the University of Rochester, came to the window and asked imploringly that somebody keep his headaches from coming back. “If they start again, I don’t think I can take it. I just don’t know what I’ll do.”
He was given the usual clipboard and pencil, and advised to fill in his particulars (name and address, contact information and payment information) and then bring the clipboard back to the desk.
When he returned the clipboard, dutifully filled out, he asked again if he could please see someone as soon as possible. He said he was sure the headaches we’re about to start. The secretary, never lifting her eyes from the novel she was reading, directed him with a bored and practiced dismissive gesture towards the vinyl seats at the far end of the waiting room. In response to his continued silent presence at the desk, she assured him - still without ever looking up - that the medical resident would be along shortly.
Time passed. The emergency room was not busy that night, and I was making good progress digesting several articles about diseases of coagulation. I completely forgot about the young man. Then, out of the corner of my eye I saw him stand up and look around, as if he were intent on finding the nearest bathroom. I continued reading, wondering if I would see further drama as he attempted to get the attention of a reluctant healthcare system. He stood there a minute or so, seemed to shudder once, began pacing slightly, rather like the lung jumper getting ready to start down the in-run. He continued scanning the waiting room, clearly looking for something he could not find, but stepping in place with steadily more agitation. He scrunched his eyes closed, then opened them and seemed disappointed at the effect, as if he had hoped to awaken somewhere else. This was repeated several times. Gently at first, but then more vigorously, he began rubbing his forehead. The rubbing accelerated and transformed into a rhythmic pounding of both temples with his fists. By this time my articles were in my lap and I was transfixed. The secretary, however, remained buried in her romance novel. He cast his glance in our direction, looking right through us for several moments but clearly not seeing us. He bent his head forward just slightly as if paying respects to an elder, and then bent forward slightly at the waist. He took two hesitating and awkward steps forward and one back and paused. I on’t know why, but I experienced it almost as the image of a cat hunting a mouse. Suddenly he seemed to stiffen. He made a little skip-step that again reminded me of the triple jumper, he began to run. Launched himself would be more accurate.
Head down, arms pumping, he flew across the waiting room, still accelerating when he hit. I will never forget either the sound of his head against the cement block wall, or how motionless he lay on the floor after the impact. I will also never forget how quickly the ER clerk went into action, producing several orderlies and a nurse magically out of nowhere, and a resident almost immediately thereafter.
X-rays were not necessary (and CT scans had not been invented) to diagnose his depressed skull fracture: it was easy to feel, even for a third year medical extern like myself. His neck was immobilized, he was ‘gurneyed’ and I did his general exam and a detailed neurologic exam under the watchful eye of the resident, who actually let me write a first draft of orders, a real treat at that stage. I was also encouraged by the resident (and appreciated by the nurses) to stay up and repeat his neuro evaluation every hour through the night.
Between doing hourly VS and neuro checks, I read about cluster headaches in preparation for presenting him on morning rounds. Up until that that point, I knew only that it was a unique form of migraine. The demonstration he provided of the debilitating impact that uncontrolled cluster can have has stayed with me ever since. He, on the other hand, had no recall of anything that had happened that evening.