A 'pillowectomy' in the ED

A patient with a gunshot wound to the head presents complaining of a fierce headache with a pillow hanging from his head.

A 'pillowectomy' in the ED
A 'pillowectomy' in the ED

As a new physician assistant, I worked in the emergency department of a small town hospital. My most memorable patient was the recipient of my first, and only "pillowectomy."

One evening a young couple had an emotionally charged argument. After reaching the point at which neither party felt the argument could be won and neither could admit being wrong, the husband refused to participate any longer. He walked off, went to bed and soon fell asleep.The wife was furious and took a .22 pistol and shot him in the head.

Luckily he had been lying on a fiberfill pillow, and the bullet passed through the pillow before entering his scalp. It tumbled along the skull beneath the galea and exited the scalp on the other side, dragging a strand of fiberfill along and back into the pillow on the other side. This obviously awoke him.

The patient walked into the ED with the pillow hanging from his head. He complained of a fierce headache, but was otherwise uninjured and denied any other neurological symptoms following his sudden awakening. After cutting the fiberfill on one side of his head and infusing a judicious line of local anesthetic, I was able to follow the course the bullet had taken across the back of his head with a scalpel.

Amazingly, the fiberfill had twisted along the track into what was essentially a thin polyester rope. The bullet itself was encased in a soft wad of fiber, and embedded in the pillow. Seeing no stray strands of fiber remaining in the scalp track, I washed the incision and scalp track with a copious amount of saline and povidone-iodine solution.

After blotting the wound dry and doing a final inspection of the scalp track, I elected to close the incision loosely with several widely-spaced, interrupted nylon sutures. A series of skull x-rays was unremarkable for fracture or radiopaque fragments. An absorbent dressing and a prescription for antibiotics completed his required care. Of course, he was instructed to follow up with his personal physician.

Although I was able to save the patient and his scalp, the pillow was terminal -- it never recovered from the trauma of the excision of the projectile. While I was with the patient, the ER nurse called the local police, as required by law. I had retrieved the bullet from the pillow, leaving it encased in its acquired ball of fiber and passed it directly to the police officer.

At this time, the patient's wife had arrived and was shown to the procedure room. The shock of realizing what she had done and the potential deleterious outcomes of her actions had depleted her rage, and she was filled with contrition. After a tearful and loving reunion with her injured but forgiving husband, the couple kissed and made up, and agreed to keep the handgun better secured in the future.

The husband refused to press charges against his wife and apologized to the police officer for the trouble they had caused. Unfortunately, the patient's primary care physician never bothered following up with me to let me know the final healing status of the patient. As usual, the only feedback one ever receives is when something goes wrong.

Rick Boldman, PA-C, practices emergency medicine in Lake Orion, MI.



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