Man's self-inflicted nail-gun attack becomes a case for medical books
OHSU Hospital - A surgical team removes an apparent record 12 nails from the Oregon man's skull and brain



Friday, April 21, 2006
ANDY DWORKIN
One day last year, a 33-year-old Oregon man picked up a nail gun and put it to his head.

Just what drove him isn't clear. Personal problems, mental illness and methamphetamine all probably played a role.

He fired. And fired again. And again. Twelve times.

Six nails clustered between his right eye and ear. The heads caught on the skull; the points pushed into the brain. He shot two nails below his right ear, four more through the left side of his face. At some point, he reloaded: Eight of the finishing nails measure 11/2 inches, four have 2-inch shanks.

A day later, he went to a small Oregon hospital. He said he had a headache.

Doctors saw nothing strange, at first. None of the nails stuck through the skin, and hair covered most of the pinpoint wounds. Then they took X-rays.

Astounded, the doctors gave him a tetanus shot and put him on a helicopter to OHSU Hospital. There, surgeons peeled back his face and removed the nails with pliers and a high-speed drill. Doctors gave the man antibiotics and psychiatric treatment. Twenty-five days later, he walked out of Oregon Health & Science University a little weak but, physically, healthy.

Doctors say his case is extraordinary: He is the only person known to have survived after having so many foreign objects embedded in his head.

"At this point, he's made a full recovery," said Dr. G. Alexander West, the neurosurgeon who led the team that pulled out the nails. "This guy was blessed in some way. I mean, that's incredible really."

Because of medical privacy laws, doctors have not identified the man who put 12 nails in his skull. The man declined to publicly discuss his story, telling OHSU officials he is working to recover and doesn't want to risk his job. But he gave OHSU doctors permission to write about the injury and surgery in the current Journal of Neurosurgery.

This case represents the only known survivor of the largest number of foreign objects (twelve) ever purposefully penetrated into the skull," they wrote. The previous record was nine, from an attempted nail-gun suicide in Japan.

When he arrived at OHSU last April, the man told doctors his head still ached, and it hurt when he moved his neck. The right side of his face drooped a little and he had trouble moving his jaw. He called the nail wounds an accident and got hostile when doctors asked just how the accident happened. A psychiatric test showed "poor judgment and insight."

"Overall, awake, alert, talkative, communicative, but in complete denial he had done this to himself," West said.

Doctors prescribed antibiotics and started discussing how to take a dozen nails from a man's brain.

The team had lots of experience. "There's all kinds of things people put in their head, believe it or not," West said.

West had tended two previous nail-gun injuries, as well as a Seattle woman who hammered a nail into her forehead. "She said she had had sex with the devil," West said, "and wanted to get the devil out." And as nail guns grow more common, nail wounds are increasing, West said.

But he had never seen so many objects in one brain.

Even one nail in the brain can kill a person, West said. But while bullets can kill with sheer energy, with lower-speed nail guns "it's all location," West said, where the nail ends up.

X-rays showed how strangely lucky this man was. One nail, nearly fatal, went through the neck, piercing muscles used to move the jaw. "It just missed his brain stem," West said. "That would have done it all. It was maybe a centimeter away."

Many nails straddled major blood vessels that feed the brain. But only one looked as if it might have touched a big vessel. Doctors worried the vessel could swell or tear when they pulled that nail out, a life-threatening problem.

If someone has one or two nails in the brain, doctors sometimes pull them out with the patient awake but sedated, West said. But faced with a dozen nails, one butting against a major artery, doctors decided to knock the man out.

Three days after he shot the nails into his brain, doctors put the man in an operating room and took them out.

Surgeons cut from ear to ear, through the crown of his head, pulling the skin down to see the nails' heads. They started with the nail judged least threatening, just below the right ear. With a bone drill, surgeons chipped away bone around the nail until they could grab the head with pliers. They pulled it out.

They kept on, drilling bits of bone and pulling nails with needle-nose and vise-locking pliers, until they reached the last nail, which touched the artery. West wanted to see the brain, to watch for bleeding when they pulled out No. 12. So after chipping around the nail head, doctors drilled a larger circle around it.

Doctors removed the donut of bone from the left skull, leaving the nail in the center. Slowly, they pulled the nail out. There was barely any bleeding.

After surgery, the man was a little swollen and had trouble moving his right side. But over the next week, his stiffness and swelling melted away. The surgeons were done with him.

"Then," West said, "we got the psychologist involved."

For three weeks, counselors and psychiatrists treated the man for a "mood disorder with suicidal intent." Then a court order keeping him at OHSU for treatment expired. Against doctors' wishes, the man left the hospital. Final tests showed a little jaw stiffness and some thinking problems, including "difficulty with concrete reasoning and abstract thought."

West only recently heard the rest of the story, as he wrote the journal article about the unusual surgery.

He phoned the man, who said he had been using meth when he picked up the nail gun and wanted to kill himself.

For West, the mention of drugs makes the case more than a medical curiosity.

"Methamphetamine is such an unbelievable, profound drug," he said.

As a trauma surgeon, West regularly sees the misery of meth. It seems to spur some users to hurt themselves, even scratching or biting off their skin. And it may weaken blood vessels, making them prone to tear, a theory West is studying.

The man also told West that, months after leaving OHSU, he again tried to kill himself. He wound up in court-ordered treatment at a different hospital. This time, the counseling and rehab took hold. The man said he had been drug-free for more than six months and was putting his life back in order.

"That was a defining moment," West said. The man saw "where his life was headed, and what it means to him."

"It's a work in progress. You never know," West said. But "in many ways, he's very fortunate."

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