Author Question: Gunshot Wound Near Clavicle

Sarah Asks:

In my novella, the main character is shot directly below the left clavicle by a sniper rifle. The bullet misses the bone, but would it have hit the subclavian artery or another artery? And if so, how long would it take for her to bleed out? She receives medical help from an off-duty paramedic within three to five minutes. Thanks!


Jordyn Says:

I reviewed a couple of anatomy pictures and the subclavian artery appears to sit higher and slightly above the clavicle or collar bone. When looking at anatomy photos, red indicates arteries (as they are taking oxygen rich blood away from your heart to the rest of your body) and blue indicates veins (bringing oxygen poor blood to your heart and lungs for more oxygen).

That being said, the left chest has all sorts of major veins and arteries. A bullet can always miss these structures— we all hear those rare stories, but I generally encourage authors to stick to the right chest for a more believable scenario if they want the character to live. Ultimately, it is your choice.

The subclavian vein, which is nestled under the artery, could definitely be nicked or severed by a gunshot wound to this area (either the right or left side). Central lines are often placed to the subclavian vein which is accessed just benenath the collar bone.

If the bullet hits the subclavian artery, the character would bleed out fairly immediately— in roughly under two minutes without any medical intervention. Your paramedic arriving in three to five minutes would likely be too late. Direct pressure to the area will help. It is hard to stem bleeding from an artery this size, but pressure could help delay the onset of death for another few minutes.

If the bullet hits the subclavian vein, the bleeding will still be brisk but could be more easily controlled with pressure than bleeding from an artery.

If you want an injury that will bleed, but would likely be survivable, I would pick the subclavian vein with people at the scene immediately applying direct pressure to the gunshot wound.

Hope this helps and best of luck with your story!

Dr. Strange Should Know Better

If you haven’t seen the movie Dr. Strange, you have been warned that this blog post will contain spoilers to the movie.

Dr. Strange, released in 2016 as part of the Marvel Universe, features a stereotypical, obnoxious, arrogant, and rich neurosurgeon. He is greatly skilled, but is known to turn down patients in order to keep his perfect surgical record. Unfortunately for the character, he is in a terrible car accident and both his hands sustain multiple fractures that cause permanent nerve damage and therefore lead to the end of his promising career.

Dr. Strange is like many patients when the medical establishment can’t offer complete healing. He begins to investigate alternative/investigative medicine for treatments. He hears from a physical therapist that a patient with a complete spinal fracture is up and walking around. Dr. Strange responds to this by saying, “Show me his file.”

I’ve said all along in this blog that medical people in films, television, and novels can do bad things. Your job as the writer is to let the reader know that you know that the character is misbehaving in his role. This allows the reader to know you’ve done your research and they can trust you as an author.

Dr. Strange asking for this patient’s chart if flat out a HIPAA violation. He never cared for the patient and he has no right to know what’s in his medical record. There are consequences for HIPAA violations and having the character suffer these is a great way to add tension and conflict to the story.

A second medical violation in the movie is the treatment of Dr. Strange’s chest wound. He suffers a blade wound to the chest and transports himself back to his old hospital to be treated by a colleague. There are a few problems with this scene.

Problem #1: That there is a sterile operating room in the ER. No, this isn’t standard. Can sterile procedures be done in the ER? Yes, but not a sterile operation as in the OR.

Problem #2: Wrong ECG rhythm. Dr. Strange has diagnosed himself with a pericardial tamponade. A cardiac tamponade is where fluid is collecting in the sack around the heart thereby impinging on the heart’s ability to pump blood.

The rescue procedure for this is a pericardiocentisis— or removal of the fluid from around the heart. His love interest confirms the diagnosis by percussing his chest. This is probably the least reliable way of diagnosing this problem. Any well equipped ER should have some sort of bedside ultrasound to aid in the diagnosis. The ECG monitor first shows a rhythm of bradycardia— the heart beating too slowly. This again is one of the least likely rhythms related to this condition.

Problem #3: Wrong placement of the needle. In the movie, the doctor is shown placing the need straight into the chest. It should be at an angle pointed to the left shoulder which this nifty video on You Tube shows.

Problem #4: Shocking asystole: I’ve blogged a lot on this. You cannot shock asystole. It won’t improve the outcome for the patient and is contraindicated. First treatment is high quality CPR and a dose of epinephrine or adrenaline. Also, this is not the correct paddle placement for defibrillation. It should be just to the right of the patient’s sternum and over the apex of the heart or more to the left side. They also cannot be placed over clothing.

Problem #5: OR is next. Most likely a patient like this with penetrating trauma to the chest would likely go to the OR, or at least some follow-up radiology studies. Not just stitched up and sent on his way.

Something Strange about Dr. Strange

Most love a good operating room scene where a brilliant mind and steady hand save the day. Dr. Strange fulfills this role in his self-titled movie and was most enjoyable to watch.

However, there is one scene that concerned me.

See anything strange besides the man who carries the name?

The two main characters are creating a burr hole in the skull to be able to retrieve the bullet lodge near the medulla. The are in full sterile attire except for their masks.

Several years ago, I was called to the OR to assist with the removal of a brain tumor guided with ultrasound. No one in that room went without a mask covering their mouth and noise. In fact, I was not even allowed to enter the suite without a mask in place.

All of the surgeons, nurses and surgical assistants surrounding the table also wore face shield to protect their eyes from any splatter of the patient’s biological fluids.

So you can imagine my disdain when watching the movie, Dr. Strange, and discovering two surgeons hovering over a patient’s head, creating burr holes in his skull without masks. Upon further research, the wearing of masks in the OR has caused some controversy.

According to Lisa Maragakis, Senior Director of Epidemiology and Infection Control at John Hopkins Health System, some studies have shown the absence of a mask in the OR “have virtually no bearing on the patient outcomes when surgeries are performed by healthy doctors in sanitary operating rooms.” (Maragakis, 2016) In some European hospitals, surgeons are no longer required to wear masks.

However, she also discusses what happens when a surgeon sneezes. Personally if it were my open brain, I’d not want my surgeon’s droplets nestling into my head wound.

Here in the US, most hospital and operating room protocols still require our surgeons to don the traditional surgical mask and encourage facial shields.

Perhaps, one day that will change, but right now, I’m glad wearing surgical masks are not strange.

References:

Sugarman, J. (2016). What Do Surgical Masks Really Protect Against? Retrieved May 28, 2018.
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Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.

Author Question: Drug Injection Scene

Kiri Asks:

I really hope you can help me. I feel like I’ve reached out to half the medical community and still haven’t gotten an answer.

I have a protagonist who suffered a ruptured aneurysm two years before the story starts. The aneurysm caused a stroke. Presently, he is mostly recovered, though he still suffers migraines and some memory loss. I have a scene where another character catches sight of yet another character giving my protagonist a shot in the arm.

Originally, I had the intramuscular injection be a vasopressor to help with his blood pressure, but then someone told me this would only be done in a hospital.

I would really like to keep this injection scene. So I changed it to an anticoagulant, though I’m having trouble verifying that this is anything someone like him might need. (Did I mention he has another blood vessel wall bulging and ready to burst, this one inoperable?)

I also have him taking beta blockers for his migraines and he later uses these to try to commit suicide by taking an entire bottle. An ER nurse told me this would certainly be dangerous. I could change it to another drug.

Any thoughts are much appreciated.

Jordyn Says:

First of all, you have two competing medications. A vasopressor raises blood pressure and are typically given IV in the ER and ICU setting. The beta blocker used for his migraines can (and often does) lower blood pressure.

Unfortunately, I don’t see either of your two options as feasible for an intramuscular injection scene— either as an anticoagulant or a blood pressure medication. If the character’s blood pressure is too low, the first thing would likely be to give him some IV fluids and just stop the beta blocker.

Some patients do go home on subcutaneous (SQ) anticoagulant therapy, but usually it’s when they have a known clot— not simply to just keep the blood thin. There are too many excellent prescribed oral medications to do this on an outpatient basis. If you wanted your patient to have a clot in the leg (deep vein thrombosis) than this therapy would be reasonable but developing a clot like this would be unlikely if he were already on anticoagulants for his brain coils related to treatment of his first aneurysm. You could read more about this here.

I’m not aware of any blood pressure medicines that are given SQ or IM (into the muscle). There are several given IV in the emergency/ICU setting but these would not be appropriate for home use. Patients are transitioned to home oral medications.

The only medication that could be given consistently SQ on a home basis with any regularity that I could see would be insulin for diabetes.

I did find this pamphlet on-line about SQ meds given in palliative care (hospice) but I don’t think any would fit your scenario. They are mostly anti-anxiety, anti-nausea, or drying agents for secretions given this way because the patient can’t swallow anymore. In fact, most of the links about SQ meds given at home were in conjuction with hospice care.

Also, SQ and IM sites and the angle at which they are given are different as well.

Probably best to find an alternative to this scene.

Author Question: Can Onset of Paralysis be Delayed after a Fall?

Kaylee Asks:

In a book I am working on the main character falls off of a one-story wall injuring his back. Could he be paralyzed? If so, would it be possible for paralysis to set in an hour or two later? Would he be able to remain conscious and still walk for about an hour? He is a spy, mid 20’s, strong, and loves to run.

Jordyn Says:

In my experience, I’ve never seen a delay in onset of paralysis. Usually, it is immediate. I’ve not personally seen people with devastating paralysis from a fall from this height. Broken legs/arms, lacerations, and concussions . . . sure. Could a spinal cord injury happen? Of course there are always outliers. If you did write this, it would help believability if the character fell directly onto their head (called an axial loading injury) or onto another hard object (like a rock or something with a hard edge) to increase the chance of a complex fracture causing paralysis.

I did some hunting regarding spinal bones specifically. This article says three meters (which equates to about 10 feet or one story) can cause spinal fracture, but just because you break the bones doesn’t necessarily mean paralysis. A person with a stable fracture of their back can be up and walking around. I’ve seen this plenty of times.

I  did find one article where a woman did have delayed onset of paralysis of four days, but if you read through the article she had a significant mechanism of injury and died as a result of complications of her injuries.

Best of luck with this story!

 

Author Question: Is There a Drug that could Mimic Death?

Toni Asks:

I’m writing a contemporary retelling of Snow White. I was wondering if you have any suggestions on how the stepmom could intend to poison her but is not successful. Instead, maybe just paralyzes her or slows her respiratory system down to where it seems she’s dead. Any suggestions?

Jordyn Says:

I brainstormed this with a co-worker pharmacist and these are our thoughts.

There isn’t a current paralyzing agent that will work for this scenario. A couple of problems with paralyzing agents is that they never just slow down respirations— they knock them out totally. Plus, in the absence of a sedative, the person is very much awake and panicked because they can’t breathe. Giving this drug alone could not mimic death and would rapidly cause death from hypoxia unless medical intervention was given post haste.

The drug we came up with for you is called Donnatal and can be given as an elixer. It has four medications: Hyoscyamine, Atropine, Scopolamine, and Phenobarbital. The hyoscyamine actually helps with intestional disroders like irritable bowel syndrome. It is the other three components that will help with your scenario.

The atropine and the scopolamine both act to dilate pupils and could mimic fixed and dilated pupils that you get upon death.

Phenobarbital is a barbiturate and can be used to treat anxiety and seizures. Overdosing on phenobarb will cause slow and shallow breathing.

Here is a patient teaching sheet for further information.

Hope this helps and best of luck with your story!

Author Question: How Long Before a Teen Diabetic Gets Sick Without Insulin?

Megan Asks:

I’m so glad I found your website. I would love it if you would answer this on your blog. Thanks for reading and I look forward to your answer.

My YA manuscript has scenes with two sixteen-year-old teenage boys on a  twelve hour adventure race in the mountains. One of the boys has Type 1 diabetes. He consistently tests his glucose and knows what to eat/drink and he has an insulin pump. All is going well until his insulin pump malfunctions and he realizes he has left his back-up insulin in a cave they had sheltered in earlier in the story.

My specific medical question: What would happen to him if he has to wait approx. one to two hours for the other boy to retrieve his insulin and return to him? What symptoms would he show? And, after taking the insulin (1 – 2 hours past his regular schedule), would he be able to function well enough to walk to the finish line area without further medical assistance?

Jordyn Says:

Hi Megan!

Thanks for sending me your question.

I don’t think your character would be affected dramatically by a one to two hour delay in getting his insulin.

Insulin works to transport sugar from the outside of your cells to the inside. In the absence of insulin, his blood sugar will start to rise but how fast it rises depends on a lot of factors. For instance, what is he eating and drinking? How vigorous is he exercising? Considering he is stopping to rest and wait for his friend will help.

The rise in blood sugar is problematic, but is actually not the most concerning issue. What usually causes the emergency is a build up of acids in the blood due to the body’s inability to use the sugar inside the cells. Because the body still needs energy to run, it begins to break down fat for energy leading to a rise in ketones in the blood— hence the name diabetic ketoacidosis (or DKA).

If he were to continue to exert himself, I could see a situation where this process could be hastened, but though he might not feel awesome— I don’t think he would be incapacitated. Also, if he’s not eating or drinking, his blood sugar could also get too low depending on what type of insulin his pump was delivering.

I found this article that gives some tips on what the patient might be feeling. In my experience, I haven’t seen anyone using the blood based ketone testing— just urine test strips.

Some sites say DKA can develop in one to two hours. That might be true, but I would be doubtful a patient would be incapacitated in that time frame. They may not be feeling great, but can function. How severe DKA is really depends on how acidic the blood is when they seek treatment. Some people have ketones in their urine, would be considered in DKA, but their blood is not that acidic. People like this can usually be rehydrated with fluids in the ER, an insulin correction given, and sent home.

The more acidic the blood— that determines the course for a pediatric DKA patient. We measure this by the pH of the blood via a blood gas. Diabetics who have very acidic blood generally end up in the ICU for many reasons I won’t outline here.

Hope this helps.