Author Question: Gunshot Wounds and Rib Fractures

Shanda Asks:

I have a scene where (in my mind at least) someone very physically fit is shot in the torso as they dive to save another from being shot. They then land excruciatingly hard on the edge of raised concrete (think like the front of an outside step) and break three ribs but that injury goes unnoticed as a result of the gunshot wound.

human-skeleton-163715_1280So my questions are as follows:

1. Would it be possible for someone to pick up the injured and run say a mile or two to get them to where help is waiting?

2. Could it be possible to have surgery for the gunshot would and the rib injuries be missed and hours later cause internal bleeding?

3. What would be the typical recovery time for the first and the latter?

4. Would it be realistic that after the second surgery (for the internal bleeding) the patient could not wake up for days having had two trauma surgeries so close together?

Jordyn Says:

Thanks so much for sending me your questions.

1.  Can someone carry an injured person one to two miles for treatment? It would depend on the physical characteristics of the character who is lifting the other person. Carrying someone one to two miles is a long way. I could possibly imagine a man doing this for an injured female and possibly a very fit male for another male, but a female doing this for a male might be stretching it. It would have to be a very fit female character.

On the other hand, could a character with these injuries get themselves to the hospital? The three cracked ribs are definitely going to slow them down and it also depends on what the gunshot wound has injured which you’re not clear on here. If the gunshot wound deflated a lung then they are going to have a lot of trouble breathing.

2. Could the broken ribs be missed on the first medical exam? Probably no. Any patient with a gunshot wound to the torso is going to get plain x-rays of the chest and probably a CT scan of the chest as well— both of which would show the rib fractures. So in the setting of modern medical care it would almost rise to the level of negligence to miss the rib fractures with a gunshot wound to the torso. I don’t see that happening.

3. To determine your typical recovery time I really need more information on this gunshot wound. Where was the character shot and what was injured specifically? The rib fractures themselves will take 4-6 weeks to heal. Rib fractures are very painful and could inhibit breathing based on their location. Also, successive ribs that are broken in more than one place can create a free floating segment that can be very detrimental to breathing as well.

4. A patient could still develop internal bleeding and need to go back to surgery even if the rib fractures are found right away. This would not be a rare event. It is reasonable for a patient to not wake up for a couple of days if they suffered a code during the second surgery due to extreme blood loss and had flat lined for a period of time.

Even the stress/shock of the surgeries close together might be enough for the brain to check out for a time. The problem with a comatose patient is they have to be in the ICU, on a vent, with a tube in every orifice as they say. For instance, a patient can’t be out cold and have no way to pee— so a catheter has to be placed so the urine can come out.

Going down that road can get very complicated for a novel depending on whose POV you’re telling it from.

Best of luck with your novel!

Happy Halloween! One Week Early

What’s not to love about Halloween for a suspense author? As you know, fall is my favorite season, but it’s no fun to celebrate alone.

Do you love Halloween? Love Candy Corns? Want to win the contents of this lovely Candy Corn themed prize basket? I’m giving it away October 31st via my newsletter– which means you need to be a subscriber of my newsletter to win. Click here to subscribe.

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Prize Includes:
1. Hand stitched (by me!) uber cute candy corn pillow.
2. One print copy of Fractured Memory.
3. One $10.00 Starbucks Gift Card.
4. One Pecan Pumpkin Cake Candle.
5. Three different flavors of candy corns! Brunch Favorites, Peanut Butter Cup, and Sea Salt Chocolate.

***Pumpkin Basket Not Included***

For November, I’ll be celebrating Pumpkin Spice with another themed basket as a give away for my newsletter subscribers. Don’t miss out!

Medical Errors in Manuscripts: Know Your Anatomy

Let’s answer the medical question posed in the last post. How do you keep an intubated patient from extubating themselves? There are a couple of options.

One is to sedate them. Sometimes sedation is necessary because the patient is so ill that we need to have total control over the patient’s breathing and we don’t want them “bucking” the ventilator. Bucking is medical lingo for the patient fighting what the ventilator is trying to do. It’s very hard to breathe on a ventilator because the machine is forcing air into the lungs. It’s unnatural in comparison to normal breathing.

skeleton-1243818_1280Two is to restrain them. Typically a patient on a ventilator is restrained at the wrists and these are secured to the bed. Even a sedated patient can have these applied. This is for safety. Lastly, in a highly cooperative, ventilator dependent patient who has grown accustomed to living with the ventilator, they may neither be restrained or sedated. This tends to be more rare.

Let’s move on…

Note to authors everywhere: Know your anatomy. Gray’s Anatomy. The book . . . not the show.

Here’s a paraphrased example I read in a published novel. I’m not going to name the novel or author to protect the innocent. The purpose is to educate.

John Doe looked at the scar that ran along his right rib line, where a splenectomy incision might be.

Did you catch the problem? Your spleen is on your left side. Anatomy questions should be the easiest to research on Google University. Simply type in “what side is the spleen”. Go ahead . . . try it now. What I got was the “left” side in the first four of five options without even going to a web site.

Take the extra time to be sure the easy things are correct.

Medical question for you: What does it mean if you have dextrocardia?

Medical Errors in Manuscripts: People on a Vent Cannot Speak

Last post I posed a medical question. Why are there white stripes on IV catheters? Answer: If the catheter is lost in the patient, you can find it on x-ray.

Now for another common medical error seen mostly on television and at times in works of fiction.

Note to writers everywhere: Intubated people (those that are on a breathing machine) cannot talk or even moan.

I’ll start by covering the basics. The sound of talking (and other noises) is made when you pass air through your vocal cords causing them to vibrate. This is what your vocal cords look like.


When a patient is intubated, a large plastic tube called an endotracheal tube (ETT) is passed down the throat, through the vocal cords, and into the trachea. The end of the ETT should sit slightly above the carina. The carina is the bifurcation, or splitting, of your trachea into the right and left lung. The ETT is positioned there so both of the lungs get ventilated or inflated with oxygen.

This is what an endotracheal tube looks like.

Adventures of a Respiratory Care Student/Photobucket

When the ETT is fitted correctly, a person should not be able to make noise because air is not passing through their vocal cords, it’s passing through the tube. In an adult, the balloon at the end of the tube is inflated so that it fits snug inside the trachea. If we hear an intubated person speaking or moaning, we know that air is passing through the vocal cords again and something is wrong with the ETT.

It could be as simple as the balloon or “cuff” needing to be inflated with a little more air so it fits snug again. It could be as complicated as the patient has become extubated—meaning the ETT is no longer in the trachea and you go in the room and find the patient holding the tube in their hand.

Medical question for you: How are intubated patients kept from extubating themselves?

Medical Errors in Manuscripts: An IV is not a Needle

This week I’m going to cover three of the most common medical errors I see in manuscripts.

Note to authors everywhere: An IV is not a needle.

Product Photo

This picture is the IV as it comes out of the package. This is an over-the-needle catheter meaning the needle is encased inside the catheter. Once the needle is inside the vein, the white button (seen at the base of the blue part) is pushed and the needle is sheathed inside the bottom plastic holder. You can see the spring fills that compartment in comparison to when the needle is visible. This is a safety feature to prevent needle stick injury. Once the needle is gone, a small plastic catheter is left inside the vein. Not a needle. The needle is gone.

When you start an IV you get a “flashback”— meaning blood is visible in the catheter. Typically, once you get flashback, you advance the catheter and needle a little more (like one millimeter) into the vein. Then you’ll slide the catheter off the needle and advance it into the vein, popping the button to sheath the needle. Then you connect tubing or a cap to the yellow portion and you now have IV (intravenous) access.

Needle recapping is a no-no in the medical setting. Every healthcare provider is drilled to never recap needles. Many devices have safety features like this one so you don’t have to recap to cover the needle.

Did you know the hubs of IV catheters are color coded for size even across different brands? For instance, a yellow hub is a 24 Gauge catheter. And catheter sizes are inverse so the smaller the number, the larger the IV catheter is. A 24 Gauge would be the size for an infant versus an 18 Gauge would be the size for an adult patient.

Medical question for you: Why are there white stripes on the plastic catheter (the part that stays inside the patient)?

What Does a Nurse Do? Part 3/3

This week, we’ve been examining the role of the nurse at the beside. Thus far, we’ve looked at the nurse as advocate and safety net. Let’s look at the nurse/physician relationship.

Here is Part I and Part II.

I work in an emergency department. I would say that I have a symbiotic relationship with the on duty physician. One cannot survive without the other. For instance, say there aren’t any nurses to staff the ED. How well do you think that one physician could provide medical care? What if the physician falls ill? Can the nurses provide medical care? What is the difference?

A physician’s role is to diagnose illness and determine the course of treatment. A nurse’s role is to initiate the medical plan of care, monitor the patient’s response to that medical plan, and educate the patient and family regarding their illness. You can see, one without the other and the ER comes to a halt.

Can a nurse refuse to carry out a physician’s order? Let’s look at one hypothetical example: A physician orders morphine for a child at ten times the normal dose. This is clearly dangerous and could kill the patient. What would a nurse do? First, I would have a conversation with the physician about the order. I would state my concerns and the physician will likely change the order. If that doesn’t work, I would approach another physician with my concerns to see if I can get an ally in re-approaching the ordering doctor. Some professionals will better handle being questioned by a peer vs. who they might consider a subordinate. Regardless of my view of having a symbiotic relationship with the physician, some doctors do view the nurse as a subordinate to just carry out the orders as written. This is becoming more rare. If that doctor to doctor talk doesn’t work, then I would call my nurse manager. If the nurse manager agrees the situation is dangerous, she can begin to pull in the medical director who can address the issue.

Say the order isn’t dangerous but I don’t want to initiate the order. Some medications are dangerous for a pregnant nurse to give but are fine for a non-pregnant patient to receive. If I was pregnant and didn’t want to give the drug for that reason, I would ask another nurse or the physician to do it.

What if the nurse has a conscious objection? What can she do then? Thoughts?

What Does a Nurse Do? Part 2/3

Let’s continue our discussion of what a nurse’s role really is and how you can use this to increase conflict in your manuscript.

You can find Part I here.

Last post we looked at the nurse as patient advocate. This post, we’ll look at the nurse german-shepherd-puppyas the patient’s safety net. Which dog would you rather have defending your house? The cute, furry puppy or the grown dog with the watchful eye? A strong nurse is the patient’s watchdog. I look out for my patient’s interests when they may not be able to do so.

I  am often the last line of defense between everything and the patient. Let’s delve into the medication arena. The nurse gives the patient’s medications. It’s my job to ensure that what the physician orders is the correct medication for the illness, for the right patient at the right dose given the right route (by mouth, intravenously, etc…). One of the challenges in pediatrics is there is no standard dose. Every drug dose is based on the patient’s weight. I’m not going to give the same amount of morphine to a 5kg infant vs. an 80kg teen. If the patient is not weighed or their weight is entered incorrectly, this can have disastrous effects when medications are given.

german-shepherd-578929_1920Medication errors do happen. I want to reassure you that there are a lot of safeguards in place to prevent such occurrences. Most departments are going to computer based medication ordering. This is beneficial in many ways. One, the order is typed and therefore easily read eliminating mistakes in reading handwriting. Second, most medication based ordering systems have built in safeguards that will check the prescribed dose against the patient’s weight to make sure the dose is not too high. In pediatrics specifically, all high risk medications are double checked by another nurse and co-signed on the chart. But as a good nurse functions as a safety net, so should the parent question what is being given to their child and why.

Let’s take a real life example. During my years in the pediatric ICU, I worked at a teaching hospital. At this particular institution, residents could rotate through the unit their second year. I had a second year resident order potassium, which is a potent electrolyte, at four times the recommended dose. Now, if too much potassium is given, it will cause the heart to stop beating. That’s how big this error could have been.

I approached the resident and questioned the order. He stated, “But the drug book says to give 4meq/kg/day.”  I explained that the “per/day” was the key term. That the drug should be divided into four doses given every six hours, no more than 1meq/kg at one time. I told him he could order it that way, but the pharmacy wouldn’t fill it and I certainly wouldn’t give it.

Needless to say he changed the order and the drug was given correctly.

Have you ever had a medication error happen to you? How do you think it could have been prevented?