Author Question: Bullet Graze Wound Near the Ribs

Ella Asks:

I’m writing a pseudo-novel, and in order to inflict the most possible pain on my character without leaving him entirely incapacitated or even dead, I have a couple questions.

1. Would one be required to go to the hospital for a bullet graze?
2. If one is grazed on the side in roughly the 6th-8th rib area, how much would they bleed?
3. If you were grazed in the 6th-8th rib space, would it be possible that the bullet would fracture a rib?
4. If so, how severely?
5. How would a fractured rib and graze impact basic motor functions?

Jordyn Says:

Hi Ella!

Thanks for sending me your questions.

I think first it’s important to understand what a graze wound is medically— which would be a skin injury without serious underlying injury. The bullet nicked the person and that’s about it. Is it required that the person goes to the hospital? No, I think going to the hospital would be determined by if they could get the bleeding to stop and how extensive the injury is. The smaller the graze the less likely the need for the hospital.

Treatment would be:

1. Apply direct pressure to stop the bleeding.
2. Clean the wound thoroughly– sometimes vigorous flushing with relatively clean water and a touch of something like dish washing soap can be enough if the character is choosing not to go to the hospital. This can reactivate bleeding because the clots are getting washed out as well. After cleaning, apply direct pressure with the cleanest item available (preferably sterile gauze) or a really clean cloth.
3. If the wound edges can come together consider using butterfly closures to close the wound. This might also indicate that the person requires stitches. Sometimes you can apply antibiotic ointment over the butterfly closures to help control infection (something like over-the-counter antibiotic ointment), but keep in mind the oily nature of these ointments will tend to loosen anything with adhesive (like the closures as well).
4. Cover with a bandage.
5. Consider a tetanus shot if it’s been over five years since the last one.

Reasons to consider visiting the ER would be a large wound, unable to control the bleeding, and/or the wound is nicely approximated (and might benefit from stitches to control bleeding and reduce scarring), and to update the character’s tetanus shot. If the character is exhibiting any difficulty breathing this would be another reason for an ER visit.

How much bleeding would occur if the graze was near the 6th to 8th rib? Again, considering a graze wound is mostly a skin injury then applying pressure should be enough to stop the bleeding. Think of this type of wound as a cut or abrasion.

Could a graze wound fracture a rib? Yes, this is possible. How severely? This could be up to you as the author. The fracture could range from a simple fracture (a line is seen through the bone but the bone is stable and the parts stay together) to a type of fracture where the bone breaks apart into small pieces. The more extensive the rib injury, the more extensive the skin injury will likely be (and also increase the chances for internal injury) and could border past a simple graze wound.

A fractured rib and graze wound will have some effect on motor functions— mostly to the upper body. The person should still be able to walk and run but the motions of the arms (while running) will be painful. Fractured ribs are very painful so a person will naturally inhibit motion of the upper body to keep the pain from flaring up so raising the arm on that side while holding a weapon will hurt, but won’t be impossible. Taking deep breaths will be painful so anything that increases a person’s respiratory rate (like running) will hurt. Pain can be treated with over-the-counter pain medication like acetaminophen or ibuprofen particularly if just a simple fracture. Every day the pain should improve and be pretty tolerable in seven to fourteen days. The actual fracture (depending on how complicated) will take four to six weeks to heal.

Hope this answers your questions and best of luck with this story!

Author Question: Does Blood Loss Effect Fever?

Fraidy Asks:

I was wondering how blood loss would effect a fever? The character is ill with strep throat (or a stomach bug) and a fever that makes her want to cover up under layers of warmth. This is before an accident involving shattered glass and deep cuts and moderately serious blood loss. Would her fever be brought down due to the blood loss or would it complicate things more?

Jordyn Says:

Hi Fraidy! Thanks so much for sending me your question.

In your question, you don’t specify whether or not the patient/character has received treatment for the cause of her fever. In the case of strep throat, they should have been prescribed an antibiotic, and should be feeling markedly better in 24-72 hours. There can still be fever, but it should not be as high as the days go on if the antibiotic is working against the bacteria that is growing.

If this accident occurred say after three days, I would imagine she should be fever free by that time.

However, let’s say the character was just diagnosed and still has increased fever related to the illness.

I would theorize that a high fever, 102 degrees and higher, could cause your character to have some exacerbated symptoms related to additional blood loss. A high fever will naturally increase a patient’s heart rate— and so does blood loss. There could also be a concern that an untreated infection could cause the patient to go into septic shock, of which one complication of sepsis is lowered blood pressure. Low blood pressure is also a symptom of blood loss— if the patient bleeds out enough.

The combination of these two things, low blood pressure and increased heart rate, in light of a patient with a high fever and blood loss can paint a complicated picture for the medical team. They may not know which (blood loss or infection) is making their patient so sick so they would take a dual approach to their treatment which could entail the following.

1. Drawing labs that look at blood counts, blood chemistries, but also those that would address sepsis concerns like blood cultures. Also type and cross for blood. Initially, for symptoms of low blood pressure and tachycardia, the patient will usually receive fluid boluses of normal saline IV.

If the patient is really hypotensive (low blood pressure) and tachycardic (increased heart rate) and is not improved from the IV fluid, the medical team might choose to give O negative blood instead of waiting for a formal type and cross to come back. If the patient is actively bleeding and the bleeding is hard to control, they could opt to start giving blood right away.

2. Consider antibiotics early in the course of treatment once any body fluids are cultured the provider thinks necessary to determine the source of infection. It is helpful if a family member could offer insight into what infection the patient might have or the symptoms they were experiencing before the accident.

3. If the blood pressure remains low despite fluid boluses IV and perhaps blood, then patients are generally placed on a vasopressor which is a class of medications given as a continuous infusion IV to help raise blood pressure.

4. Treat the fever with a fever reducing medicine like acetaminophen or ibuprofen. If the patient is headed to surgery to treat wounds from the car accident, then acetaminophen (or Tylenol) might be preferred.

Hope this helps and best of luck with your story!

What Could Go Wrong Series? The Intoxicated Patient

What Could Go Wrong Series – The Drunk Patient

Medical shows love to use imaging procedures in their episodes, but often times the scenes do not follow a realistic procedure protocol or the drama is escalated in over the top scenarios.

Everything from doctor’s running the MRI machine to using the wrong probes or technology in ultrasound, our television shows get the details wrong more often than right. Good thing most actors are easy on the eyes so we tend to forgive the script errors a bit more.

In an effort to provide positive change and help writers produce accurate material for their story lines, the What Could Go Wrong Series will reveal realistic scenarios that could (and likely have) happen in a medical setting.

Imagine an intoxicated patient comes into the x-ray department from the ER for multiple images of an extremity. They’ve recently been involved in a fight.

The technologist has to position the patient’s extremity into a painful posture to get diagnostic images. The patient cusses the radiographer. They haul off and hit the healthcare professional, knocking her to the floor. She gets back up, dusts herself off and dives back in, calling for help to restrain the patient.

Unlike most TV shows where a slew of physicians rush in to aid the staff, some doctors will remain in their offices or in the ER department tending to other patient cases. If we wait for them to intervene, the attacker could inflict more damage.

In real life, other x-ray team members will help by entering the room and donning lead shields. They will hold the patient in position while another radiographer takes the image from outside the room. Healthcare workers will act in the moment and move as a team to keep the scenario under control.

If for some reason, a physician is nearby or in the department, then they might help with the situation. However, most radiologists read from their offices, and ER doctors remain in their work space taking care of other trauma cases. From their locations, they might not even hear what has happened in the radiology suite.

Real World Facts

Radiographers and other healthcare professionals must deal with verbal patient abuse. When things turn physical, we must stay calm and keep a clear head.

A 2017 study by the National Institute of Health determined that patient to worker assault in the healthcare setting was a serious occupational hazard with front line staff being at a higher risk for Type II violence. (Arnetz, 2017)

These scenarios impact the employee’s well being, decrease morale, and can cause depressions or even post-traumatic stress long after the incident is over.

New Storyline

Now, imagine a TV character with this story line. A drunk patient attacks the healthcare worker, a nurse, doctor, technologist, etc. and the emotional and psychological stress impacts every area of their life for several months. Even after the patient sobers, the effects of what he’s done could provide issues in his life and or recovery.

Sounds like an episode or two with loads of drama yet realistic to real world healthcare.

References

Arnetz, Judith E, et al. “Preventing Patient-to-Worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention.” J Occup Environ Med, Jan. 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214512/

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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.

 

A Nurse’s Open Letter to Teachers Everywhere

I probably shouldn’t write this post. It will probably be considered controversial– even though it seems like it shouldn’t. However, I am writing from a place of lessons learned and I want to share those lessons with . . . teachers everywhere.

I was happily reading some on-line celebrity news (as a destressor) when I came across this article about Anthony D’Amico. The article explains that his 2 m/o daughter went in for her regular immunizations and he experienced ” . . . an overwhelming urge to punch out the nurse . . . ” as she was delivering the infant’s shots.

Now, I’m sure, he meant this as a unifying post among parents everywhere– that none of us like to see children experience pain. I get that. As a pediatric nurse, however, I was horrified. His first instinct is not to pick up and comfort his child or say reassuring words, but to injure the nurse providing lifesaving preventative care. I’m sorry . . . that just not cool.

Would it surprise you if I told you that nurses experience the most violence of any profession . . . including police officers? Here’s just one of many articles that eludes to that fact. I first started nursing in 1993. My first job was as an adult ICU nurse. During that first year, an elderly vented patient grabbed my stethoscope that was on my neck and began to choke me with it. I could not break their grip and only when a passing respiratory therapist saw my predicament was I freed from possibly a very serious injury and/or death. Sadly, that’s not been my only incident. Getting cursed or sworn at is common— not rare. I’ve been personally threatened with unwarranted law suits just so I would bend to a family’s demand. I’ve had men raise their fists at me more than once. I’ve seen so much worse happen to other healthcare workers.

When I first started nursing those twenty-six year ago, it was an unwritten expectation that these events were tolerated and nothing happened to the perpetrators. It was, “part of the job”. These “people are sick” and “they don’t know what they’re doing.”

Well, a police officer can still charge a drunk person if that person injures them physically. For decades, a nurse was not permitted to even think this was an option.

Not only do nurses experience violence from patients and their families, but from co-workers as well. In my own state, a hospital close to where I live (I am not employed there) a nurse was nearly strangled to death by a doctor.

Now, that is SLOWLY changing. Hospitals are beginning to see and understand that patients, families, and co-workers should not be allowed to commit violence against nurses (or any healthcare worker) for any excuse or reason. It’s inspired the hashtag #silentnomore.

People should be held accountable for their actions despite being sick, tired, and or frustrated. Change is not a speedy process. Hospitals are balancing employees need for safety and the image they project. It is a complicated issue. Should a nurse be able to involve law enforcement if a mental health patient injures them during a psychotic break? Not an easy answer. And I might add, nurses are reluctant to do so knowing the underlying medical states that drive many of these situations, but they are also so very tired of the violence. This violence contributes to reduced quality of life, PTSD, moral injury, and people leaving the profession.

This is why I write this post. Not for me and my fellow nurses who know this hell that we live in with violence . . . but for the legislators and school administrators who are loosening consequences for students who are defiant, disruptive, and dangerous. I speak specifically of this new law in California that passed the Senate and is moving forward to their assembly.

Interestingly, I couldn’t find much commentary about the CA law except from conservative commentators. Here is one such example. Perhaps it’s because California lawmakers believe that there is bias in how school based punishments are merited out.

I don’t know the veracity of those claims. That’s not the point of this piece because this trend of backing off of student punishments for outrageous classroom behavior is not isolated to one state. Here’s one example from 2002 where a teacher resigned because a Kansas school board wanted her to reverse failing grades for students who had plagiarized. 

I am writing this because when disruptive classroom behavior and even violence is tolerated in schools from children or teens— they eventually become adults and then it becomes a problem for all of us. Ask any pediatric nurse when limits should be set and it starts from the beginning.

At some point we have to set firm and clear boundaries for bad behavior. When did it become reasonably sane to allow anyone to exhibit unruly and/or violent tendencies without consequences? Nurses have known all along that this was insanity and we are suffering from this, but felt powerless to do something about it because it was an expected part of our jobs. Nurses are now collectively saying we can’t live like this anymore.

Teachers . . . unruly and violent behavior should not be tolerated parts of your job. If we say to students that there is “zero tolerance” for violence and bullying then how can we allow it to happen to another one of our most trusted professions? The issue is, the behaviors before violence need to first be curbed. Kids know what boundaries are– their job is to test crossing them. Now the boundary is moving to allow more egregious behavior from students toward their teachers.

This is healthy?

So from this nurse to teachers everywhere– please fight to uphold the standards of behavior you expect in the classroom. Don’t give an inch. It could be your life that is at stake.

If anything, please learn from this nurse’s storyOr this nurse’s story. Need another one? Or this? Maybe her story will change your mind.

Hold the line in the classroom . . . hold the line for all of us.

When a Cardiologist Becomes a Heart Patient: Dr. Paul C. Ho

Today, Redwood’s Fans, I have a special guest blogger for you. Dr. Paul C. Ho is a cardiologist who suffered a heart attack which led him on a journey of self discovery. Today, he shares his thoughts here and I hope you’ll check out his book, Art on the Human Heart.

Welcome, Paul!

I’m a board-certified cardiologist and a cardiac arrest survivor—a heart doctor who became a heart patient. I believe these experiences make me somewhat of an expert storyteller from both a doctor’s and a patient’s point of view. As I reflected on playing these dichotomous roles in the health-care arena, the story of my autobiographical novel, Art on the Human Heart, came to be.

Aside from its anatomy and physiology, are there other functions or meanings to the human heart? The ancient Egyptians and the ancient Greeks considered it to be the seat of emotions. The Bible says, “In the heart dwells feelings and emotions, desires and passions. . . . The heart is the seat of the will and understanding.” For millennia, this centrally located organ has been implicated in our perception of the outside world and capable of generating a behavioral response to our feelings—the very essence of our presence, our being.

But which is the chicken or the egg? The age-old question applies here to the “emotional” aspect of the heart. When we are happy, the heart feels a sense of openness and a certain lightness. Conversely, anger can bring troubling heart palpitations and chest tightness. There is no doubt that “heart emotions” can be influenced by outside stimuli—whatever makes us happy or angry. But could the heart itself be the originator of feelings that may alter behavior and outcome? Is there then a true nature of the human heart?

As a cardiologist, my professional focus is on the physical nature of the human heart. As we all know, unhealthy life habits, such as cigarette smoking, eating fatty foods, and lack of exercise, can lead to the development of acquired heart diseases. Parallel to outside forces influencing heart emotions, external factors can also affect physical changes in the heart. What if the intrinsic nature of the heart can lead to the development of heart disease? For example, in an innately angry or unhappy heart, could the negative emotional tone trigger early heart ailments? Surely in medical literature, we are seeing an increase in reports of such associations.

When I suffered my own heart attack, I was only thirty-nine years old. I was young, living a healthy lifestyle, and did not have a predisposing genetic factor for heart disease—there was no obvious medical cause for my near-fatal condition. Why then did I almost die at thirty-nine? I questioned if the nature of my heart had something to do with it. At the time, I was extremely hard-working and had an angry, perfectionist, and type A personality. Was I subconsciously dissatisfied with my life? Was I unaware of deep-seated unhappiness? Could that have been the cause?

To better understand what happened to me, I wrote my novel to explore the true nature of the human heart through the eyes of a high-powered, high-stress cardiologist. When I became sick, my compassion turned inward toward myself for the first time in my life. Recognizing that well-being goes beyond conventional medical treatment, I dug deeper into the meaning and nature of our hearts. What truly makes us happy? What truly makes a healthy heart? To save ourselves, as I tried to do in the aftermath of my heart attack, we must understand the true nature and desires of our own hearts— nobody else can do this work for us.

I hope you will enjoy my book and learn as much as I did about our true hearts.

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Dr. Paul C. Ho is a cardiologist and a heart attack survivor. He has published numerous medical papers and is a reviewer for several medical journals. Art on the Human Heart is inspired by his love for creativity, exploration, and self-discovery. Dr. Ho studied engineering and medicine at the University of Pennsylvania, Temple, Dartmouth, and Harvard. He was the chief of cardiology in a hospital system and was awarded several patents for his medical device inventions. Dr. Ho enjoys traveling to remote places and has worked in native communities including locations in Alaska. He lives in Hawaii with his pooch, Bear-Bear.

Author Question: Help Me Knock Out My Character!

Elizabeth Asks:

I need to temporarily drug character. She will ingest it unknowingly (probably through coffee). I’m also considering having her drink one glass of wine, so the culprit could be the drug itself or the combination of the two, but I’m open to other possibilities.

It would need to be an OTC drug or something with easy access. Also, the drug would either have to wear off on its own or need be handled by an EMT without access to a hospital or medical equipment. What drug would get the job done? Would sleeping pills work and if so which kind would be best? How much would the character need to ingest? And how long before it takes effect and wears off?  Thank you!

Jordyn Says:

Hi Elizabeth!

Thanks for sending me your medical question.

You specify that the drug would need to be over-the-counter or something with “easy access”. Your two possibilities would truly be something over-the-counter or a prescription medication is stolen from someone else.

There are plenty of over-the-counter medications that cause sleepiness. The three most common would probably be diphenhydramine (Benadryl), dimenhydrinate (the active ingredient in the Dramamine that causes sleepiness), and doxylamine succinate. Several combination medications contain these active ingredients. For instance, if you look at multi symptom cough medicines, you’ll likely see one of these medications. Same with Tylenol PM or Advil PM. To a lesser degree, Melatonin and Valerian Root can also cause drowsiness.

The problem with all of these over-the-counter preparations is that they don’t have the same predictable impact. One person might take one of these medications and fall asleep in fifteen minutes. Another might take it and not be sleepy at all.

A safer bet would be to have this character steal a prescription medicine from someone. This opens up your possibilities of what drug to choose that would have a more predictable effect. Some of those drug categories would be benzodiazepines (such as Valium and Xanax), opioids (like morphine and fentanyl), and the hypnotics (like Ambien and Lunesta). Also, muscle relaxers like Soma and Flexeril have sleepiness as a side effect.

Then, of course, your character could obtain an illegal drug like Ketamine or GHB (aka the date rape drug).

The OTC medications will probably have the least disastrous side effects if given in normal doses. Your chances of injuring your character go up exponentially with these other drug classes if proper medical attention isn’t give if the character stops breathing. This would be the leading cause of medical calamity using a prescription or illegal drug.

In the end, it’s up to you to decide. I think the best thing for you to do would be pick a drug from each of these classes: over-the-counter, prescription, and illegal— and research a few to decide. If you type in the exact name of the drug and the question you want answered (like dose, onset of action, etc) you will usually find drug guides that can answer these questions for you.

Hope this helps and good luck with this story!

Child Abuse Injuries: Part 2/2

April is Child Abuse Awareness Month. Last post, I covered how a given history for an injury may be a signal that an injury was intentionally inflicted. Today, I’m going to cover how the injury itself may give off clues for an abusive injury.

1. The injury is beyond the child’s developmental level. You’ll notice this is the first clue I gave concerning the history, but it also plays into the injury itself and I’m going to talk specifically about infants. Any bruising in an infant to the face, head and neck when they are not yet pulling themselves up to a standing position is concerning for abuse. To create an injury, you have to fall off of or run into something and you need to have some velocity behind it. Now, of course, injuries in this age group can have lots of accidental causes, but the story needs to match the injury.

2. The injury has a pattern. Consider typical childhood bruises. They are roundish in shape, of varying circumferences, and received from a low-velocity type injury . . . say the child running into a counter with their forehead. Anything that makes a visible pattern generally requires high-velocity force to imprint the pattern onto the skin. If I loop a belt and tap you with it, there likely won’t be any injury at all. However, if I take it and swing it at you like a pitcher throwing a baseball, it has the potential to create a loop like bruise.

3. The injury is not over a bony prominence. Again, if you have children, think back to their younger days when injuries were common. When they fell, where did they bruise? Head (scalp, forehead, nose, chin), elbows, shins, and knees. Most often, kids fall or run into something in a forward motion. Bruising to the buttocks in a diapered child is particularly concerning. Often, they will fall onto their bottoms, but they also have extra padding.

4. There are a lot of bruises. This is not definitive but can be a signal for abusive injury, particularly if the pattern is not a normal bruising pattern as in #3.

None of these items is taken in isolation as a single indictment against the caregiver. Let’s say you accidentally drop a toy onto your two-month-old’s face while cleaning up. It causes a bruise and you want it checked by the pediatrician. The pediatrician is not going to report you. Why? You have a plausible story (dropping something onto the baby’s face), it is a low velocity injury (the bruise is probably small and round) and there is only one.

Medical professionals look at the totality of the child’s case: the history, the social environment, and the injury is considered before a report to child services is made. Reports are not made lightly.

The above offers some beginning guidelines. In the comments section, give a specific injury that might be concerning for abuse.