Author Question: Transfusing Blood Post EMP Blast

Alyssa Asks:

An EMP took out all electricity 2 years ago— meaning no electricity, refrigeration, or other modern medical machines. The city has been isolated since then. Ruling gangs have raided the hospitals, but our gang of survivors managed to snag a number of essential hospital supplies including a field transfusion kit.

Patient is 6 years old. She has lost a large amount of blood from a scalp wound. They don’t know how much blood since it’s dark and they weren’t there when it happened, but she’s sheet-white, cold and clammy skin, blue lips and fingernails, shallow breath, quick pulse but low blood pressure. No access to Saline. Looks like blood is the only option.

Our nurse, she tells the others about the risks, even though the donor and recipient have the same blood type. Antibodies causing a reaction, infection, too much blood, etc. But it’s a dire situation.

Could they run an IV from the donor into a blood bag using gravity? Bags suspended in cold water to keep it cold and inject anticoagulant into the bag port once the blood starts filling it?

They’d only use one unit. Once they fill the bag, they’d use another blood tube to run it into an IV attached to our young recipient. Again, they’d use gravity, but the girl would be on a table and the blood bag suspended above her, maybe hanging on a hanger on a back of the door. Would this work?

Jordyn Says:

Thanks, Alyssa, for sending me your question. It is fairly complicated so I’m going to give a little background.

First of all, kids do not get the same amount of blood as an adult. We transfuse kids based on their weight. Your average 6 y/o weighs about 22 kg. Kids get 10ml/kg for their transfusion volume so this child needs approximately 220 ml of blood. We also don’t routinely transfuse whole blood. What we give is packed red blood cells— exactly as the name sounds. One unit of whole blood is split up into many different parts (packed red blood cells, platelets, and plasma).

What you’re talking about is giving whole blood which will lessen the amount of packed red blood cells your patient is getting. I’d stick with transfusing about 200 ml of whole blood as a marker to start. One unit of blood can hold up to 525 ml so your patient would need roughly half of one bag. It will be hard for your character to measure that in this situation so the nurse will have to go off improvement of her patient’s vital signs. These would include improved color, warmer skin, decreased heart rate and increasing blood pressure.

Bags that collect blood already have a component inside to keep the blood from clotting so I don’t think I’d even worry about an anticoagulant. I don’t even know that you’d really need to worry about cooling the blood. Collection takes somewhere between 10-30 minutes depending on the size of the vein accessed. Usually for blood collection the antecubital vein is used (the one at the crook of your elbow).

While the blood is being collected from the donor (yes, by gravity— the bag lower than the donor), the nurse can start an IV in her patient. You would need a set of IV tubing to puncture the blood bag, prime the tubing with the blood, and then give it to your patient. No air in the line, please. Hanging the unit by any means possible is fine as long as it is higher than the recipient.

Usually, blood is given with a filter in the line so if they had stolen a blood transfusion field kit then hopefully this would be part of it.

Your other option is to do old style person to person transfusion of which you can see a photo here and not mess with collecting the blood at all.

Hope this helps and good luck with your story!

Author Question: Treatment of the Burn Patient

Jennie Asks:

What happens when someone gets burned? What do the EMT’s do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.

First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.  The second man’s arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor.

I have the paramedics taking the first man to the hospital. I describe very little about his condition. However, the hero is attended by the heroine who is an EMT. His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot if he needs one?

Jordyn Says:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving some of their own medications (like an asthma inhaler or nitroglycerin tablets.) A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT’s, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.

2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.

3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding— it is possible that an IV could be started and the patient could get an IV narcotic for pain (something like morphine or fentanyl.)

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound like the hand and foot. The electricity enters one part but has to exit somewhere.

The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. This could be evaluated initially by a 12-Lead ECG and lab work that measures muscle breakdown specific to the heart. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can’t see it externally except and the entrance and exit sites.

The other thought was the extent of your patient’s burns and this would make a difference in their medical care. Burns are generally calculated based on the percentage of skin that is affected. You can find examples of these tables by clicking this link. Adults and kids are calculated differently.

Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help burn patients maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this and is dependent on the burn percentage), pain medication (like morphine), and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn’t had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? For instance, this link shows all of the Denver Metro Prehospital Protocols. Referencing these will be one of the best sources for researching what type of prehospital care your character would receive for their given ailment.

***This content originally posted December 10, 2010.***

Author Question: Medical Complications for Badly Broken Leg 2/2

Today, we’re continuing with Mareike’s question dealing with a character who has several medical complications from a broken leg as a result of a physical assault. You can read Part I here.

wheelchair-1629490_1920Today, I’m hosting Tim B. (my own physical therapist!) If you’re south of Denver and need an excellent physical therapist I’d be happy to refer you.

Here are Tim’s thoughts on the rehab aspects of this character. He also gives great insight into the medical treatment of such a fracture.

Welcome, Tim!

If a person has a compound, open, major fracture of the leg (the part between the knee and ankle), then the most likely treatment would be an ORIF (open reduction, internal fixation), or plates and screws. People with ORIF are then not given a cast.
If the fracture was comminuted (bone is fragmented versus a straight fracture), the typical treatment might be ORIF or an external fixator (halo). You can view this link for photos.

That person would then be non-weight bearing for at least 6 weeks (or more, depending on radiographic evidence of healing), then transitioned into partial weight bearing. They would use crutches or a wheelchair during the non weight bearing phase. The weight bearing phase would progress according to radiographic healing, more than anything else. There is no protocol, per se.

If a person is casted all the way to the hip, then there most likely would have been a fracture extending into the knee joint line, such as a tibial plateau fracture—which could be one of several fractures, including a compound fracture let’s say in the mid-shaft of the tibia/fibula.

Sometimes, an external fixator is applied (in the case of badly damaged and very swollen surrounding soft tissues). After swelling decreases, another procedure could take place (removal of external fixator and placement of internal plates/screws). A cast to the hip would not be used for a fracture below the knee, most likely. So the knee must be involved somehow for the cast to need to go all the way to the hip. Most people are issued a knee immobilizer after these fixation procedures. Perhaps in regions/countries where immobilizers and braces are not commonly found a person could be casted.

Compartment syndrome could be a result of the initial mechanism of injury—lots of soft tissue damage along with bleeding from the fracture—causing compression of the nerves and blood vessels of the leg. Or compartment syndrome might result from a cast that is too tight. Or a bedridden person who doesn’t move at all (same mechanism as a person developing a DVT due to lack of movement).

If blood vessels and/or nerves are compromised in the initial injury or by permanent damage from compartment/compression, the first attempt would be microsurgery by vascular/neurosurgeons to try and repair. Also, a release of the compartment would most likely take place.

Compartment releases are left open and frequent dressing changes take place until swelling comes down. It leaves a wide and long scar in the long run. It takes a little time to realize if it was successful or not (nerve and vessel repair). Perhaps a week later it would really be evident if the correction was successful, or if the leg/foot was “dying” due to lack of blood supply. Those dead areas would not be able to bleed, would probably start turning color, would start to smell, and might be numb.

PT would vary greatly.  Typically, non weight bearing to partial with appropriate crutch use while working the regions of the body surrounding the leg, including even the upper body for strengthening. Progression depends upon radiographic evidence of bone healing for the most part. Range of motion of the knee, ankle, and hip would be emphasized (for most people who have immobilizer but not casts).

Hope this helped and best of luck with your story!

Author Question: Medical Complications for Badly Broken Leg 1/2

Mareike Asks:

Greetings from Germany!

The character in question has several injuries, the most important of which is a severely broken leg (I’m talking cast all the way up to the hip). He got these injuries by being attacked and beaten up.

knee-1406964_1920I’m thinking open or compound fracture because then I can have him develop a bone infection. What I’m wondering is the order of things and how long it would take to develop what and how to recover, how long it takes, and so on.

I want him to either develop compartment syndrome and/or the above mentioned bone infection. From my understanding of the sources I’ve read, an infection can result from the treatment of the compartment syndrome, but not vice versa, so it would make sense to have that order, right? Those two are the main life/health threatening complications I could find while researching.

My ultimate goal is to write a story of recovery. Of the hardship, the struggle and pain, the setbacks. The physical therapy, the fear of whether or not he can go back to his old job.

Any resources you could point me towards when it comes to recovering from a very nasty break that might or might not require amputation or might lead to a disability would be greatly appreciated.

Jordyn Says:

Greetings from the USA! I’m going to give some thoughts on your question. I also consulted with a physical therapist since a large portion of your question deals with recovery and we rarely know what happens to patients in the long run.

I’ll give Tim’s thoughts on PT next post.

One thing I want to make clear is that treatment in the US is going to differ from medical treatment in Germany. If your novel is specific to Germany, then you really should run these thoughts by a medical person in your country. Some things should be similar, but some may also vary widely (like treatment of the actual fracture— use of fixators versus casting, etc.)

My first thought is it is really hard to get an open fracture of the leg from a beating. It’s not impossible, for sure, but we normally see injuries like this from mechanisms with a lot of velocity behind them— car accidents would be one example. So, sadly for your character, for this to ring medically true, I would probably add a weapon of some sort— like a metal pipe. And it’s more likely from repeated hits than just “one lucky” one.

The other thing is to understand the difference between compartment syndrome and the bone infection you mention which is called osteomyelitis. Compartment syndrome is a condition of swelling leading to a lack of blood supply. When you injure your body, it responds by swelling. Think of a sprained ankle.

Sometimes, this swelling can become so severe that is compresses on the blood vessels inside the extremity and either diminishes blood flow or cuts it off completely. This can be from just the injury, a cast or splint that is applied too tightly, or swelling after a cast was placed correctly.

Things begin to die when they don’t have blood supply. To alleviate the pressure, a fasciotomy is often done, which is a long cut through the skin and underlying tissue. It is a deep cut. If you Google pictures of a fasciotomy you’ll quickly get the idea. Not for the faint of heart. After this type of procedure, you have an open wound. Open wounds are always at risk for infection, but it doesn’t necessarily mean the bone would get infected.

Osteomyelitis is an infection of the bone. An open fracture (where the bone punches through the skin) can place a patient at risk for this type of infection. The dirtier the wound the more apt for infection. Wound infection does not develop immediately. Usually it takes 48-72 hours (24 hr at a minimum). Antibiotic therapy for osteomyelitis is extensive lasting 4-6 weeks. You can read an overview here.

Also, here is a link that deals with treatment of compartment syndrome.

With these injuries, coupled with the  added complications of compartment syndrome, fasciotomy, and/or osteomyelitis (or some other infection), your character is looking at 2-4 weeks in the hospital. He would likely go home on oral antibiotic therapy for his bone infection.

He’ll also need extensive rehab which Tim will highlight next post.

Author Question: Bullet Wound to the Chest

Gwyn Asks:

I’m writing a scene in which a cop is injured during a confrontation with a suspect.  I’d like to tell you about the scenario I have in mind and hopefully you can tell me how realistic it is.

ammunition-2004236_1920Cop, mid-thirties, in excellent health and physical condition is shot with a low caliber bullet from about 10 feet away.  The bullet hits his chest, goes through the lung and exits out the back.  He’s got colleagues nearby who administer basic first aid and the EMTs get there within 5 minutes.  Say about 15 minute drive to the hospital.  They radioed ahead so the hospital is expecting them and has an OR ready.

First of all, what are the chances of survival?.  Second of all, assuming survival, what are the chances (best case scenario) of full recovery – to the point he can return to active duty.  How long would the recovery time be, how soon would he get out of the hospital, and what complications — pneumonia, blood clots, etc should the doctors be worried about?

Finally, if a full recovery is highly unlikely, are there little changes I can make to the scenario to make it more likely?

Jordyn Says:

Hi, Gwyn! Thanks so much for sending me your question.

In short, this is a survivable injury.

You don’t specify in your question whether this police officer is shot in the right or left chest. Right chest would probably be preferred as there are less vital structures on the right side of the chest then the left.

ambulance1You give your victim immediate first aid and EMS responds quickly. Keep in mind that you’re going to need a paramedic to respond to give more advanced field procedures. A basic EMT is limited in what they can do— CPR, wound dressings, assisting the patient with some of their own medication administration. Depending on the state, some EMTs can start IVs, so if your novel is set in a specific location then I would research this for that area. Assuming he has a paramedic respond then he’ll get an IV, IV fluids, oxygen, and possibly pain medications. Of course, a set of vital signs and cardiac monitoring.

In an urban setting, a drive time of fifteen minutes to the hospital seems a little long. If a rural setting then you’re probably fine but you might need to adjust there as needed.

A bullet passing through the chest is likely going to puncture and deflate the lung. This character will need a chest tube to get the air out of his chest and reinflate the lung. A chest tube can be placed in the ER. This patient would get a CT scan of his chest. If the medical team isn’t worried about any other injuries than this patient may not even need to go to the OR.

A patient with a chest tube will need to be admitted into the hospital. How long it takes the lung to reinflate depends on the size of the pneumothorax or the degree to which the lung has collapsed. Generally, a patient’s chest tube is connected to a drainage box that uses suction to help the lung reinflate. Patients with this type of injury will get daily (or every other day) chest x-rays to see how the lung is expanding. After the lung is fully expanded, the suction is stopped, but the box remains in place. This is generally referred to as placing the chest tube to water seal.

If the lung stays expanded to water seal for one to two days then the medical team would feel good about removing the chest tube. Then the patient would be observed for another one to two days to make sure the lung stayed reexpanded.

Pending any complications, you’re looking at a hospitalization of 4-7 days. Pneumonia is probably your more likely complication. Having a tube in your chest hurts. Because of this, patients don’t want to take deep breaths. This can lead to the smaller air sacs in the lung staying collapsed and trapping bacteria which could lead to pneumonia.

If you add a complication like pneumonia, then you’re easily adding another one to two weeks that he’s out of commission.

If you just stick with a “simple” collapsed lung I would say he’d be out of work for about two weeks. He won’t be physically 100% of what he was before the injury but he should feel back to his physical baseline in about a month.

I would say he can work, but he’s going to have some physical limitations. It would be up to his department what his physical capacity needs to be before he can return to work. Half days at a desk job is not unreasonable for a few weeks.

He’d likely become short of breath during any exertional activity (like running after a bad guy). However, considering his physical shape, he should bounce back fairly quickly.

A nice overview can be found here.

Hope this helps and good luck with your novel!

Author Question: When Was Pregnancy Related Anemia Discovered?

Robin Asks:

I’m looking but I can’t find gestational anemia. I need to know if they would have diagnosed that in 1912 and what they might have called it. If it was diagnosed, what treatment might they have prescribed?

Jordyn Says:
blood-1813410_1920
First of all, I’ve never personally heard the term gestational anemia so I started my Google search with “when was anemia first discovered” and then started narrowing it down from there to pregnancy related anemia. I wasn’t having much luck on doing a basic Google search and decided to head over to Google books where I’ve had better luck with historical questions.

There, I found a book called An Antropology of Biomedicine and from that found the following information:

The discovery of the link between macrocytic anemia (a lack of red blood cells in which those that remain are swollen) and folate (a water-soluble form of vitamin B) was first made in India in 1928, when a British scientist Lucy Wills traveled to Bombay to work with “Mohammedan women” who were commonly found to have this particular form of anemia during pregnancy.

So, it looks like the discovery was made after your time frame, Robin.

Author Question: Surviving Stab Wounds to the Abdomen

Anonymous Asks:

I have a character in my story who is stabbed three times with a three inch, narrow blade trench knife in the abdomen. I’m trying to avoid the guts or arteries and make it as non-lethal a spot as possible. He is a doctor and also a spy. I would like him to live and make a complete recovery.

He is two hours away from a hospital and has a friend to help him get there. Here are my questions:

1. Would it be feasible for him to live that long while he gets to the hospital for treatment?

2. Would he want to leave the knife in during travel time so he doesn’t bleed to death?

3. Or do I need to rework the scene so he’s closer to the hospital? If two hours is too long, what’s the maximum time he could have in travel before it’s too late?

Jordyn Says:

anatomy-254129_1280This is an example of all things are possible, but not necessarily probable. Of course, people survive devastating injuries every day. Miracles do happen. This is the category I would put your character in to.

The largest problem with him surviving these injures in the length of the knife and how many stab wounds he has. Three inches is long when it comes to knife wounds— particularly if the full length is buried into the abdominal area. We have to operate on a worst case scenario until the patient proves otherwise. Looking at the picture to the right, you can see all that is located in the abdomen and how likely it is that something devastating to this patient would be punctured or nicked.

If you want to keep the scenario as is, then I would have all the punctures be to the lower abdomen and to either side. This could puncture the intestines and bladder. These would need to be surgically repaired, but should be survivable (if the bleeding is minimal) for a couple of hours.

You’d definitely want to avoid the left upper and right upper abdomen which house the spleen and the liver. If these are punctured, your character would likely bleed out within two hours. Also, more midline to the abdomen is the descending aorta (a very large blood vessel), which also would lead to rapid hemorrhage and low survivability.

Leaving the knife in is up to you as an author. I could see his friend doing either thing. In a panic, he removes the knife. Or, maybe he has some medical knowledge where he thinks leaving it in place might be a good idea. I would pick whatever increases the tension for your scene.

Two hours is reasonable if you pick the injuries I describe above. I would caution you, though, to give the reader an image that there is little bleeding and the pain is somewhat tolerable. Rapid bleeding, a hard distended belly, accompanied by signs of shock (rapid heart rate, rapid breathing, sweating, paleness, clammy skin) would be poor prognostic indicators for surviving two hours.

Hope this helps and good luck with your novel!