Author Question

Author Question: Polar Bear versus Shoulder

/ Jordyn Redwood / Leave a comment

Laurie Asks:

I’m a debut Christian romantic suspense author and I wondered if you could help me with a medical question.

My hero is mauled by a polar bear. He’s suffered a dislocated right shoulder, tearing of the ligaments, rotator cuff, and whatever tendons are in the shoulder and across his scapula. He’s got bite punctures on his upper arm, his right ear was bitten and repaired via plastic surgery. He’s got a scalp laceration with twenty-eight staples to reattach it.

My hero is an RCMP cop and he needs to get back to work.

Can you tell me what he’d have done surgically to repair the rotator cuff and ligaments? How long would he realistically be off work and need physical therapy?

Jordyn Says:

I reached out to Tim Bernacki, an awesome physical therapist, who rehabbed by own shoulder after I dislocated it. If you live near Castle Rock, Colorado check out clinic called Front Range Therapies. I highly recommend him.

Tim Says:

A massive rotator cuff tear (RTC) along with ligament tears and dislocation would lead to quite a surgery. One of a kind. The massive tears I’ve seen used multiple anchors (versus one or two for the “common” repairs).

Some of the massive tears also used either synthetic or pig skin patches because of the tear size. The ligaments would also need to be repaired with more anchors. This person would be in a sling with an abduction pillow at the side for probably eight to ten weeks (versus six weeks for the smaller tears).

Therapy could start earlier than when the sling comes off but would entail only passive range of motion (provided by the therapist). The tricky thing here is that if one portion of the RTC is torn, the protocol would incorporate stretching of that repair last in the sequence of stretches. Likewise, strengthening would incorporate moving in that one direction later than others.

With this person, all directions of movement would need to be respected. This person will need a truly great therapist, or I would expect them to get about eighty percent of their range/use/strength in the end. If all goes well, I would anticipate full range around four months post-op.

Strengthening would begin around three to four months post-op and could go on for at least three to four months itself. For full duty police work, minimum time from date of surgery to return to work I’d guess is eight months, but more likely around ten months. Most police officers return to working on restricted/light duty (if the injury was work related). Light duty is typically communications and/or desk work, working cold cases, helping with investigations, but not leaving the station.

Author Question: Rehabilitation after Gunshot Wound Injuries

/ Jordyn Redwood / Leave a comment

Sean Asks:

Hi Jordyn!

Looking for a little bit of help with some 9mm gunshot wounds. I was going for non-lethal aside from possible bleeding out and injuries that would have long recovery time.

I have a character get shot at point blank range in the lower right abdomen from the front. Then in the right shoulder/clavicle, also from the front, about five to ten feet away, breaking the clavicle. Finally, in the left calf from behind from ten to fifteen feet away, breaking the tibia which is made worse when the shooter grinds his foot into it.

I’m guessing the shoulder/clavicle and calf/tibia would require a sling or cast and a serious amount of PT. The abdomen wound I’m guessing would require some reconstructive surgery depending on if and how much the bullet bounced around?
I figured it would take her almost a year to walk without assistance from those.  Am I close in that assessment? Thanks in advance for ANY help!
_______________________________________________________________________________________________

Jordyn Says:

 

Since this is largely a rehab question I reached out to Tim Bernacki, a great physical therapist, who I highly recommend from personal experience. If you live near Castle Rock, CO look up his clinic, Front Range Therapies.

Tim Says:

Generally, time frame of healing is 6-8 weeks for most things, especially soft tissue. All these injuries would require surgery. The clavicle fracture would require an open reduction/internal fixation (ORIF)—this means that there is an incision made and hardware placed to stabilize the fracture.

I wouldn’t know what is done if the clavicle is “shattered” and is in a multitude of pieces. The wound would have to be a glancing hit that results in a fracture. Anything more severe in the area could result in ruptured arteries, as well, and the person cannot die from this wound.

The tibia fracture also would require an ORIF—either plate, screws, or rod with locking screws. The difficult thing in all this would be that due to the leg recovery, the person will be using an assistive device, but probably cannot use crutches due to the clavicle pain. Perhaps a walker could be used. Depends on how conditioned the person is, how young, etc . . .

The leg injury would require limited weight bearing for 6 weeks I would guess. If all heals as expected according to x-rays, then they would transition into weight bearing as tolerated (WBAT). Probably would have a limp for several weeks after that. Likely wouldn’t run until four months following surgery if all goes well. The clavicle would probably have a sling for maybe 2-4 weeks (if no repairs to muscle or rotator cuff were done). After that, overhead reach would be most affected and for several months.

As for the abdominal injury, other than not bearing down with pressure for a short time, I wouldn’t think there are other issues to consider.

I’ve seen some gunshot wounds (GSW) where the bullet enters, hits a long bone, changes course and travels along the bone. This assumes the round is a practice round (full metal jacket) and not a hollow point. Hollow point bullets or defensive rounds open up when they hit something, resulting in a much-enlarged object/wound. I’ve seen rounds left in place because taking them out was unnecessary and I’ve seen rounds removed because of the location. Sometimes there are exit wounds and sometimes there aren’t depending on what stops the round. Sounds like there wouldn’t be an exit wound with the clavicle and leg but could be with the abdominal (perhaps in the low back).

Hope this helps and good luck with your story!

Author Question: The Perfect Skull Fracture

/ Jordyn Redwood / Leave a comment

Ethan Asks:

I’m looking for the Goldilocks of skull fractures. My main character is a college age male that got into a fight. I’ve tried doing my own research but I’m second-guessing myself on which part of the skull to hit. I’m looking for a crack (not a shatter), minimal blood loss, he stays conscious for ten minutes or so, and a hospital stay of about five to seven days. I’m guessing there’s no way to avoid a concussion, as long as there’s no permanent brain damage I can work with it. Is such a skull fracture possible? If so, where on the skull?

Jordyn Says:

Yes, there is such a skull fracture that I think would fit your scenario perfectly.

In a small amount of cases, patients who receive an injury to the side of their head causing a fracture of the temporal bone can tear their middle meningeal artery causing an epidural bleed.

An epidural bleed/hematoma is considered a neurological emergency. Most of these patients will require surgery to save their lives. With epidural hematomas, the patient can have an initial loss of consciousness followed by a distinctive lucid period, and then worsening neurological status after that.

This article gives a nice overview of the condition and treatment for epidural hematomas. Also, this is a good article as well.

Hope this helps and best of luck with your story!

Author Question: Drug Dosing in Super Human Metabolism

/ Jordyn Redwood / Leave a comment

Racheal Asks:

I’d love to hear your thoughts on the topic of medicine and dosage within the context of someone with super-human levels of heightened metabolism. Obviously, the concept pushes the question dangerously towards completely fictional answers, but I’m hoping for any input you have at least in the abstract. For instance, would you give the patient more concentrated doses, more frequent doses, larger doses?  What kind of medicines would be prescribed/would correlate with the metabolism bit in context of painkillers and treatment of a gunshot wound?

Jordyn Says:

Regarding your question surrounding metabolism– I think both could be true that the patient may need to receive higher doses and be dosed more frequently depending on the half life of the drug. Fentanyl and Versed could be two of the drugs given for chest tube placement– one for pain and one so the patient doesn’t remember the procedure. These would be given if the patient is fairly stable with good blood pressure. You could look up these drugs and see how fast the peak. Peak time is when the patient will be under the full effects of the medication. From that, you could put in whatever metabolism rate you wanted (2X, 3X or faster) and be able to determine how much more quickly they would need to be redosed on the medication. Also, you could look at the drugs half-life. Half-life is when 50% of the drug is metabolized by your body. You could look at this number, factor in their sped up metabolism rate, to also know how frequently they might need the drug.

You can ususally research this on-line fairly easily by searching for drug information sheets. I’ve included one here for Fentanyl.

I thought this would be a great question to run by Sarah Sundin who is a fabulous author and real life pharmacist. I hope you check out her wonderful historical novels set during WWII.

Sarah Says:

A higher metabolism would lead to a higher clearance — shortening the half-life of the medication. That would mean increasing the frequency for dosing from every twelve hours to every eight hours or every six hours. Often that means an increase in dose as well. Of course, we have to clarify “metabolism.” Some drugs are cleared by the kidneys (renally) and some are cleared by the liver (hepatically) and most are a combination of both. Whatever function you speed up for your character would have to match the primary method by which that medication is cleared.

To research how a drug is metabolized in the body you would search for “pharmacokinetics of Fentanyl” as an example. These articles would help you determine by what method in the body the drug is cleared.

Hope this helps and good luck with your story!

Author Question: Details for Chest Tube Placement

/ Jordyn Redwood / Leave a comment

Rachael Asks:

I’m sure you get questions on this all the time, but I was wondering what insight you can provide on traumatic wounds. My project is science fiction and the characters in question have enhanced healing and a sped up metabolism which I’ve just been using as my cure-all, smooth-over for any inaccuracies thus far. But then I found your blog- which has been incredibly fascinating and entertaining.

The first question I had which led me here was in general for a gunshot wound to the chest though not involving the heart. Namely, the various potential complications, the meds, supplies, or procedures that may be employed, and the sorts of phrases and terminology and reactions that may be overheard from the staff working on the patient. I’ve read on the risks of things like a sucking chest wound and consequential lung collapse, punctured lung, of course blood loss, but I still am at a loss for particularly the things the medical staff on hand would be saying or doing. (Bonus points if you have any tips for the internal monologue for the victim besides “ow.”)

Jordyn Says:

Hi Racheal! Thanks for sending me our question.

Your question is hard to answer. You don’t give specifics of the injury though it looks like you’re leaning toward a collapsed lung. There are a couple of ways you can research the feel of an emergency and that is by watching reality based (non scripted) shows that center on emergency medicine or look for teaching videos (or live videos where they capture the procedure on a real patient on You Tube).

For instance, a patient with a collapsed lung will likely need a chest tube placement. You can search You Tube for “placement of a chest tube” and see what comes up. The below video is pretty good as it gives lots of technical detail on what the physician is doing, seeing, feeling, and even what medicines might be prescribed for the patient. However, it does lack a lot of language of what would be said to the patient during the procedure.

The next video shows more patient interaction and what might be said. Between these two videos you could probably extrapolate together a scene. I will say that typically patients are connected to a larger suction device, but what the below physician is connecting to looks to be a more portable device so the patient can be up and walking. Also, a patient with a tension pneumothorax who is crashing may not receive local anesthesia and may even be unconscious.

Your best option, once the scene is written, is have a medical person who actively is practicing in the field review it. If your scene is written from the POV of the doctor placing the tube, it would need to be more technical versus if you’re writing it from the POV of the patient. You can also search Google for patient experiences of having a chest tube placed to get a feel for the inner dialogue you’re looking for.

Hope this helps and good luck with your story!

Author Question: Causes of Respiratory Distress in a Ventilated Patient

/ Jordyn Redwood / Leave a comment

Terry Asks:

My question is what would make a person in a drug induced coma go into respiratory distress? My character is having really strange dreams/nightmares in his comatose state and I want to introduce a dark force (ie death), that is trying to take him. At the same time, in the hospital that dark force is actually a respiratory distress, but I can’t find any information on what would cause him to go into distress or how that would be handled by the doctors and nurses.

Image by Simon Orlob from Pixabay

Jordyn Says:

A patient in a medically induced coma will also be intubated (a tube inserted into the trachea to help the person breathe) and will be ventilated by a machine.

There is a pneumonic that most medical people run through when a person on a ventilator develops trouble breathing and it is the D.O.P.E. pneumonic. I first learned it in Pediatric Advanced Life Support (PALS) that is a class taught by the American Heart Association.

I’ll give you what they stand for and the medical treatment the nurse/doctor would take.

D: Dislodgement: Dislodgement means the tube is somewhere it shouldn’t be. The endotracheal tube (ETT) could be out of the patient (termed accidental extubation) or it could have migrated into the right bronchi thereby only ventilating one lung. If the tube is completely out (or sitting in the mouth— no longer in the trachea) then the patient would need to be reintubated. If the tube is in the right bronchi, it simply needs to be pulled back a little bit until there are breath sounds in both lungs and equal chest rise when the machine gives a breath. Often times, after measures are taken to correct the situation, a chest x-ray would be taken to verify the tube is in the right place.

O: Obstruction: Obstruction can mean a lot of things. It more commonly means that there are secretions in the ETT tube that need to be cleared. If that happens, they would be suctioned out. However, obstruction can also mean something like a developing pneumonia that may require increased settings on the ventilator and initiation of antibiotics. Ventilated patients are at high risk for developing pneumonia (if they don’t have it already).

P: Pneumothorax: This indicates that one lung has collapsed. Because the lung is deflated it can no longer be ventilated properly and is causing difficulty breathing. Treatment for a pneumothorax is placement of a chest tube to reinflate the lung. The patient should improve after the chest tube is placed, but it does take time for the lung to fully reinflate. Ventilated patients are also at risk for a collapsed lung, particularly if they are on pretty high ventilator settings.

E: Equipment Failure: This can mean something is wrong with the ventilator itself. It can be as simple as the machine became unplugged. Not all ventilators have battery back-up. If this is causing the patient to have respiratory distress, we simply take the patient off the ventilator and begin to bag the patient manually via the ETT until the problem can be sorted out.

Any of these situations can cause respiratory distress in a ventilated patient. It is your choice as the author which one to use.

Hope this helps and good luck with your story!

Author Question: Blood Types and Blood Transfusions

/ Jordyn Redwood / 2 Comments

Ryana Asks:

I want to do a story set in WWII and one of my climaxes is when a Jewish soldier gives blood to save a German soldier’s life (or vice versa). My question is this: do different races have different blood types? Like, do Jews have a blood type no one else has? I don’t want to do something medically incorrect just because I think my story is good.

Jordyn Says:

There are eight different blood types and all ethnicities/races can have one of these blood types though some are more prevalent in a race than others. Here is an interesting link where the Oklahoma Blood Institute looked at what blood types certain races were and their break down.

I think the harder part of your question is would these two soldiers, by chance, have the same blood type where it wouldn’t cause a life threatening reaction in the soldier receiving blood. I was able to Google this question and found this link. As you can see, the best odds are if both soldiers are O-positive and yet that random chance that both are the same blood type is only 38%. The next highest is if both are A-positive at 34%. The other blood types fall precipitously after that. Of course, if the soldier giving the blood is O-negative (this is the universal donor) then there should be no reaction regardless of what blood type the receiving soldier is. On the reverse side, the universal recipient (someone who can get anyone’s blood) is AB-positive.

It would actually increase conflict in your story if the soldier receiving blood DID have a transfusion reaction. This type of reaction would be called a hemolytic transfusion reaction. This article reviews some of the varied responses a patient can have. Of course, you’d have to consider the time frame of your piece and what treatment would have been available then.

Hope this helps and good luck with the story!

Author Question: Emergency Care of the Suicidal Patient

/ Jordyn Redwood / 2 Comments

Riannon Asks:

I’d really appreciate your help in answering some questions. I’ve Googled as much as possible, and I just can’t seem to find answers for some things.

At one point in a play I’m writing, a character attempts suicide. His goal is not actually to die, but he does go through the process. What happens is that he’s very drunk and it’s a combination of probably alcohol poisoning and a lot of pills, something relatively accessible lying around the house, but potentially lethal in a high dose and then he calls 911 right afterwards.

So my questions are:
1. Would he be allowed to have visitors the next day? Essential for plot reasons.
2. Would visitors have to be family members or something or would friends/acquaintances be able to fudge their way in?
3. Before someone visits a patient, is the patient told that they’re coming and who they are? (I have very little knowledge of how hospitals work.)
4. How screwed up would he be physically?
5. Would he have to be committed to psych, and if so, when?
6. What could he have overdosed on?

Jordyn Says:

Hi Riannon!

Thanks so much for sending me your questions.

1. Would he be allowed visitors the next day? Depends on where he is at in the process. I’ll give you the process a patient goes through at our hospital, but you might need to adapt it if your play is located in a specific town, state, etc.

When a patient comes in with a suicide attempt, they are placed on 1:1 observation. The patient must be “medically cleared” before they can participate in a mental health evaluation. What that means is that they are no longer in danger medically from what they ingested AND that they are clear mentally to participate in the process. For instance, our patients would have to be below the legal limit for alcohol in order to participate. During the time of medical clearance and during the mental health evaluation (as for pediatrics parents are involved in the process) the patient is allowed to have visitors. A limited number. We try to keep it to two at a time and generally only immediate family.

If the patient is deemed to be a danger to themselves and does not voluntarily consent to treatment, then they are placed on an M1-Hold. This will have different names in different areas, but it is a legal document where the patient is involuntarily committed to a mental health institution for stabilization for about three days. Most mental health facilities will strictly limit visitors and may not let anyone visit during the initial 24-48 hours. Depends on the facility.

2. Could family/friends fudge their way in? I think I’ve mostly answered this above. If the patient is at a mental health hospital probably not without inside help. These are generally locked facilities that will keep a close eye on who is coming and going.

3. Is the patient notified of visitors? I can give you the ER answer and that is it depends. If the patient is unconscious then probably not. If the patient is conscious then we do want to inform the patient of who is there, but we would likely keep it to immediate family. We don’t want to inflame an already volatile situation so if the patient would become harmful to themselves or others then visitors are restricted. Pediatric patients will sometimes try and not have their parents visit, but parents are part of the process, so we encourage them to be at the bedside as long as the patient can be safe.

4. How screwed up would he be physically? Depends on a lot of factors. What he took. How much he took. And how long before he sought medical care.

5. Would he be committed to psych? If so, when? Yes, in this instance, he would be committed involuntarily if he did not agree to a voluntary admission. This would happen once he’s medically stable and after his mental health evaluation. Sometimes, patients may not be medically cleared for 12-24 hours (sometimes longer depending on the drug’s half life). Then we have to wait for an available mental health counselor which can take an additional 3-6 hours. Then waiting for placement could be another 3-24 hours. It can be a very lengthy process. Mental health beds are not that easy to find at times. Patients are held in the ER until they have a bed placement. It is also a requirement of our hospital that patients be transported by ambulance to their mental health facility and generally family members are not allowed to ride in the ambulance with them. This is a safety concern for the EMS crew.

6. What could he have overdosed on? This is really up to you as the author. Any drug can be toxic given in enough quantities and alcohol ingestion on top of that can make things much worse. Some of the more common medications most people have at home that can become easily toxic, in my opinion, would be acetaminophen (Tylenol), aspirin, and diphenhydramine (Benadryl).

Hope this helps and best of luck with your novel!

Author Question: Multiple Survivable Stab Wounds

/ Jordyn Redwood / Leave a comment

Joseph Asks:

I am writing a story inspired by the Saw franchise in which a man is forced to stab himself with three Swiss army knives. The knives will remain in. For the best chance of survival, should all the stabs be in the lower abdomen, or also bladder and/or hands/forearms?

I’ve heard the hands, forearms and lower abdomen are the three safest places to survive a stabbing, although of course technically there is no safe place, but those three areas avoid major organs/arteries/blood vessels. Though I’ve also heard stab wounds to the extremities i.e. hands can cause lasting disabilities. Where should he stab himself and how long until he is expected to die? He will be able to call an ambulance immediately, and maybe could use some cloths nearby to help put pressure on the wounds, assuming the pain is not debilitating.

Jordyn Says:

Hi Joseph!

Thanks for sending me your question.

I would agree with most of your assumptions as far as the extremities in general and the lower abdomen. You don’t include the legs. I think another relatively *safe* area would be the front of the thigh into the muscle or the back of the calf. Anywhere in the extremities where there is a large muscle mass. You could browse anatomy pictures of the extremities looking for diagrams of where the arteries are located to make sure you avoid them.

The lower abdomen is a good choice as well for suvivability. The problem can be puncturing the intestines and spilling gastric contents into the the abdominal cavity. If this happens, this can set up infection and sepsis though this would take a couple of days. You mention in your question that your character will be able to call for an ambulance immediately, not sure if that’s what you intended to say, as a delay in calling for an ambulance would definitely increase the conflict in your story.

Next to bleeding out, developing infection and sepsis would be the greatest risk of death for this character, but would likely take 2-3 days to develop.

Any stab wound to the hands or feet could be a set up for a life long debilitating injury. Many of these can be repaired, but I personally ruptured a tendon in my hand over twenty years ago and have limited range of motion to that thumb. The decision to make as the author is what, if any, long lasting effects you want the character to suffer.

Hope this helps and best of luck with you novel!

 

Author Question: Stab Wound to the Lower Abdomen

/ Jordyn Redwood / Leave a comment

Katerina Asks:

My character, Faith, is stabbed with a switch blade (about  8.5 cm long)  in the lower abdomen. I have three questions about this.

1. Can she die from this and how long would it take?
2. Would she have to go to the hospital?
3. If she survives will there be any permanent or semi  permanent  damage?

Jordyn Says:

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

You don’t give specifics on exactly where in the lower abdomen your character gets stabbed (left, right, or mid line). If stabbed in the lower abdomen, there are fewer things that can be hit that will cause you to die immediately— generally from blood loss. Though there is that descending aorta to worry about.

The lower abdomen mostly contains intestines, the bladder, and reproductive organs for the female. A person can die from injury to these body parts– most likely from infection leading to septic shock. This would be unlikely should your character receive medical care shortly after the injury.

If you choose to go this route, I would say death from sepsis could be as early as 48-72 hours to as long as a few weeks. On the early side if the character did not receive any medical treatment and there are some nasty germs either on the knife or the intestines are punctured leading to contamination of the abdominal cavity and no surgical repair or antibiotics are given.

Longer if there is surgery and antibiotic therapy but the person is infected with a resistant strain of a bacteria or fungus, or is immunocompromised, etc.

A stab wound of this type should be evaluated in the hospital. Again, this would be up to you as the author and what kind of conflict you want to have for your story.

It’s hard to say if this character would have any lasting effects from the wound as you don’t give specifics as to the injury.

Best of luck with your story.