Author Question: Stab Wound to the Abdomen in a Young Girl

Loinnir Asks:

There’s a scene in my story where one of the main characters, a short and slightly underweight 13 year old, is stabbed in the abdomen (I was thinking the epigastric region) with a 4-5 inch blade which is almost immediately ripped out by the perpetrator. Around 25-30 minutes pass before she arrives at the hospital (she is transported by car, not an ambulance as the witnesses don’t have any way to call one).

So, I was wondering how likely she is to survive, the type of treatment and expected length of recovery, and what would the protocol be for the witnesses (her five friends, all minors)?

Jordyn Says:

Thanks for sending me your question.

I think the biggest risk in an underweight (thin child) being stabbed with a 4-5 inch blade (which is fairly long) in the epigastric region is hitting the descending aorta (or one of the large veins). Particularly if the blade is pulled out, there would be little to stem the bleeding. Of course, it would depend on the angle and depth of the blade but this would be one of the more concerning injuries. If the blade is angled up, you could also hit the diaphragm, a lung, and possibly the heart. Angle the blade to the side and you have the spleen on the left and the liver on the right.

Biggest risk of death for this victim would be hemorrhage. Considering she is being transported by car versus ambulance, she would die in just a few minutes if her descending aorta or heart were hit. A lung injury could be survivable if care is given within thirty minutes depending on how much of the lung is deflated.

If you want her to live, I would also avoid hitting the liver or spleen on either side as she would bleed to death before getting to the hospital.

Getting stabbed in this area could also injure the small intestine. This is probably the more survivable injury. It would require surgical repair and a short hospital stay if the surgery went well and there was no other damage. They would have to ensure her bowels were working, she was passing gas, and could tolerate food and fluids before discharging home.

Medical treatment in the ER for a stab wound would be a set of vital signs, continuous monitoring of ECG, oxygen levels, and breathing. IV placement (likely two—one in each arm in the antecubital space), normal saline fluid boluses, labs (particularly those that measure blood levels and organ function of the abdomen) and blood if needed. They’ll check her urine for blood and if she’s menstruating she will get a pregnancy test. She would likely get x-rays of her chest and abdomen as well as a CT scan of her abdomen checking for injuries. Antibiotics would likely be warranted if her intestine had been perforated. Then to the OR to repair any injuries.

I’m not sure what you’re asking as far as the five minor witnesses. I checked with my brother who works in law enforcement and he said there are no legal issues in interviewing a juvenile witness. If your question is concerning medical care, I don’t see a reason for these kids to be evaluated if they are uninjured. At the scene, they would likely be held until parents arrived to pick them up.

Best of luck with this novel.

Author Question: What Kind of Car Accident Matches these Injuries?

Mary Asks:

I have a couple questions. My young adult characters (a total of six— four of them intoxicated) were involved in a car accident. The two sober ones were in the first vehicle. My plan was to have the driver suffer from a broken wrist, maybe a bump on the head, nothing too serious (this can change if it needs to). If he is that okay would it be unrealistic to have his passenger hit her head hard enough to lose consciousness and suffer memory loss when she wakes up? I was thinking of including pretty severe amnesia, but as for the other four characters, would their level of intoxication let them walk away with little to no injuries, or would they still arrive in the ER with at least the unconscious passenger?

Jordyn Says:

There are so many variables in car accidents that you could basically do whatever you wanted, but I’ll give you some guidelines.

If you want the injuries to be less severe, I would not have a very serious car accident. For instance, your two sober characters in the first car should not be traveling probably over 45mph. Are there air bags in the car? Did they deploy? Typically they’ll deploy in a front end collision. Now air bags are not like soft little pillows when they inflate so facial injuries are not uncommon with air bag deployment so your driver breaking his wrist (if he were bracing the steering wheel in anticipation of the accident upon impact) with a bump on his head would be reasonable if he were seat belted into the car.

The sober passenger— I’ve never really seen “pretty severe amnesia” in head injuries unless the brain injury was very significant (like brain swelling, bleeding requiring intubation, medical coma, etc). This could be achieved if this passenger was not wearing a seat belt and maybe came up over the top of the air bag into the windshield. Or, for some reason, the air bag failed to deploy and they hit the dash board or they’re driving an older car without air bags.

Generally people with amnesia related to a “simple” concussion will remember what happened to them in a few hours— generally after sleeping so everything can “reset” itself. Most often, in the ER, we observe them until they are at their “neurological baseline” which means they basically have to be the same way they were before the accident as far as knowing who they are, where they are, and what time it is, and somewhat remember what happened. Also, their physical symptoms will have to be improved (little to no headache, no repetitive vomiting or nausea, good motor function, and can walk with little to no dizziness).

So to have “pretty severe amnesia” which I think you mean to have the amnesia to persist over days or weeks then I think this character would need a more severe head injury— which could probably be achieved if the passenger went through the windshield because she wasn’t wearing a seat belt.

The drunk kids— with an offset front end collision of around 45 mph and they were all seat belted into the car with air bag deployment then I could see them walking away with little to no injures. Likely, EMS would transport them to the ER for a medical exam because 1) they are minors (I’m assuming under 18) and 2) they’re drunk and could be responsible for an accident. The police might be interested in a legal blood alcohol levels which can be very tricky (for instance, our ER doesn’t do them. We’ll do a medical one, but this isn’t released to the police). Now, could a prosecutor later obtain those medical records through the courts? Probably with a warrant.

Hope this helps and best of luck with your story.

Author Question: Gunshot Wound Near Clavicle

Sarah Asks:

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


Jordyn Says:

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

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

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

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

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

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

Hope this helps and best of luck with your story!

Author Question: Drug Injection Scene

Kiri Asks:

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

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

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

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

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

Any thoughts are much appreciated.

Jordyn Says:

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

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

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

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

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

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

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

Probably best to find an alternative to this scene.

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

Kaylee Asks:

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

Jordyn Says:

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

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

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

Best of luck with this story!

 

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

Toni Asks:

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

Jordyn Says:

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

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

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

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

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

Here is a patient teaching sheet for further information.

Hope this helps and best of luck with your story!

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

Megan Asks:

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

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

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

Jordyn Says:

Hi Megan!

Thanks for sending me your question.

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

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

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

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

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

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

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

Hope this helps.