Author Question

Author Question: Pedestrian vs. Truck 2/2

/ Jordyn Redwood / Leave a comment

Today, we’re continuing with Luna’s question. You can view Part I here. In short, a 24 y/o woman has been hit by a truck throwing her into the air. When she lands, her head hits a concrete divider.

What will the doctor check or say when she first arrives at the emergency department?

If EMS care has been provided as I outlined in the previous post, we would do the following in the ER:

  1. Check vital signs and level of consciousness. If vital signs are abnormal, we would address those immediately. For instance, if her oxygen level is low, then we’ll provide more oxygen and evaluate whether or not the patient needs to be intubated (a breathing tube into the lungs). EMS may have already done this. If so, we’ll check the placement of the tube. If her blood pressure is low address that by giving either more fluids, blood, and/or a vasopressor (which is a medication given via a continuous drip to raise blood pressure). Of note, sometimes giving lots of IV fluid with head injuries is problematic.
  2. Draw lab work. In this case, we would check multiple labs. Blood counts, chemistries, and labs that look at how well the blood is clotting.
  3. Radiology studies. This patient automatically buys herself a full spine series (looking for fractures in the spinal cord) and a head CT (that would look for bleeding– and other things). Other labs and studies would be ordered depending on what other injuries were found. As previously stated, this patient would likely have more than just the head injury. A chest x-ray as well particularly if intubated to check placement of the tube.

Is surgery needed? 

This would be up to you as the writer. Would there be a case in this scenario where surgery might be indicated? Yes. Hitting your head into a concrete barrier could definitely cause some fractures in the skull where bone fragments could enter the brain. This patient would get a neurosurgery consult for sure.

Does she require blood transfusion for the surgery? 

Whether or not a patient gets blood is largely dependent on what their blood counts are. We look at this by evaluating a patient’s hemoglobin and hematocrit or H&H in medical lingo. If low, the patient gets blood. In trauma patients where there is a concern for bleeding, we draw blood every few hours to trend this lab. If it’s dropping, we know the patient might be bleeding from somewhere.

What machines would be used to keep her alive?  

In this case, likely a ventilator (or breathing machine).

How long will she be in the hospital? I am writing for two days.

Unfortunately, I think this patient would be hospitalized much longer than that. A brain injured patient that requires brain surgery would likely be hospitalized for a week or more. A week on the short end if they wake up and are neurologically intact meaning that they can speak, walk, and talk. That they know who they are, where they are, and what time they are in. Also, are their cognitive abilities intact (memory, ability to do simple calculation, etc). If this patient had a simple epidural bleed, then perhaps home in a few days if the above is normal.

The reason I say a week for this patient is the concern for brain swelling surrounding this type of injury. Brain swelling peaks around 48-72 hours and patients generally get sicker when that happens.

Thanks for reaching out to me, Luna! Best of luck with this story.

Author Question: Pedestrian vs. Truck 1/2

/ Jordyn Redwood / Leave a comment

Luna Asks:

I hope you can help me with my writing. I need some details for my character.

She is a 24 year old girl that was hit by a 4×4 pickup truck while crossing the road. She was thrown and her head hit the road divider. She was bleeding moderately (not too heavy) from her head injury. She was conscious when her friend sent her to the hospital where later the doctor said she had brain hemorrhage as a result from that accident.

Can I have the details for:

  1. Will she have shock and shortness of breath on her way to the hospital?
  2. What will the doctor check or say when she first arrives at the emergency department?
  3. Is surgery needed?
  4. Does she require blood transfusion for the surgery?
  5. What type of machines would be used to keep her alive?
  6. How long will she be in the hospital? I am writing for two days.

Jordyn Says:

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

First off, this is a VERY significant trauma to this young woman. There are some specifics missing from your scenario that would be helpful in answering your questions such as how fast the truck was going when it hit your character. The fact that you mention that the victim was thrown indicates a higher rate of speed. Being thrown coupled with the fact that her head hits a very hard surface (the concrete divider) doesn’t bode well for your character.

From your questions, it sounds like you want this to be a more minor injury. If you want this to be a survivable injury (which could be doubtful) you would need to change the nature of this accident and make it less lethal. For instance, the character isn’t thrown a distance. The truck isn’t traveling at a high rate of speed. Or, your character is in a vehicle of her own.

I will answer these questions based on your scenario as is, but keep in mind, this is a very serious accident and if the character survived, she would likely have an extensive hospitalization.

Will she have shock and shortness of breath on her way to the hospital?

You don’t specify in your question whether or not 911 was called and the patient was transported via EMS to the hospital. I would recommend that you do this. You also outline in your scenario that her head wound isn’t bleeding a lot. This is another part of your question that will need some revision. Head wounds do bleed extensively and heavily. If you’ve ever seen a minor laceration to the head you’d be impressed. The scalp is very vascular (meaning lots of blood vessels supply the area and therefore a much higher rate of bleeding).

Yes, this character could be in shock likely related to the blood loss from her head wound, or her head injury, or psychologically from the fact that she’s just been hit by a truck. Keep in mind, the head injury may not be her only injury. Anyone hit by a vehicle and then thrown will likely have other injuries such as broken bones, possible internal injuries, other cuts, lacerations, and abrasions.

If the patient was transported by EMS, they would first provide for C-spine stabilization (placement of a C-collar and backboard) while simultaneously assessing her breathing. Whether or not she’s breathing would be up to you. I could see it either way in this scenario. If she’s not breathing, then they would assist with her breathing. In addition, they would control any visible bleeding by applying pressure and dressings. She would be placed on a monitor to track her vital signs. An IV would be placed and IV fluids would be started.

Since this is a lengthy question, we’ll conclude tomorrow.

Treatment for Partial Thickness Burns

/ Jordyn Redwood / Leave a comment

Robin Asks:

I have a question regarding burn care. The main character in my novel is burned in a house fire and receives second degree burns to his back. How long would the wound be oozing? If it’s second degree burns, would he require skin grafts? What is the general treatment for second degree burns? What pain medications would be ordered?

Jordyn Says:

With burns to the back, it would really depend on what percentage of his back is burned. Burns are always calculated in percentages so it’s hard to know exactly what the treatment would be without knowing that number.

However, in general . . . second degree burns are now called partial thickness burns in medical terminology. Usually, to qualify as a partial thickness burn, the skin is reddened with blistered areas. These will probably ooze quite a bit for a few days.

Current treatment is to slather the burned area with triple antibiotic ointment, generally leaving blisters intact. After the ointment is in place, the burn is covered with something that won’t stick to the leaking fluid (called serous or serosanguinous fluid) like non-stick gauze pads and then roller gauze is applied around. This is why not knowing the burn size is problematic.

If the burn is large, covering most of the back, then the torso may need to wrapped to keep the non-adhesive barrier/dressing in place. The goal is to leave blisters intact. Blisters can be popped if they are problematic in size but the skin may be left over top because it provides a protective barrier. Exposed raw skin is the most painful. Blisters are also left intact because they provide a barrier against infection.

These dressings would likely be done until the skin heals which can take up to two weeks. As far as home pain medications, once the wound is covered it usually decreases the pain dramatically because the raw, exposed nerve endings aren’t coming in to contact with air anymore. These days, the patient might be sent home with a few doses of Lortab or Percocet (three days is becoming more common) with the patient instructed to take Ibuprofen on a schedule as well for pain control. I don’t think this is a situation where skin grafting would be required.

Hope this helped and best of luck with your novel!

Author Question: Gun Shot Wound/Severed Brachial Artery

/ Jordyn Redwood / Leave a comment

Sandy Asks:

I am writing a scene where my heroine gets shot in the scuffle with the bad guy. If she’s shot in the brachial artery in her left arm, is it conceivable that she’d pass out and bleed a lot? Her firefighter hero is there and immediately rips off his shirt and balls it up to stop/slow the bleeding. He then uses a strip of fabric from another shirt to tie around that and then carries her to a waiting police car to get her to the hospital—in this case, an ER clinic.

How much danger is there of bleeding out? Is the pressure wrap enough? Can she survive? What would be the treatment? Surgery, I assume, and blood transfusions. Would she remain unconscious and for how long?

Jordyn Says:

Yes, it is conceivable that she would pass out and bleed a lot. The brachial artery will bleed briskly and quickly and without direct intervention she could bleed to death in a matter of minutes (3-6 min). I think both methods to control the bleeding need to happen quickly. The firefighter can direct a bystander to apply direct pressure while he fashions the tourniquet as he will have more experience. The tourniquet should be applied above the level of bleeding. After those two measures, I would have the firefighter continue direct pressure at the sight with a compression dressing. This will be better than continuing to hold direct pressure.

To your specific questions:

Without intervention, this character is in great danger of bleeding out. With immediate intervention, she should be all right.

I would do both the tourniquet and the pressure dressing.

Initial treatment by EMS would be to establish IV access very quickly and start supporting the fluid loss with IV fluids. A set of vital signs. Possibly oxygen if her heart rate is really elevated, her oxygen level is low, or she’s exhibiting any kind of distress.

Since she is being transported by a police car, these would then become the initial steps performed in the ER.

Upon arrival to the ER, labs will be drawn to check her blood counts. If low, then blood transfusion would be warranted. Repairing a severed artery will require surgery.

Whether or not the character goes unconscious depends on a lot of factors. A person can just pass out from looking at blood and the stress of being shot in addition to blood loss. If a person passes out from blood loss, they should regain consciousness as soon as their blood pressure is normalized either with IV fluids and/or blood transfusions.

You mention an “ER clinic”. I’m not quite sure what you mean by this, but a free standing ER, urgent care, or an “emergency” room outside a major hospital can have limitations in the type of care they can deliver. So, if it’s such a situation, the patient would need to be transferred to a larger hospital (for surgery, admission, etc).

Best of luck with this story!

Author Question: How Fast Does A Tranquilizer Dart Work?

/ Jordyn Redwood / 4 Comments

Alyson Asks:

I’m writing a script where the villains shoot people with a gun but we discover later it was only a tranquilizer. Is there a tranquilizer drug combination that can be shot from a distance (can be close range) at a person that would take effect fairly immediately? Or would stop them from being able to communicate immediately.

Jordyn Says:

Thanks for sending me your question.

There is no drug combination given intramuscularly (IM or within the muscle as a dart injection would be) that would incapacitate a victim immediately or even within a few seconds. For instance, Ketamine takes 3-4 minutes to work IM. This will be the case with most drugs given via this route— the range of 2-4 minutes for onset of action.

Hope this answers your question.

Best of luck with your story.

Author Question: Medical Condition for Elderly Man to become Comatose

/ Jordyn Redwood / 2 Comments

Amanda Asks:

I have an elderly character who is about 90-years-old. As things stand, he is very sharp mentally and physically and fairly strong for his age. The story needs are for him to be in a coma, whether natural or medically induced, for several weeks.

My question is, is there a cause or condition that would make this plausible at his age, that he could still awake from when it’s time for him to re-enter the story? I did some preliminary poking around and it seems like medically-induced comas are less common in the elderly. What might happen to him to put him in such a state (naturally or medically), that he could still awake from?

It could be anything at all for the story. I just don’t know what’s feasible and what’s not. And how long can he be in the unconscious state before it becomes too unrealistic?

Jordyn Says:

Lots of things can cause someone to be in a coma caused by direct injury to the brain or something that would cause lack of oxygen to the brain.

One thing that is quite common in the elderly is a subdural hemotoma. Sometimes, if the clot is big enough, it will cause pressure and swelling on the brain enough to induce a coma. Usually, surgery would be used to drain a blood collection like this. One of the most common causes of a subdural hematoma in the elderly is a fall where they strike their head. As we age, our blood vessels become more fragile. If your character was also on a blood thinner for any reason— this would increase his risk for bleeding and potentially the size of the blood clot.

Any significant, direct injury to the brain can cause coma. A serious car accident. Falling off a ladder onto your head. Etc.

More medical causes, particularly in his age group, could be a stroke or a heart attack. A stroke causing a coma might be hard to write. In real life, it has a high mortality rate. Not to say it’s impossible but any direct injury in the brain (either through blood bleeding where it shouldn’t or the brain dying because of lack of oxygen causing death of brain tissue) is going to be hard to overcome with a mentally intact patient on the other end.

A heart attack, where he was deprived of oxygen for a period of time, could cause coma. Generally, over four minutes of down time without resusitative efforts is getting into the brain death arena. Even patients who are revived after four minutes will typically have brain death or proceed there. Of course, there are always outliers.

However, even a patient who gets immediate resuscitation (CPR at the least) can still proceed to coma once a pulse and good blood pressure are reestablished.

If I were you, I would pick either a subdural hematoma or a heart attack. I think this will be more likely to preserve the mental state of your character. If the heart attack, I would have it be a very short down time before he is treated and gets his pulse back.

Comas are very hard to write into stories. The length of time is up to you— that happens in real life. A coma of 1-2 weeks for these situations might be a little on the outside but possible.

The problem with a character in a coma for a lengthy period is that normal bodily functions must be tended to. We have to maintain the body functioning as close to how it does when we’re awake. So, the patient must be fed (either through a nasal, oral, or surgically implanted feeding tube). The character will still need to pee and poop— so a catheter can be placed to drain urine. We generally don’t like catheters to stay in long term because it increases the risk of infection for the patient and the elderly are more at risk for this.

Also, a patient in a coma is likely going to need ventilatory assistance and if they are on a vent over 7-10 days then generally there will be talk of putting in a trach.

The longer the coma, the more rehab a person will need. Even if in a coma for 1-2 weeks, the amount of generalized muscle atrophy will be significant. A character who is a 90 y/o who awakens from a coma after being bedridden for 1-2 weeks would probably go to inpatient rehab for several weeks/months and then outpatient rehab for a couple of months– and that might be underestimating. It’s just hard to recover from these types of injures as we age.

Hope this helps and best of luck with your story!

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

/ Jordyn Redwood / Leave a comment

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?

/ Jordyn Redwood / Leave a comment

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

/ Jordyn Redwood / 2 Comments

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

/ Jordyn Redwood / 1 Comment

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.