Brain Injury

Author Question: Prioritizing Medical Care

/ Jordyn Redwood / Leave a comment

Ethan Asks:

My main character was in a fight. He has a skull fracture with epidural bleed, a dislocated shoulder, and a twisted ankle. He arrives at the hospital unconscious. Would the ER try relocating the shoulder right away or wait for him to regain consciousness first? Just a common anterior shoulder dislocation. Also how? I’ve seen too many videos to know the ‘tried and true’ from a best guess. How would you do it?

Jordyn Says:

For this patient, the neurological injury would take precedence. It doesn’t matter much about his shoulder if he never wakes up. So, if he does have an epidural bleed, that would be the surgical priority. When he’s under anesthesia for the surgery and his epidural bleed has been stabilized, they could relocate the shoulder intra-operatively.

The videos you’ve seen are probably accurate— yanking and pulling a certain way to get the shoulder back in. Sometimes, if the patient is just sedated enough, the shoulder will relocate on its own, but it is more common to have to pull it back in to place.

The only thing that might make them rush with the shoulder is if they felt that the patient wasn’t getting blood flow into his hand on that side. Since he’s unconscious, he really couldn’t say if there were any numbness to that hand that would also be an indicator he might be having trouble with blood flow into the hand.

That being said, I’ve not personally seen neurovascular compromise with a “simple” shoulder dislocation (though I’m sure it does happen on occasion) so precedence would be his head injury.

What is the Glasgow Coma Scale?

/ Jordyn Redwood / Leave a comment

Often times on television and in movies, you’ll hear a medical character exclaim, “His GCS is 5!” or some other variation. What is this score? What does it mean for the patient?

The Glasgow Coma Scale (GCS scale) is one way to gauge the significance of brain injury. There are three components to the measurement. Eye Opening. Verbal Response. Best Motor Response. In general, the highest score is 15. The lowest score is 3. You can be dead and still score a 3 so the higher the score the better.

Eye opening looks at four components and each is given a score:
4: The patient opens their eyes spontaneously.
3: The patient opens their eyes after being spoken or shouted to.
2: The patient opens their eyes to a painful stimulus.
1: No eye opening at all.

Verbal response looks at five components:
5: The patient knows person, time and place.
4: The patient can speak but is not oriented.
3: Speaks unintelligibly.
2: Moaning.
1: No verbal response.

Best motor response looks at six components:
6: The patient can obey a two part request such as touch your nose and then your shoulder.
5: The patient moves to push away a stimulus. For instance, if I’m starting an IV in your left hand, you take your right hand to push it away. This is called localizing pain and the patient usually needs to move across their midline or above their clavicle (if the stimulus is placed to the head) to score here.
4:  Pulls extremity away from pain.
3: Abnormal flexion.  Also referred to as decorticate posturing.
2: Abnormal extension. Also referred to as decerebrate posturing.
1. No motor response.

Initially, we might look at the overall score to determine whether or not a patient needs to be placed on a breathing machine. Generally, a score equal or less than eight is used as a cut off point. The lower the initial score, the more likely the patient will be intubated. Over the long term, the GCS can be used to trend improving or worsening neurological status.

Have you ever heard this scale used on television or in a movie?

Author Question: Long Term Coma

/ Jordyn Redwood / Leave a comment

Tina Asks:

I’m a self-published author who has written two books from a YA fantasy series (The Arid Kingdom) and am now working now on a modern fantasy action novel.

I’d be really grateful if you could help me with some medical advice regarding this scene:

There is an accident during a concert. A girl who was singing on the stage has her head hit by a stage lamp. She falls unconscious and remains so for eight months.

Questions:
1. Some other character with an open injury (a dagger injury) will be in the same hospital. Will they be in the same ward?
2. After she wakes up, will she have some memory problems?
3. I expect her to have some mobility issues after staying in a lying position for such a long time, like she’ll have to learn to walk again. Will her arms present similar issues?
4. How long does the recovery stage last and how is that done?

Jordyn Says:

Let’s first tackle the character who is in a coma for eight months.

What a lot of authors don’t consider is that humans eat, poop, and pee so all of these things need to be provided for in the unconscious person. If she has perpetual unconsciousness, she would need to be fed by a tube. Also, she’ll still need to poop and pee and since she can’t walk to the bathroom then she’d be placed in an adult diaper (or a catheter placed for urine drainage especially in the beginning). There are other things medically we consider in a perpetually unconscious person– most importantly– can they breathe adequately. Some can, but most end up with a trach.

When she wakes up, will she have some memory problems? You have some latitude here as a writer. Could go either way. She’ll probably be fuzzy until she figures out what happened but as far as her retaining her past experiences/memories you can decide.

This character would have whole body muscle atrophy from being bedridden for eight months. So yes, arms will be weak as well. She would be easily fatigued. Even something basic like brushing her teeth will be taxing.

Once she does wake up and is considered stable, she would be transferred to a rehab center and then transitioned to outpatient therapy. How fast and well a person does in rehab can be largely up to them. If she works hard, has a positive spirit, etc she could progress quickly if she has no other injuries. However, considering her length of unconsciousness, I’d imagine rehab would take months. Maybe eight weeks on the short side. I consulted with a physical therapist on this and he agrees. Could easily be longer. Two to four months as a range.

The character with the dagger injury would likely not be on the same ward. The unconscious person would likely initially be admitted to the ICU. The dagger injury, could even go home if not surgical. If surgical– then a regular surgical floor unless extenuating circumstances required ICU admission. Depending on the hospital, some ICU’s are split between medical and surgical.

Hope this helps and best of luck with your novel.

Treatment of Car Accident Victim with a Brain Injury

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Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!

Author Question: Unconscious Teen Struck in Head by Baseball Bat

/ Jordyn Redwood / 1 Comment

Ari Asks:

Hello and thank you for this blog. It’s a brilliant resource and I’m grateful to have the opportunity to reach out to a professional in this setting.

I have two scenarios in a novel I’m writing that I could use your help with.

First, a teenage boy is struck in the head with a baseball bat. He is knocked unconscious and falls into a coma. When he arrives in the ER, I would like some compelling dialogue between the first responders to convey his condition, rather than just typing it out in the slug lines. What are some of the measures that nurses and/or doctors would take in responding to this injury? Also, what type of jargon or verbiage would make this scene convincing to someone in the field?

Second, is the scenario where the doctor informs the parents of the same boy about his condition. In what setting would he/she do this? Or for that matter, who would be the person to inform the parents to begin with?

Thank you for taking the time to help writers do your profession justice.

Jordyn Says:

Hi, Ari. Thanks for reaching out and all your compliments regarding the blog. I’m glad you’ve found it helpful.

Typically, when a patient arrives to the ER via EMS, they give a report on their patient when they get to the assigned room. In this case, it might be something like this:

“This is John Doe, age 17, struck in the head with a baseball bat at 1600 today. Pt with immediate LOC (loss of consciousness). Was unconscious upon our arrival. Responds only to pain. We started an IV, drew labs, and started normal saline TKO (to keep vein open). His Glasgow Coma Score is eight (this is bad). Vitals signs are as follows: Heart rate 100. BP 124/62. Respirations 16. Pulse ox 100% on 100% non-rebreather. Parents are here. No chronic illnesses. No drug allergies.” 

The ER team will place him on a monitor, assess the status of his IV, and do a thorough physical exam of the patient including an extensive neurological exam. I would follow the link above and do some reading on the Glasgow Coma Scale and how it’s scored.

A Glasgow coma score of eight or less will likely lead to the patient being intubated because there is concern that he would not be able to maintain his airway.

Taking into consideration this patient’s mechanism of injury and the fact that he is unconscious, he would receive an expedited CT scan of his brain to look for injury— likely bleeding in this case.

Past this, it would be hard for me to talk to you about all the things the medical team would say. It’s your scene. If it is a compelling scene in the novel, I’d have a medical person review it.

Keep in mind the POV character you’re writing the scene from. If it comes from a medical person’s perspective, then the use of technical terms, etc is more warranted because they should sound like they know what they’re talking about. If the scene is from a lay person’s POV— then you can write more generally about the medical things being done.

Who informs the parents about their son’s condition? These days, parents are generally not separated from their child, even in instances where the child has lost their heartbeat. The parents likely followed the ambulance and would be updated upon arrival in the patient’s room. A nurse or a doctor can update the parents and give them the medical plan of care as outlined by the physician.

Hope this helps and happy writing!

Author Question: What Happens to the Child of an ER Patient?

/ Jordyn Redwood / Leave a comment

Susan Asks:

I am wondering what happens when a mother is injured and her seven-year-old child is with her. The unconscious woman is discovered by a passer by who calls 911. She wakes up, an ambulance arrives and she is taken to the ER.

I assume the child who is fine would go with them if the police haven’t been called. The woman is from out of town and knows no one in the city so the child can’t be picked up by anyone. The mother has a concussion and is kept overnight for observation. I am most interested in learning what would happen with the child at the point that they arrive at the ER while the mother is being examined.

Jordyn Says:

From the EMS standpoint— yes, they would bring the child with the parent.  As far as in the ER, if the mother is awake, the child would be in the room with her. The ED staff can assist with care of the child until the mother is feeling like she can manage. A child this age could be given activities to keep them entertained (coloring, snacks, a movie, etc).

If the child needs more than that then a member of the staff (like an ED tech or volunteer) could provide some assistance until the mother is feeling better and able to care for the child on her own.

Also, a concussion is not a reason for admission to the hospital. Not even overnight observation. Concussion patients are generally not admitted— even with a loss of consciousness at the scene. Even a minor car accident with loss of consciousness does not require admission if everything else is okay.

You don’t specify her mechanism of injury in your question. For concussion we want to see them alert and oriented and that their concussion symptoms (headache, dizziness, nausea) improve or resolve. CT scanning is more common in the adult population for head injury so if that shows no bleeding then there’s really no reason for her to stay in the hospital. If you need her admitted, I can help you have the character meet admission criteria.

Hope this helps and happy writing!

Author Question: Pediatric Near-Drowning

/ Jordyn Redwood / 1 Comment

Carol Asks:

I’m writing a scene that involves a child approximately eighteen-months-old. She was submerged for an unknown period of time (no more than a couple of minutes) on a beach after being struck by a rogue wave that knocked her down.

When found, she has a pulse, but is not breathing. Rescue breathing is started within thirty seconds of rescuers reaching her. She coughs up water shortly thereafter and is breathing on her own by the time the ambulance arrives.

This is the outcome I’ve written. Would this be correct?

A couple of days in the hospital for observation. She’s a princess so they insist on whatever tests CAN be done even if they normally wouldn’t be (X-ray, CT to check brain function.)

Neurologist tells the family that given the length of time in the water, how quickly she was given CPR, and the total length of time not breathing, she will likely suffer only minor cognitive issues at worse, and those may will not present until she starts school.

I’m presuming oxygen via nasal cannula or mask as well as an IV started in the ER.

This does not take place in the US, but I’m presuming standard procedure would be an investigation to find out how she ended up unattended long enough to make it to the waterfront. It’s truly an accident– the first time the child escaped from the house. Is this acceptable? Particularly if there was supporting video evidence?

Jordyn Says:

The scenario you have outlined is reasonable.

Here are a few of my thoughts.

This is a patient we would probably admit into the hospital– at least for a day. More depending on what happens in the first twenty-four hours would determine the need for a more lengthy stay.

For instance. as long as the child has an oxygen requirement with this type of mechanism, they can’t go home. Even if they have normal oxygen levels, any type of increased work of breathing would also probably keep them in the hospital until that resolved. However, if the child’s oxygen levels are normal and they exhibit no signs of respiratory distress for twenty-four hours then we might be hard pressed to keep them in the hospital. Remember, you have to be really sick to stay in the hospital these days.

Of course, with her position as princess, it could be easily foreseen that everyone operates with a greater degree of caution.

Chest x-ray would be reasonable and expected in this case. Paramedics starting an IV and oxygen, particularly in the case where the child received rescue breathing, also good. However, one of the first things that will happen when the child get’s to the hospital is that we will remove the oxygen to see where she settles out on room air. This would be an important piece for us to know. She’d be placed on an oxygen and heart monitor with frequent assessments of her breathing.

As far as doing other testing, particularly a CT scan to determine if there’s been any brain damage, I would argue against this. Now, do physicians “cave” sometimes to pressure by royalty. Of course— I’m sure this has happened. Just as here, if it were the president, some testing might be done that might not be necessary to “cover your . . . “.

Medically, however, if she never lost her pulse and was quickly revived, I think the risk of brain damage is extremely low. As long as your heart is beating, your brain is receiving some oxygen. Your blood does have a reserve volume of oxygen molecules on your blood cells for situations just as this. Children are very oxygen sensitive, and it doesn’t take long for them to lose their pulse in an oxygen deprived state. Knowing she still had a pulse when she was pulled from the water, especially considering her age, would mean to me that her down time was probably very little.

Also, the CT scan will likely not show any injury. Absence of injury also doesn’t mean she may not have learning difficulties in the future. So, I don’t think there’s much to be gained by that test— and the subsequent exposure to radiation which is something we balance a lot in pediatrics.

As far as the investigation, I think what you outline is reasonable, particularly if there is supporting video evidence of her slipping from the castle.

Thanks so much for your question. Good luck with your story!

Author Question: Pediatric Fall From Skateboard

/ Jordyn Redwood / Leave a comment

Carol Asks:

A four-year-old falls off a moving skateboard onto a driveway (no helmet, or pads.) Someone was doing something he wasn’t supposed to do.

This is what I’m proposing happens to this child.

Result: Greenstick fracture in one of the bones of the forearm and possible concussion?

Treatment: Cast in ER and keep overnight for observation? Possible sedatives or stronger meds (like codeine) for pain that may make her sleepy?

Follow: Specialist?

Jordyn Says:

Thanks, Carol, for sending me your question.

I’ll answer in the same way you sent your scenario to me with my opinion.

Result: Yes, greenstick fracture is good. You can hit the link for further information. However, we don’t use this term (as least not in Colorado.) We say “buckle fracture” as in the bone buckles or squishes a little. Bones in this age group are very pliable. This is a very common fracture in kids. The fracture is not a line crack through the bone. Concussion, yes. And you’re right– this kid needs a helmet on!

Treatment:

Splint in the ER. Casting is rare in the emergency department. The difference between the two is a splint only has hardening material on one side and is secured in place by an ace wrap. This leaves space for the injury to swell and can limit the potential for developing compartment syndrome— though that would be rare for this type of fracture. Casting has circumferential hardening material— usually something like fiberglass sheeting that hardens. Also, some providers are just placing a removable type wrist splint on these fractures since they are very stable and the child will usually self limit activities until the pain goes away.

I’m going to assume your child/character has a mild concussion. No loss of consciousness. No amnesia. Maybe a headache, nausea, dizziness, etc. We would not give any sedative or narcotics to this patient— for the concussion nor for the fracture.

Ibuprofen is the preferred drug of choice for the fracture and even for the headache that might be associated with the concussion. Some providers are against ibuprofen in concussion because of a concern for increased bleeding (ibuprofen makes platelets less sticky), but that’s with multiple dosing. We give Ibuprofen often to kids with head injuries and they do fine. Acetaminophen can be given for headache and it will help with pain from the fracture, but it will do little to help the swelling of the fracture. This is why ibuprofen is preferred for broken bones because it helps with both pain and swelling.

Assuming this child has a normal neuro exam and is at their normal neurological baseline (meaning, they are acting as they normally do at home)— then they would be sent home. There is no reason to obs this kid overnight.

Follow up: With orthopedics in 7-10 days for reevaluation of the fracture with cast placement. Cast would be on for 4-6 weeks.

Hope this help and good luck with this story.

Author Question: Family Notification of Death

/ Jordyn Redwood / 4 Comments

Themelina Asks:

I have read some of your posts and I am wondering if I could please have some help regarding a book I am writing. I have three scenes in my book that are in a hospital. The background story is that a girl gets notified that her mom and sister have been in a car crash. Her mom has died and her sister is currently in surgery. Is it right that a police officer comes to her house and lets her know or does something else happen?

After she finds out she faints, and hits her head. I don’t want to make this part sound too serious. However, I still want her to go to the hospital. So what floor would she go to? How long would she stay?

Lastly, the third scene is where the sisters see each other after surgery for the first time. She is paralyzed. How could she communicate with her?

Jordyn Says:

Thanks, Themelina, for sending me your questions.

Question #1: Who would notify the family of the death? I could see this happening a couple of ways. If the mother was declared dead at the scene of the car accident then the police would notify the family. If the mother is transported to the hospital and the hospital team declares her dead then it probably falls on the hospital team to notify the family.

We don’t generally like to give death notifications over the phone. I’m not saying it’s not ever done, but not preferred. We would likely call the family and ask them to proceed quickly, but safely, to the hospital. This might also be preferred because the sister is requiring surgery and except in the most extreme cases surgeons generally like consent before they operate. If there is not a parent to give consent (you don’t mention a father in your scenario) it could fall to the sister, if she is eighteen or over, to give consent for her sister’s surgery.

Question #2: People who pass out and hit their heads are rarely admitted to the hospital. I’m assuming you want this sister to suffer some form of concussion. She gets the awful news about her family, passes out, hitting her head in the process. If she wakes up rather quickly (a few minutes or less), is oriented to person, time and place, and doesn’t show neurological signs of a brain injury that might require surgery then she would get a physician evaluation, a few hours of monitoring to be sure her symptoms are improving, and then she would be discharged home. There would also be no need to wake her up through the night. This is a myth.

Question #3: You don’t specify in your question the level of the sister’s paralysis. Her ability to talk will depend on the level of paralysis. Patients paralyzed from the neck down are, at least for a while, on a ventilator. When a person has a trach, there are special adapters for the trach that allows people to talk. However, a trach is not placed at the beginning and it takes time for a person to learn to talk with the special valve. If she is on a breathing machine and can’t write (because her arms are paralyzed), but is awake and can understand questions then we use a system of eye blinking for responses. One blink for “yes”. Two blinks for “no”. And obviously more simply phrased questions.

Hope this helps and good luck with your story!

Traumatic Brain Injuries: Initial Treatment

/ Jordyn Redwood / 1 Comment

Last post, I have a primer on traumatic brain injuries (TBI) that you can find here. Today, I thought I’d give an overview of the treatment guidelines.

Remember, the basis of treating TBI is manipulation of the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF). Additionally, sometimes a portion of the skull is removed.

1. Manipulating Brain Tissue.

Removing brain tissue is an option and may be done to tissue that has died. Recovery of the patient is dramatically influenced by what part of the brain was removed.

Another management strategy is to put the brain at rest by placing the patient in a medically induced coma. Medication is used to heavily sedate the patient. Typically, the patient is on continuous EEG monitoring to ensure a minimal amount of brain activity is present. The purpose of the coma is to reduce the metabolic demands of the brain in hopes of keeping swelling down and allowing the brain time to heal.

Additionally a diuretic, either hypertonic saline or Mannitol, can be given to draw water out of swollen brain cells.

2. Manipulating Blood Flow.

This can entail a couple of areas. Remove blood that has collected in the brain. Sometimes when the brain is injured, blood vessels within the brain are ripped open. Two types of bleeding can occur between the brain and the skull: a subdural or epidural hematoma. A subdural hematoma occurs from veins. An epidural hematoma occurs from an artery. Depending on the size of the hematoma, a neurosurgeon may choose to operate and remove it. Sometimes bleeding occurs within brain tissue. This type of bleeding can be small and more diffuse. Although a risk for the patient it may not be an option to surgically remove it.

Another way to change blood flow is to manipulate the size of the blood vessels inside the patient’s head. This can be done by increasing the rate of the patient’s breathing on the ventilator thereby decreasing their blood level of carbon dioxide. When this level is lower, the blood vessels inside the patient’s brain shrink in diameter. This therapy is controversial and if done, only a mild drop in carbon dioxide levels is the goal.

Lastly, the blood pressure can be manipulated. A certain blood pressure or blood flow to the brain must be maintained in order to keep the brain alive. This is called the cerebral perfusion pressure (CPP) and is calculated by using the patient’s blood pressure and their intracranial pressure (ICP). Reducing the blood pressure is an option but you must maintain the cerebral perfusion pressure as well. This can be a challenging balancing act.

3. Manipulating Cerebrospinal Fluid (CSF)

A drain is placed to remove excess cerebrospinal fluid.

4. Removing a Portion of the Skull.

This is a viable option for management of brain swelling. A portion of the skull is removed (hemicraniectomy) to allow the brain room to swell. The portion of the skull that is removed is preserved by freezing so that is can be reattached at a later point once the swelling has eased.

Have you had a character in your novel with a traumatic brain injury? If so, what type and why did you choose it?

***Reposted from January 19, 2011.***