Author Question: Assault Injuries

Author Question: My MC, a 17 year old female, is beaten up by her father. He was drunk, angry, so backhanded her across the face, which knocked her into a bookcase. Then while she was on the floor he kicked her repeatedly with sharp-toed cowboy boots, though runs out of steam fairly quickly and goes off to his bedroom. (She managed to curl herself into a ball to protect her internal organs.)

So right now this is what I’m looking at for her injuries:

1. Mild concussion (from hitting a shelf with her head — this would also possibly produce a small cut/gash because the edge of the shelf is sharp.)
2. Bruising to the face (from where he backhanded her.)
3. Broken ribs (I have 3 for now — is that too much?)
4. Pneumothorax from one of the ribs — just punctured, NOT collapsed.
5. Crack in the mid-shaft humerus of her right arm (from being kicked.)
Lots of bruising (obviously.)
First of all, are these injuries plausible given the scenario?
Jordyn Says:

These are a “good” array of injuries that would be plausible as a result of this type of beating. However, you can’t have a punctured lung without some amount of air getting out. It may be a small amount that would not require chest tube placement but there would likely be some if the lung were “punctured”. That’s likely the only way the medical team would know the lung was punctured was by evidence of air on the chest film. So, it might be easier to just go with cracked ribs.

Question: Would she be able to drag herself a few feet across the living room to get her father’s cell phone (left on a table), then crawl out the front door to the porch (the living room is just inside the front door)?

Jordyn: Yes, she should be able to do this.

Question: What might she experience? (Obviously pain, but I would assume she would have a great deal of trouble breathing, get oxygen-deprived, light-headed, nauseated …)

Jordyn: Yes, great pain. Rib fractures are quite painful and inhibit a person from taking full breaths so the patient tends to take more shallow breaths to prevent the pain. This could lead to lightheadedness (as well as the head injury), increased breathing rate, and increased heart rate (from pain, anxiety, fear.) If you go with a more serious lung injury (like a collapsed lung) then this could lead to lower oxygen levels, increased work of breathing, and diminished level of consciousness.
Question: What would be the ER procedure when she is brought in by her best friend’s family? It’s a very small-town medical center that barely qualifies as a hospital. When she’s brought in the staff is already busy on a multiple-patient car accident. Would it be plausible for the ER team to keep her waiting for a while after they take her back to an exam bay? Or would they worry about internal injuries and get her x-rayed right away? (As I said, it’s small-town, so goof-ups are possible.)

Jordyn: It depends on her presenting condition. If she’s awake, alert and oriented and doesn’t appear to be in imminent distress (such as significant difficulty breathing from whatever lung injury you choose) then it is plausible for her to wait while the car accident victims are being taken care of.

An ER evaluation is going to include vital signs, a medical history and history of the event, and then targeted x-rays for everything that hurts. So, chest film and right arm films at the least. Her head wound wound be irrigated and stitched closed if needed. Staples would be used if the wound is in the scalp. Tetanus shot needs to be within five years. CT of the head isn’t necessary for her head injury unless she has a focal neuro deficit (like I can’t move one arm) or unconsciousness. Depending on the x-ray results– her arm, at a minimum, would be placed in a sling until pain resolves. A stable fracture to the humerus can’t be splinted– only placed in a sling. 
This is the basics any ER should cover. 
This beating is a reportable injury so if the police haven’t been contacted– the ER staff should do so.
Question: The way I wrote it in the original draft was that she was taken to an exam bay right away, but then left to wait for a couple of hours. Then she was x-rayed and because of the pneumothorax, was taken back to a procedure/operating room to be intubated. The doc and a nurse came in while she was being prepped, to tell her friend’s family what her injuries are. (Would they put a cast on her arm? At what point would that happen, before or after the intubation?)
And then, how long would she be in the hospital?

Jordyn: Intubation is not the primary treatment for a collapsed lung– otherwise known as a pneumothorax. Placement of a chest tube is. This is what is required to safe the patient’s life. If you intubate and don’t place a chest tube the patient will die anyway because they will continue to accumulate air into their chest– especially with positive pressure ventilation– the machine forcing air into your lungs. Usually, just placement of a chest tube is enough.

A sling to her arm as noted above.
 

And then it depends (as with all things in medicine) how long the chest tube would stay in. I would say three-five days at the shortest. The lung has to re-expand, it has to stay expanded off suction, then the tube is removed. The patient is watched maybe one more day to make sure the air doesn’t come back.

Medical Critique: CBS Drama Hostages 2/2

This week, I’m medically analyzing the CBS drama Hostages. In the previous post, that you can find here, I said I’d give them some kudos . . . and I will . . . I promise, but it will come at a later time because I’m having too much fun dissecting this episode.

These posts do have spoilers . . . you have been warned.

Last post I discussed the first three issues I had with the episode and they are as follows:

1. Gunshot wound victims are at high risk of dying from blood loss– not heart arrhythmias.
2. Physicians don’t carry hospital grade defibrillators in their back pockets. Maybe Tom Cruise does but I digress . . .
3. Physicians are generally not comfortable operating a defibrillator. This is generally a nursing function once the physician prescribes the amount of electricity he wants delivered.

Onward we go.

Issue Four: After the husband is “brought back to life” Ellen, played by Toni Collette, goes about diagnosing his problem. Keep in mind she’s a cradiothoracic surgeon. Now, she will have gone through a general surgery rotation but her specialty will be everything above the diaphragm.

Her husband has a wound to the left upper quadrant of his abdomen. She sticks her finger into the wound– perhaps up to the first knuckle and declares, “Your renal vein has been severed.” or something relatively close to that.

Wow. Just . . . wow.

Your kidneys lay in your mid-lower back. I like the image here a lot and it comes from the noted website. I think this website is AWESOME. There aren’t any gory pictures but it has several photos of drawings similar to this one that shows the anatomy as it lies under the skin drawn with ink.

This is how we think in medicine. We say . . . “The patient was shot here . . . what is underneath or along the tract that could be damaged.” And from that we order labs, x-rays and advanced imaging like CT.

In reality, there is no possible way to diagnose a renal vein severing with a finger probe to the front of the abdomen . . . or to the back of the abdomen. This needs advanced imaging techniques. Now, there is some gross (not as in yucky) techniques that could likely lend to the diagnosis of injury somewhere along the GU tract. Blood in the urine. Perhaps urine leaking out of a wound. But to be so specific needs advanced imaging.

http://meded.ucsd.edu/clinicalmed/abdomen.htm

And I can’t imagine suturing that vein closed with the patient awake and moving around. Those suckers are small.

I actually do think there would have been a better injury to give this character’s husband that would have been more in her skill set and MORE dramatic and that is the tension pneumothorax.

A tension pneumo could easily happen in a gunshot wound to the chest. The lung is hit and leaks air into the chest cavity. If enough air accumulates in the chest it actually pushes or shifts the chest organs (lungs and heart) to the unaffected side (imagine a balloon blowing up in the affected side.)

Treatment for this type of injury is a chest tube and could be fashioned from something from the home and perhaps something from her medical supplies. You’d need a large size tube– they are big– think maybe 1/2 the size of a diameter of a garden hose and come in various sizes. Once placed, she could secure it with sutures and place the end in water lower than the patient so air didn’t get back into the chest.

To diagnose– you listen to breath sounds. There are no breath sounds on the affected side. Tracheal deviation– which means the trachea is shoved to the unaffected side. There are also temporary measures that can be done until a chest tube can be placed– like sticking a needle in the chest. Then she could have figured out what she needed to fashion a chest tube.

Often times, when I spend time interviewing an expert, I have always come up with a better scenario, and a more realistic one than what I imagined would be good.