Castle: Dying From Medical Inaccuracy

Personally, I loved the show Castle. Sadly, it’s been cancelled and perhaps it’s for the best– especially if Season 8, Episode 21 entitled Hell to Pay is any indication of the attention to detail they were giving their medical/forensic scenarios.

The following is the assessment medical examiner, Lanie Parish, gave concerning New York’s latest murder victim.

“He bled to death from a wound in his left side. My guess is whatever he was stabbed with punctured his subclavian artery. After that he would have had about thirty minutes to an hour tops.”

There are TWO major problems with the above assessment.

First, your right and left subclavian arteries are located just below your collar bones. So, if you’re stabbed in the left side, it’s really hard to hit that sucker. That got me thinking about what is on your left side that could cause brisk bleeding. Your spleen is located on your left side tucked pretty nicely under your lower left ribs. Perhaps they meant splenic artery which would have been appropriate for the scenario.

Second is the time frame. If you have a severed artery, the bleeding will be severe and deadly if not controlled in a matter of minutes. There is no way this character would have survived thirty to sixty minutes– I’d give max time at ten minutes and that might be pretty generous.

So Castle, at least go out on a high note with a medically accurate death scenario.

Seven Medical Posts for Authors on Blood Loss and Bleeding to Death

How fast a person can bleed to death is a very common question among authors and I’ve done several posts on the topic. About a month ago, I got a comment asking a variation of the question.

It’s as follows:

Although I’ve worked in an animal clinic for years, I wasn’t sure how much of what I’d seen there translated to the human side. I’m currently editing someone’s manuscript and the injuries in a couple of scenes struck me wrong enough to do some digging before revision. A couple of things I’m still looking for is how long a person remains conscious with arterial or venous bleeding (in one scene, this is from a femoral injury) and whether/how much accelerated heart rate from exertion speeds bleeding?

Jordyn Says:

It’s hard in medicine to give actual time frames. The best demonstration I ever saw of how fast it took to bleed out was from a physician that drilled a hole into a two liter bottle of pop and then squeezed it mimicking a heartbeat. He said the size of the hole could be equated with an injury to the popliteal artery (which is behind your knee) and that bottle was empty in about two minutes.

Devastating injuries to larger arteries (your aorta for instance) can cause the patient to bleed out (hemorrhage or exsanguinate) in 1-2 minutes. It’s fast. For instance, if you rupture your descending aorta in a hospital and they know exactly what is wrong with you, and even have a couple of IV’s in place, your chances of survival are still not awesome.

Some general rules:

Arterial bleeding is faster than venous bleeding. This is because the pumping action of the heart causes more brisk blood loss. That being said, all bleeding can lead to death if not controlled. It’s probably safe to assume that bleeding from an artery without any intervention could lead to unconsciousness in one to three minutes and death in under five minutes.

Uncontrolled venous bleeding might take upwards of twenty minutes or days. Again, if not controlled in any way. Again, this could be variable. The author has a lot of leeway.

Does a fast heart rate accelerate bleeding? Yes. The faster your heart beats, the more blood spills, particularly from an arterial bleed. This is a double edged sword because your body will compensate by increasing your heartbeat during blood loss to compensate for all those red blood cells on the pavement and not in your body carrying oxygen.

Here are other posts on the topic of blood loss:

Author Beware: Arteries vs. Veins.

Author Beware: Arterial Bleeding vs. Venous Bleeding.

Killing my Arteries: Truth or Die by James Patterson. Can IV drugs be given in an artery? 

Pregnant Woman Bleeding to Death.

Pregnant Woman Bleeding after Delivery.

Bleeding to death from gunshot wound to the arm and back? What organs can be hit to bleed but not be lethal?

What other questions do you have about characters bleeding to death?

Author Question: Survival After Abdominal Aorta Injury


Jessica Asks:

I’m writing a war scene where a character is hit by a piece of shrapnel in the abdominal aorta; the other things I wanted to know were:

1. How long would he remain functional (as in able to walk, run, shoot etc) with that kind of blood loss?

2. This character wears a device called a ‘Scorpion’ which is an injector that dumps stimulant drugs into his bloodstream. Would this cause him to bleed out faster? 
Jordyn Says:

The abdominal aorta is a large blood vessel in your abdomen. The answer to your questions depends on how badly the abdominal aorta is injured. If it was simply nicked—that would give your character some more time and if his limbs were uninjured he could probably run, walk, and shoot if the injury to his belly wasn’t grievous. Theoretically, if it was just a little leaky he could do all right but I’d make it clear to the reader that the medical team found that the abdominal aorta wasn’t really injured.

If his abdominal aorta is completely severed– he’s dead in under one- two minutes. That’s a fatal wound. The odds would be against him even if he were inside a hospital when this happened. He might be able to hold a weapon and fire for a few seconds but I don’t see him being able to stand, etc.

As far as would the use of a stimulant cause him to bleed out faster— yes, if nothing is stopping the flow of blood like a dressing. A stimulant increases your heart rate so it’s like turning a hose up with a higher flow– if nothing is capping off the end of the hose the fluid loss would be greater.

Hope this answers your questions and happy writing!

Medical Critique: CBS Drama Hostages 1/2

As you know, I’m critically watching some of the new Fall TV shows for medical accuracy. I’ve already posted about the CBS drama Hostages. You can find that here.

This week, I’m going to knock it down but then offer it a helping hand back up. Episode 5 is going to be the brief knock down.

If you haven’t watched all the episodes you have been thusly warned that there will be spoilers in this post.

If you’re not familiar with the show, the President needs an operation and his surgeon, played by Toni Collette, and her family have been taken hostage to force her hand to assassinate him or her family will be killed.

In episode five, the family plots to escape. They end up getting split up. The husband at home. The children on a bus to Canada and Ellen (Toni’s character) almost getting on the bus until she sees video of her husband being shot in the gut.

And, of course, even though he’s a cheating slime ball she goes home to save his life.

Issue One: One of the ways a person who has been shot and is bleeding dies is of exsanguination– meaning all their blood leaks out. The reason significant blood loss kills you is that your body is no longer delivering oxygen and you go into shock/circulatory collapse. What you really need is BLOOD to save your life. Without it– nothing the medical team can do will pull you out from the drain you’re swiftly traveling down. When our trusty surgeon arrives home she finds her husband unconscious and not breathing . . . no pulse.

She starts CPR– yea!! Then asks Mr. Hostage taker to get her medical bag from which she happens to have a hospital grade defebrillator.

Issue Two: There are only a few shockable rhythms. I’ve blogged about the use of electricity here. A likely rhythm for the patient to be in strictly from blood loss is what we call PEA or pulseless electrical activity. There is actually two parts of good heart activity. The electrical component and mechanical component. You need both working appropriately to propel your blood forward and keep you alive. You can actually have normal electrical activity and yet the heart is not mechanically beating– thus the term pulseless electrical activity.

In the case of this character’s husband– his heart likely has normal electrical activity but since he’s lost so much blood– it doesn’t have blood filling the chambers and so doesn’t have anything to pump out. Hence the lack of a pulse.

I’m guessing this husband’s injuries would lead to this set-up. Normal electrical activity with no pulse. So he doesn’t need electricity. He needs BLOOD.

Issue Three: I don’t know any physician anywhere that has a hospital grade defibrillator for their private use. Or would know how to work it . . . quickly. Now, this isn’t a backhanded slap to my physician co-workers. They know how to do their job very well. This just isn’t necessarily in their skill set. Nurses usually set-up the defribillator. The physician orders the desired amount of electricity.

I’ve taught advanced resusitation courses for two decades and I can tell you, across the board, every type of physician struggles to get it programmed. These classes are not a requirement for EVERY physician to take either.

So– wrong treatment with too much ease of use.

What would have been more believable would have been for her to have an AED (automatic external defibrillator) in the home. These are designed for lay people to use and some people do actually have them for home use. They basically diagnose the shockable rhythms and provide electricity if indicated. It’s what many first responders are carrying to even high school settings. They are very user friendly.

Check out my post on Thursday where I’ll continue my discussion of this particular episode.

Author Question: Exsanguination

Heather S. asks:

I came across your website while browsing for some information for a project. I am currently a nursing student and am doing a project on arterial bleeding. I am trying to find specific exsanguination times for the major artieries in the body. I have had no luck after searching online and multiple medical books. I just need a simple answer, i.e carotid artery 2-20 minutes. I have a few times, however, I feel that they are inaccurate. Please see below:

I-stock Photo

Carotid – 2-20 min

Brachial – 5-60 min
Femoral – 5-60 min
Aorta – 1-2 min
Popliteal – 5-60 min

I would greatly appreciate your help as it seems you are extremely interested in medicine. This might go on to help your other readers as I came across the questions dated January 12, 2012 where you discuss exsanguination. Thank you!

Jordyn Says:
Your question is not an easy one.

Any major artery (and the ones listed are major) that is completely severed will likely lead to the patient’s death in less than five minutes. I saw a demonstration once where a physician simulated this happening.

He took a 2 Liter bottle (an empty pop bottle) and filled it with water. He drilled a hole into it (to simulate arterial severing) and then squeezed it at a regular rate to simulate the heart pumping. That bottle was empty in a matter of three minutes. Yes, we timed it.He said the diameter of the hole he drilled equated to the popliteal artery which is behind your knee.

However, the injury may not be a complete separation which is why you have the varying time lengths. Of course, if the person gets some type of medical treatment (like a pressure dressing that stems the bleeding) they may last a lot longer as well.

I know this answer isn’t a clear cut answer but in medicine . . . they usually aren’t.

Heather’s Follow-up Question:
Could I say the smallest time is the fastest time to bleed out without medical attention and the longest time is a small bleed from an artery?

Jordyn Says: Yes, this is reasonable. 

Author Question: The ER Doc and the EarthQuake

Patrick Asks:

In my novel, I have an ER doc on vacation with his family. An earthquake strikes. His 14 y/o son suffers grievous injuries (I’m thinking a concrete pillar falls across his midsection.) The doc knows that in the best of situations, in an equipped trauma center, he’d only have a slim chance of saving his son’s life. As it is all he can do is try to comfort his son and be with him as he dies.

So my questions are threefold:

1.  What would be the signs that would convince him that his son is doomed and there’s nothing he can do?

2.  How long would it take for the poor kid to die?
3.  How would the doctor identify himself, or think of himself, in a casual situation?

Jordyn Says:

Hi Patrick! I am happy to help with your question.

#1: What would be the signs that the son is going to die?

Essentially the scenario you’ve set up would be death from hypovolemic shock (the son is bleeding out). Or, organ dysfunction from crush injury. But, let’s stick with hypovolemic shock as it will work well in this scenario.

What would be more concerning to the father and trained ER doctor would be his signs of shock— this would lead to his death. I’m going to use the medical words because this is how your ER doctor would think and then I’ll put what they mean in parenthesis.

I think one thing that helps is to understand the symptoms in light of the injury. When you’re bleeding out, you’re losing blood. Blood carries oxygen. So the body compensates by trying to circulate those remaining red blood cells faster.

Shock is your body’s inability to meet its oxygen demands (hypovolemic shock is one type of shock.) So, initial signs of hypovolemic shock are: tachycardia (increased heart rate to circulate the blood faster), tachypnea (increased breathing rate to load more oxygen on the cells that remain), complaints of thirst, pallor (pale skin– circulating red blood cells gives you your color) and diaphoresis (sweating). Also, diminished, weak, rapid peripheral pulses. Peripheral pulses are those at your wrist (radial) and feet (pedal). This would progress to central pulses–those in your neck (carotid) and groin (femoral)— being weak and thready.

In kids (this is my area of specialty)– the blood pressure will be normal initially because kids can do really well at compensating for shock up to a point.

So– hypotension (or low blood pressure) is then an ominous sign. One way a trained ER doctor can estimate what his son’s blood pressure is is by palpating his pulses.

eMedicine

For instance:

If you have carotid, femoral and radial pulses: Your BP is at least 70mmHG systolic.

If you have carotid and femoral Pulses: Your BP is at least >50mmHG systolic.

If you have only a carotid pulse: Your BP is about 40mmHG systolic.

You cannot discern diastolic pressure using this method.

As his shock progresses, his level of consciousness will begin to wan. He’d have periods of being coherent– then unresponsive (depending on how fast you’d want this death to occur). The brain is oxygen hungry so when it doesn’t have enough– you become unconscious.

His ultimate sign of impending death will actually be bradycardia (low heart rate– less than 60 beats/minute) progressing to asystole (no heart beat). This is how kids generally die. The child would become unconscious. His breathing would slow/stop. His heart rate would slow then stop. Pupils will dilate and become unresponsive to light.

#2. How fast would this happen?

This is really your choice. If your character has a major aortic rupture (this is a major blood vessel–your descending aorta– that is in your abdomen) death could take place in 1-2 minutes. Also the spleen and liver are highly vascular (meaning they have a lot of blood vessels) and crush injuries to these organs would lead to rapid exsanguination (bleeding out) as well. Or, you could have slow leaking type bleeding that could take longer to die from. All bleeding– if not stemmed– can lead to death.

#3. How would he refer to himself? “Hey, I’m Dan, I’m an ER doctor.”
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Patrick J. Worden is the author of several books, including the just released novel, VoraciousHe blogs on culture and current events at http://pworden.com/.

Author Question: Bleeding to Death

S.W. asks: This is the scenario: A woman has given birth attended only by her partner. After an exhausting long labor, the birth goes reasonably well, but a couple of hours later, she hemorrhages. My question is, would it be possible for her to bleed to death while sleeping?

My plot needs her partner to be in the same room, under the influence of alcohol or drugs which he takes to ‘celebrate’ after the birth. I need him to not realize what’s happening until it’s too late to save her.

Jordyn Says:

I do think this scenario is plausible on a couple of levels.

When a woman has bleeding complications related to delivery– she’s obviously losing blood. Simply, blood carries oxygen to each of your organs.

When there has been significant blood loss– the woman will lose consciousness because of two aspects: not enough blood to carry the oxygen to her brain and/or low blood pressure. You have to have a certain blood pressure to perfuse your brain– and therefore stay conscious.

She would go unconscious and could appear just to be sleeping to the one who’s under the influence of all those meds/alcohol.

The pregnant woman would continue to bleed and never regain consciousness. She would die from exsanguination.