Gunshot Wound

New Medical Device: X-STAT

/ Jordyn Redwood / Leave a comment

As a medical nerd, I’m always a little fascinated by new medical devices and what they can do. I was alerted to this device by Mike H. via Facebook (Thanks, Mike!) and found it worthy to post upon to keep all your medical treatment scenes in those novels up to date.

The Blaze

It is true that not all bleeding can be controlled by direct pressure. It is also true that bleeding is the leading cause of death when it comes to bullet wounds (unless you have suffered a direct hit to either your heart, brain, and/or spinal cord which is likely the end of your life here on earth.) Uncontrolled bleeding from limbs is one thing that harkened back the use of the tourniquet. First by the military and now by civilian EMS agencies. They found the concern over tissue damage didn’t pan out in the research.

For those other folks who get shot in the chest and/or abdomen, it’s always a race to the hospital where definitive control of bleeding can happen– which usually necessitates a trip to the OR– which takes time. You may have heard the term “Golden Hour” which is generally the preferred window to get the patient to definitive treatment before they die.

Rapid control of bleeding could actually extend this hour in my opinion.

Enter the X-STAT.  For lack of a better term, the X-STAT is a tampon shaped (sorry, guys) device that is filled with dime-sized medical grade sponges that are coated with a hemostatic (stops bleeding) agent. It is inserted into the wound and the plunger places these sponges deep into the wound where they expand (like the firework snakes) and stem bleeding without direct pressure. The expansion of the sponges prevents them from being forced out of the wound.

Genius.

Thus far it seems to be listed as an investigational device and its use is limited but if it does what it says it does I think this could mean a big difference for trauma patients.

You can read more about the X-STAT here. 

What do you think of the X-STAT? Would you use it in a novel? You can bet I’ll find a way to.

Medical Critique: CBS Drama Hostages 2/2

/ Jordyn Redwood / Leave a comment

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.
  

Medical Critique: CBS Drama Hostages 1/2

/ Jordyn Redwood / Leave a comment

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: Speech Therapy after Traumatic Brain Injury

/ Jordyn Redwood / Leave a comment

Karen Asks:

I’m writing a story about a man who is shot in the head in a way that impacts his ability to speak.  Long months of rehab restore his speech but leave him with a stutter.  Is this feasible?  Which part of the head would he need to be shot in?  What else could be impacted by such a wound?  Can you recommend any websites or resources about gunshot wounds or speech therapy?

Jordyn Says:

Karen– thanks so much for sending me your question.

Generally, the left side of the head is considered to contain the speech centers of the brain–in most cases. It might depend on whether or not your character is right or left handed.

97% of right handed people have their speech centers on the left hemisphere.

19% of left handed people have their speech centers on the right hemisphere– which may be where the phrase “left-handed people are the only ones in their right mind” come from. I LOVE this phrase speaking as a left-handed person.

68% of people have language abilities in BOTH hemisphere.

To read more on these areas– check out this link: http://webspace.ship.edu/cgboer/speechbrain.html
A good case to look into would be former Arizona Congresswoman Gabrielle Gifford’s. She received a serious gunshot wound to the head and had extensive rehab– over many many months. It might give you an idea of how long the road to recover is for some of these victims. It can be years.

http://www1.uabhealth.org/BoneandJoint/victims-gunshot-head-daunting-road-ahead

http://www.aans.org/en/Patient%20Information/Conditions%20and%20Treatments/Gunshot%20Wound%20Head%20Trauma.aspx

http://www.everydayhealth.com/blog/dr-black-brain-health/the-outlook-for-recovery-from-a-gunshot-wound-to-the-brain/

I think you have a lot of leeway as an author to decide what you want to do after brain injury because we don’t understand as much about the brain as we do other organs. It might be hard to pinpoint sources of “speech therapy after gunshot wound to the head” (which is how I first started to Google your inquiry) but a gunshot wound would be considered a traumatic brain injury so I started to Google that and came up with several other resources as well. Here’s a great You Tube Video that demonstrated a speech therapy session that could be great for a fiction novel.

http://youtube.googleapis.com/v/UQJ3VFvT7SA&source=uds

What else could be impacted? Anything really. Again– you have a lot of leeway here. There could be motor issues as well. Difficulty walking. Difficulty with fine motor skills. To the other extreme which would be coma.

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After creating Christian education curriculum for 25 years and writing over 250 published articles, Karen Wingate has turned her attention toward historical and contemporary fiction.  She lives with her husband and Welsh Corgi in Western Illinois.

Gun Shot Wound: Dianna Benson, EMT

/ Jordyn Redwood / Leave a comment
EMS expert and author Dianna Benson blogs today writing a first person account of caring for a gunshot wound victim. I love how she’s written this post with such detailed information that portrays the medical info so accurately.

EMS 4. Gun Shot Wound. 123 Main Street, Apartment G. 
I flip my book closed—Jordyn Redwood’s newest suspense—and zip it inside my backpack. I rush from my station’s crew quarters to the ambulance bay.
My partner slips behind the steering wheel; I signal us en route to the call via our laptop nailed to the dashboard.
“Twenty-nine year old male, GSW in abdomen, conscious and breathing,” I relate the facts as I read them on the laptop screen. “Raleigh PD already on scene.”
I wait for further information to display; my nerves rev up. GSW calls often place EMS in deadly situations. Even if the scene is safe at first, bystanders, the shooter, even the patient can turn violent. Prepared for anything at any given moment is the hallmark philosophy to staying alive.
“RPD in process of securing scene,” I read the new information out loud. “Stage near the manager’s office.”
“Manager’s office?” my partner turns our ambulance left at an intersection. “That can’t be far enough.”
I hear the fear in his voice. Only six months ago, he suffered a knife wound from a patient’s husband who didn’t want us to resuscitate his wife. 
“I know these apartments,” I say. “Building G is in the back. Furthest away from the office.”
More information came across the screen.
“Patient took off on foot. Stumbled away from the shooter. He’s down. Gas station on corner of Hill Street and Brown Avenue.”
Once we arrive at the gas station and notice RPD has the scene in their control, I duck under the yellow tape blocking the public from our GSW patient lying supine in one of the parking spaces like a car. Five firefighters surround the patient, each one pressing towels to his abdomen, as countless cops hold the perimeter they’ve established.
The firefighters step away, allowing us to take over medical care.
    
 “Sir, can you tell me your name?” I yell over the chaos surrounding me.
“Ronald,” he uttered with a flutter of his eyes.
I peek under the wad of bloody towels to examine the wound in his upper abdomen. Since bullets often act like a plug, gun shot wounds often don’t produce heavy external bleeding. This one the exception.
“Package and go,” I say to my partner. “Ronald, what medications do you take?”
“Nothin’.”
Gunfire whizzes near my ear, busts the car window next to us. My heart is pounding as cops tackle some guy behind me. The scene is safe again.  
With the help of the firefighters, my partner and I log roll the patient onto a spine board, place the backboarded patient onto our stretcher, and wheel it toward our ambulance.
I lean my face near Ronald’s ear. “What about street drugs, Ronald? I’m not a cop, so it’s best for your health if you tell me the truth. I don’t want to inject any med—”
“Nothin’.”
“Okay.”
We load the stretcher inside the ambulance.
“Any health issues? Allergic to anything?” I continue to ask Ronald questions.
“No, no,” he says, squirming. “The pain. It’s bad. Real bad.”
“I’m sure. Hang in there with me, okay?”
One of the firefighters slip behind the steering wheel as two others hop into the back with me and my partner.
I place a bunch of bandages over the bullet wound, crisscrossing and stacking them. I spike an IV bag, as my partner inserts an eighteen gauge needle into our patient’s arm. As I connect Ronald to our cardiac monitor via a 12-lead, one firefighter maintains direct pressure to fresh towels over the bandages, the other wraps a BP cuff on the patient’s right arm then clips a pulse ox to his left index finger for a blood oxygen saturation reading.
I glance at the readings on the monitor. “Hypotensive and tachycardic,” I shout over the sirens wailing and engine roaring. “82 over 54. Pulse 160.” I feel his left radial artery. It’s thready. “Trendelenburg,” I say, instructing the firefighter on my right to lift the foot of the stretcher, a treatment of hypoperfusion (shock), this case hypovolemic shock due to blood loss.  
I’m thinking the bullet pierced the vena cava. If so, this patient is bleeding internally and surgery is vital.
As my partner shoots morphine in the IV catheter, I notice our patient’s eyes are closed and he’s still and silent. Blood oozes from his mouth. His oxygenation reading drops to 91%
“Ronald?”
He’s unresponsive. I press my fingers to his carotid artery. Pulse still present.    
I suction blood from his mouth. In order to protect his airway, I slide a lubricated oropharyngeal airway down his throat. With a curved laryngoscope, I lift the epiglottis and gain a visual of the glottic opening and white vocal cords. I drop the orotrachael tube between the cords, down the trachea. I connect a bag valve mask over the tube opening. To keep him oxygenated, I squeeze the football-size bulb every five seconds.  
I read the newest vital signs on the monitor, “74 over 46. HR 168.”
My partner grabs the radio, switches it to the closest trauma hospital.
“Wake Med ED? This is EMS 4.”
“Wake Med. Go ahead EMS 4.”
“We’re en route with a twenty-nine year old male. Abdominal GSW. Tachycardic at 168. BP falling, last reading 74 over 46. Trendelenburg position. Administered morphine. Endotrachael in place. ETA five minutes.”
I glance at the cardiac monitor screen. “Astyole,” I shout out. “Take over bagging,” I tell one of the firefighters.
I begin chest compressions, as my partner injects epinephrine and vasopressin into the IV line. Nine compressions later, Ronald’s eyes flash wide.
I smile down at him. “You still hanging in there with me?”
He nods as we pull into the emergency department.   

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Dianna Torscher Benson is a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. Her first book releases March 2013.

After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMS degree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need. Her suspense novels about adventurous characters thrown into tremendous circumstances provide readers with a similar kind of rush. You can connect with Dianna via her website at www.diannatbenson.com.