Author Question: Delayed Death by Crossbow

Ben Asks:

Here’s my scenario that I would appreciate some advice on:
I’ve got a 25 year old woman that is shot through the left calf and the upper torso (I was thinking, maybe having the upper body shot piercing her shoulder) by crossbow bolts made of wood in my fantasy novel. The weapons that shoot her are each one-hand-held, meaning that they can be aimed and fired with only one hand.
What I need to know is this:
1. Would this outright kill the character?
2. If yes, where on the average human female body can I have two crossbow bolts made of wood puncture that body in such a way as to negate instant death, but still leave months of recovery time for that character, if she gets the proper medical help fast enough?
For background information, the science level of the world I am writing is roughly the same level we have today in America and Europe, the same with this world’s medical tech and knowledge.
Jordyn Says:
Thanks for sending me your questions.
1. A wound to the calf is unlikely to outright kill someone immediately. Any bleeding that’s not controlled if brisk enough can lead to death. Infection is a risk with any wound– particularly those that are caused from things (like arrows) that penetrate the body deep into its tissues leaving bacteria and other microorganisms behind.

The shot to the torso has more likelihood to cause death if it hits the right structure. On the left side of your chest are your heart, great blood vessels, and lungs. If the shot was more to the shoulder then an outright kill would be less likely and the risks above would be more prominent (bleeding and infection).

2. A shot to the calf and the shoulder have the potential to set your character back several months. If you don’t want the character to die– I would avoid having a shot to the torso. A projectile to any extremity can cause the bone underneath to fracture. Fractures typically take 6-8 weeks to heal.

If you didn’t want to go with a fracture of the bone from the projectile– you could have onset of infection (depending on how sick you’d want her to be for those months). Systemic infection can easily cause death. Local infection to the wounds can be problematic as well. You could also go with tendon damage to the arm or leg which would inhibit movement of the extremity. Healing and rehab of tendon and/or ligament damage can take months as well. Whenever an extremity isn’t used because it’s immobilized you always get muscle atrophy (muscle wasting) which causes weakness of the arm/leg, etc. It takes time to rehab that as well.


Good luck with your novel!

Author Question: Treating Injuries Related to Torture 2/2

Today, we’re wrapping up Taylor’s questions about treating injuries related to torture. You can find Part I here.

Question #2: She was whipped/flogged, and has wounds from that across her back. Her shirt is torn, and dried blood makes the fabric stick to the wounds, which is (obviously) painful. How long does it take for mild infection to set in? (Nothing major – no blood infection, sepsis, etc. Just the beginning signs – redness, swelling, warmth, etc.)  How would the wounds be treated? Antibiotics? Cleaning the wounds – how is that done? Can they be stitched?
Jordyn Says: These wounds will need to be cleaned for sure. To get stuck material from wounds we generally saturate them with saline to dissolve the blood and peel away the fabric. I did a recent post specifically about wound infections but on the short side is 12 hours. More commonly is 48 hours and considering her condition, wound infection is going to be a big concern. They cannot be stitched up.

Here is another post I did on stitches but outside time frame for stitching someone up is 24 hours and that is only if the wound is super clean which these would not be. Taking her to the OR for wound cleaning, debridement and dressing placement might be an option if they are extensive. They could do a better job with better pain control. The reason they can’t be stitched is concern for infection– we don’t want to trap pus/germs in a wound. Better to let it drain out. They’ll want to be sure she’s had a tetanus shot within the last five years. If not, she’ll get a booster. Antibiotics are probably warranted in her case– something for skin infections like Keflex. 

Question #3: When the soldiers rescue her from the hospital, how do they move her? She doesn’t have a spinal injury; she’s able to sit up and move in bed. Lying on her back on a stretcher wouldn’t be very comfortable. I guess she would have to lie on her side (the one that isn’t bruised and battered). Are there any other precautions they would need to take?
Jordyn Says: If they aren’t concerned about spinal cord injury than transporting her in a “position of comfort” is reasonable but she’d still have to be secured in seat belts some way.   
Question #4: How long do cracked ribs typically take to heal? She was kicked and/or stepped on by her captors, and has 1 or 2 cracked or broken ribs. If they are only cracked and bruised, if she was given some sort of wrap/brace, is it plausible that she would be able to go “out in the field” again after 2 weeks or so? She won’t be jumping out of helicopters, leaping tall buildings in a single bound, or anything like that – she’ll be interrogating suspects, maybe running for a bit in a foot pursuit, and will have some involvement (to be determined) in the take down of a very bad guy near the end of the book.
Jordyn Says: Cracked ribs usually take six weeks to heal. Here is some information on treatment of cracked ribs. Wrapping cracked ribs is not recommended anymore. We want the patient to be taking deep breaths so they don’t develop pneumonia. Wraps inhibit this. Cracked ribs are painful but not an unstable fracture so she can interrogate suspects and run but it will be quite painful and she’ll have decreased stamina for sure. A take down will be quite painful too because it will be hard to protect the area. 
Hope this helps and thanks so much for your questions! Best of luck with your book. 

Author Question: Treating Injuries Related to Torture 1/2

Taylor Asks:

I have some character injury questions that I could use your help with, if you don’t mind! I contacted you last year with a bunch of questions about car crashes and injuries for another book that I was working on, and you were a tremendous help. I have some questions for this story, and thought I’d reach out to you again.
This story is a political thriller. One of my characters (Erin) is an American government agent who is ambushed and kidnapped by an Iraqi insurgent/terrorist leader while working in Iraq. He took her for two reasons. One is that he wants to use her as leverage/a bargaining chip to get what he wants. The other, more significant, reason is revenge. John (her current partner/coworker) had been a member of the US Army Special Forces. During a mission in the Middle East, he killed a fairly high-ranking terrorist who was responsible for the deaths of several US military members. That happened to be this man’s brother. Now this man has taken Erin, and plans to kill her – he wants John to know the pain of losing a loved one, and plans to make them both pay for John’s “crimes.”
One of her guards helps her escape after three or four days. He can’t deliver her back to the Americans, so he takes her to a local hospital and hands her over to the staff there for medical care. She is then rescued by the military a few days later. 
Iraqi insurgents are well known for their methods of torture and brutality to their captives. Fortunately for Erin, she was spared the worst of it; all things considered, they didn’t treat her TOO terribly.
Question #1: She’s hungry and dehydrated (they gave her very little food and water.) Other than IV fluids and adequate food and water after she is rescued, is there anything else that would need to be done?
Jordyn Says: In a time frame of four days, yes, she is likely dehydrated but she shouldn’t be terribly malnourished. A couple of liters of fluid (Normal Saline or NS) should get her feeling much better. Than some fluids that have some sugar and electrolytes in it at maintenance until she’s eating well and peeing well.  

We’ll continue with the remainder of Taylor’s questions tomorrow!

Author Question: Amputations and Infections

Kariss Asks:

A Navy SEAL team is on a mission in Ukraine. One of the guys gets shot in the leg by a sniper and then gets debris in his leg when the boat explodes. They dive into the Black Sea to get away before getting to the getaway boat. He is sent to a military hospital in Germany and then sent back stateside to make decisions with his wife. In the story, I need him to have his leg amputated but also be a potential candidate for a bionic leg/prosthetic down the road.

A few questions in that regard…where would he need to get shot in the leg for that to be an issue? I thought a major artery. But I’m not sure that is accurate. Would infection be a problem from the dirty water and wound? If so, how long would that take to set in? Since I need amputation to be the final outcome, how long would doctors deliberate and monitor issues before choosing to amputate? I think my timeline may be too long in the book and I want this to be accurate.

Also, I have one of the SEALs call the wounded warrior’s wife to let her know there is a problem and they are coming home. Because of mission sensitivity, he can’t tell her what happened, especially over the phone. My editor thinks a doctor would be the one to contact the wife instead of someone on the team. But I’m not sure that would be true in the case of classified special forces ops. Any input on this?

Jordyn Says:

Thanks for your question. It’s an excellent one and I’ve pulled in several people to help so thanks Tim (who serves as a military chaplain) and Angelique (a physician co-worker) for your insights.

Question #1: There are many indications for amputation– only one being lack of blood flow to the extremity. So damage to a major artery doesn’t necessarily have to be your mechanism of injury. Top three reasons would be trauma (the extremity has lost too much muscle, bone, etc), infection, and vascular insufficiency (damage to the blood supply that keeps the tissue alive.)

Question #2: Is infection a concern because he was swimming in gross swamp water? Yes, this will be a concern. Infection could show up in as little as 12 hours. More commonly is 48 hours. Of course, there are always outliers. What you could research is common skin infections, microorganisms, and such in the geographical area your incident happens. You might find something better that fits your time frame.

Question #3: How long would the doctors take to make a decision? Here, you could basically make the medical scenario fit your timeline. If you want them to amputate right away– go with major loss of tissue from the extremity. It’s basically not salvageable. Or– longer (days to weeks) then you could use a scenario where infection sets in, he doesn’t initially respond to the antibiotics, they try a different antibiotic– maybe surgical debridement, etc. That process could take a week or more.

Question #4: Notification. This is directly from the chaplain’s e-mail to my query.

I can only speak based on my experience in the Navy, and please recognize that the various military branches handle casualty notifications in different manners. That being said, a doctor would not be the one to call giving the nature of the incident. A command representative in addition to a chaplain would generally make an in person visit to the primary next of kin, in this case, the spouse. Also, if this is really a soldier, then he’s Army, whereas, the other branches would refer to themselves as Airmen, Sailors, or Marines. 

As a side note, in discussing your question with the physician, she said below the knee amputations are easier to fit with a prosthetic versus an above the knee amputation so consider this as well for your story.

****************************************************************************

Kariss Lynch began her writing career in third grade when she created a story about a magical world for a class assignment. Chasing her dream into college, she received a degree in English at Texas Tech University and fell in love with writing faith-based fiction about characters with big dreams, adventurous spirits, and bold hearts. Her first novel, Shaken, book one in the Heart of a Warrior series, released in February 2014, with the second book, Shadowed, scheduled to release in Winter 2015. Kariss is a diehard Texan, born and bred in Dallas, where she now works as a writer for a local communications ministry.

Safe Surgeries Not Without Risk

Not only am I a pediatric nurse, but I’m a mother of two girls age 9 and 11. I tend to worry. Not about the little every day illness and injuries– like say my daughter’s broken arm that I didn’t have evaluated for 24 hours. Hey, it wasn’t deformed and she had good blood flow. Perfectly okay to see if rest and Ibuprofen made a difference.

What I do worry about is those zebras in the forest. This phrase is typically used for those diagnoses that happen but are a rare occurrence. Like your child with a nose bleed probably (99.5% of the time) doesn’t have cancer.

But– this is what I worry about out. Every headache is a brain tumor. I probably palpate lymph nodes more than I should which got me into an anxious worry cycle when my youngest was around three-years-old.

I looked at her one day and she has a lymph node bulging from her neck. She was otherwise fine– which was actually more worrisome, because she didn’t have a reason for the lymph node to be so prominent. No ear pain, sore throat, fever, scratch . . . etc.

I took her to her pediatrician and he wasn’t concerned. They did a CBC– which is a blood test that looks at red and white blood cells. It can give an indication of cancer but is generally not considered definitive. Even after the CBC came back normal, my mind wasn’t completely at ease so I scheduled to take her to the ENT. They, too, were nonplussed but could see how worried I was and so the physician says– “I don’t think it will show anything to biopsy this node but I will take it out if it will make you feel better.”

And that’s when my nursing brain kicked in and began to override my mommy brain. I was risking surgery to ease my anxiety. I was going to give her a scar so I could sleep at night when this trained and well-respected physician and given me reassurance. I asked him what would be the most conservative bridge between surgery and easing my worrying and he offered to track it by exam every three months for a year.

Done deal.

Not too long after that we cared for a patient that got an infection after this type of surgery. Post-operative infection is a known complication of ANY surgery and doesn’t imply that there was negligence.

My concern is this– many parents are choosing surgery as first line defense when, perhaps, problems could be managed another way. Doctors are deferring to parents, at times, against their medical gut to cover themselves from potential lawsuits– such as a parent insisting on a CT for head injury. This isn’t always in the best interest of anyone. 

Next post I’ll be analyzing the case of Jahi McMath– who is the girl who suffered a surgical complication that led to brain death. Do I think, from what’s been written about the case, that the hospital could be responsible for her death?

Author Question: Antibiotic Usage

Amanda Asks:

I thought it would be good conflict to give my nurse protagonist TWO patients with rival needs. The fast facts:

A) Fugitives from the law.
B) No access to medical treatment.
C) The nurse does have some Amoxicillin but just enough for about another week for Patient #1 (the man she loves), who has been on it for almost five days now (fever broke, lucid now, still sick though.) He has bacterial pneumonia, rib fractures, and malnourishment.

They’re running for their freedom if not their lives. In comes Patient #2, who dug a tracking device out of his body with a non-sterile instrument and now has cellulitis (red streaks from the wound, low-grade fever, awesomeness.)

My nurse has to give him antibiotics or he could die.

But if she gives them to Patient #2, Patient #1 could relapse. And die.

So . . . Nurse Jordyn . . . which patient truly needs the medicine the most? Is there any use whatsoever in giving each of them half of it?

If she gives the whole dose left to Patient #2, will Patient #1 necessarily relapse? Is it unrealistic if he doesn’t?

If she gives the whole dose left to Patient #1 will Patient #2 necessarily die?

And now for the big question: as a nurse, what would YOU do?

Thank you, you are awesomely awesome.

Jordyn Says:

Wow, Amanda. This is a very intense question and not as hard an answer as you might think.

The issue you’ve given these two patients . . . Patient #1 has presumed bacterial pneumonia because I’m assuming no chest film was taken (which would be a definitive diagnosis) since they are running from the law. Patient #2 has cellulitis. 

The reason this is an easy answer is that Amoxicillin is typically not used to treat skin infections. What is generally used is an antibiotic called Keflex. This uber-smart nurse would know that and continue to give the Amoxicillin to the man with the pneumonia– particularly if he was improving. If the patient improves it can be a logical assumption that the antibiotic had something to do with it and he should finish the course of treatment.

That being said— let’s consider your questions.

Is there a benefit in giving each half the dose? Yes and no. This could be effective and also dangerous. Under dosing an antibiotic could lead to partial treatment and some bacteria still being left alive. Now, the bacteria have been exposed to the antibiotic and may mutate leading to a resistant strain which could ultimately put them both in danger.

Would patient #1 die if treatment stopped half-way through? Again, yes and no. He could survive and be fine but also develop a more resistant infection later on.

Would patient #2 die without treatment? Yes, this is probable with a bad cellulitis. Likely, what would happen eventually, is the bacteria gets into his blood and he dies from blood-borne sepsis or blood poisoning as it is sometimes called.

I do hope one of these fine gents lives.

Treatment of Infected Wounds

This post is in direct response to a question from Sue Harrison about taking care of infected wounds. What exactly is the treatment protocol.

Treatment of infected skin wounds is usually one of the easiest things we can do from a medical perspective. Unless it’s a superbug which is another concern entirely– but we’ll keep it simple for this post.

Here’s a short list of the treatment protocol.

1. Keep the wound from getting infected.  This boils down to a couple of things. In the ER– doing good wound irrigation for things like road rash and lacerations. Washing wounds physically removes the bacteria. If the bacteria aren’t present– they can’t fester to produce infection. Once the wound is cleansed– apply a topical antibiotic (like Neosporin or equivalent) to stem infection from developing.

2. Dressings should be changed once or twice daily. Unless it’s saturated– it can be left alone. The more things are mucked with– sometimes the more apt they are to become infected. You introduce more bacteria by touching.

Okay– say you’ve done all those really great things and it STILL gets infected.

One– is it really infected? Sometimes, people assume that mild redness is infection (this should only be 1-2mm around the wound edges) when it really is normal healing process. If the redness extends beyond 1-2mm– then there is more concern for infection.

Other signs: pain, swelling, pus draining, foul smell, red streaks running from the wound, swollen lymph nodes near the area, and fever.

Treatment:

First question: Should the wound/abscess be drained? Drainage is good because, just like irrigation above, it removes the bacteria. Some MRSA wounds are being managed just this way– with just drainage and no antibiotics– which is good to help prevent more resistant strains of bacteria from forming.

Second question: Place on oral antibiotics– but which one? This will be a good one to run by a doctor if it is important for the integrity of your ms. The most common one for surface skin infection is Keflex. But for abscesses– maybe something more along the lines of Clindamycin.

Sue– hoped this helped!!