Author Question: Treatment of the Burn Patient

Jennie Asks:

What happens when someone gets burned? What do the EMT’s do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.

First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.  The second man’s arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor.

I have the paramedics taking the first man to the hospital. I describe very little about his condition. However, the hero is attended by the heroine who is an EMT. His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot if he needs one?

Jordyn Says:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving some of their own medications (like an asthma inhaler or nitroglycerin tablets.) A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT’s, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.

2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.

3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding— it is possible that an IV could be started and the patient could get an IV narcotic for pain (something like morphine or fentanyl.)

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound like the hand and foot. The electricity enters one part but has to exit somewhere.

The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. This could be evaluated initially by a 12-Lead ECG and lab work that measures muscle breakdown specific to the heart. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can’t see it externally except and the entrance and exit sites.

The other thought was the extent of your patient’s burns and this would make a difference in their medical care. Burns are generally calculated based on the percentage of skin that is affected. You can find examples of these tables by clicking this link. Adults and kids are calculated differently.

Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help burn patients maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this and is dependent on the burn percentage), pain medication (like morphine), and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn’t had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? For instance, this link shows all of the Denver Metro Prehospital Protocols. Referencing these will be one of the best sources for researching what type of prehospital care your character would receive for their given ailment.

***This content originally posted December 10, 2010.***

Author Question: Medical Complications for Badly Broken Leg 1/2

Mareike Asks:

Greetings from Germany!

The character in question has several injuries, the most important of which is a severely broken leg (I’m talking cast all the way up to the hip). He got these injuries by being attacked and beaten up.

knee-1406964_1920I’m thinking open or compound fracture because then I can have him develop a bone infection. What I’m wondering is the order of things and how long it would take to develop what and how to recover, how long it takes, and so on.

I want him to either develop compartment syndrome and/or the above mentioned bone infection. From my understanding of the sources I’ve read, an infection can result from the treatment of the compartment syndrome, but not vice versa, so it would make sense to have that order, right? Those two are the main life/health threatening complications I could find while researching.

My ultimate goal is to write a story of recovery. Of the hardship, the struggle and pain, the setbacks. The physical therapy, the fear of whether or not he can go back to his old job.

Any resources you could point me towards when it comes to recovering from a very nasty break that might or might not require amputation or might lead to a disability would be greatly appreciated.

Jordyn Says:

Greetings from the USA! I’m going to give some thoughts on your question. I also consulted with a physical therapist since a large portion of your question deals with recovery and we rarely know what happens to patients in the long run.

I’ll give Tim’s thoughts on PT next post.

One thing I want to make clear is that treatment in the US is going to differ from medical treatment in Germany. If your novel is specific to Germany, then you really should run these thoughts by a medical person in your country. Some things should be similar, but some may also vary widely (like treatment of the actual fracture— use of fixators versus casting, etc.)

My first thought is it is really hard to get an open fracture of the leg from a beating. It’s not impossible, for sure, but we normally see injuries like this from mechanisms with a lot of velocity behind them— car accidents would be one example. So, sadly for your character, for this to ring medically true, I would probably add a weapon of some sort— like a metal pipe. And it’s more likely from repeated hits than just “one lucky” one.

The other thing is to understand the difference between compartment syndrome and the bone infection you mention which is called osteomyelitis. Compartment syndrome is a condition of swelling leading to a lack of blood supply. When you injure your body, it responds by swelling. Think of a sprained ankle.

Sometimes, this swelling can become so severe that is compresses on the blood vessels inside the extremity and either diminishes blood flow or cuts it off completely. This can be from just the injury, a cast or splint that is applied too tightly, or swelling after a cast was placed correctly.

Things begin to die when they don’t have blood supply. To alleviate the pressure, a fasciotomy is often done, which is a long cut through the skin and underlying tissue. It is a deep cut. If you Google pictures of a fasciotomy you’ll quickly get the idea. Not for the faint of heart. After this type of procedure, you have an open wound. Open wounds are always at risk for infection, but it doesn’t necessarily mean the bone would get infected.

Osteomyelitis is an infection of the bone. An open fracture (where the bone punches through the skin) can place a patient at risk for this type of infection. The dirtier the wound the more apt for infection. Wound infection does not develop immediately. Usually it takes 48-72 hours (24 hr at a minimum). Antibiotic therapy for osteomyelitis is extensive lasting 4-6 weeks. You can read an overview here.

Also, here is a link that deals with treatment of compartment syndrome.

With these injuries, coupled with the  added complications of compartment syndrome, fasciotomy, and/or osteomyelitis (or some other infection), your character is looking at 2-4 weeks in the hospital. He would likely go home on oral antibiotic therapy for his bone infection.

He’ll also need extensive rehab which Tim will highlight next post.

Author Question: Bullet Wound to the Chest

Gwyn Asks:

I’m writing a scene in which a cop is injured during a confrontation with a suspect.  I’d like to tell you about the scenario I have in mind and hopefully you can tell me how realistic it is.

ammunition-2004236_1920Cop, mid-thirties, in excellent health and physical condition is shot with a low caliber bullet from about 10 feet away.  The bullet hits his chest, goes through the lung and exits out the back.  He’s got colleagues nearby who administer basic first aid and the EMTs get there within 5 minutes.  Say about 15 minute drive to the hospital.  They radioed ahead so the hospital is expecting them and has an OR ready.

First of all, what are the chances of survival?.  Second of all, assuming survival, what are the chances (best case scenario) of full recovery – to the point he can return to active duty.  How long would the recovery time be, how soon would he get out of the hospital, and what complications — pneumonia, blood clots, etc should the doctors be worried about?

Finally, if a full recovery is highly unlikely, are there little changes I can make to the scenario to make it more likely?

Jordyn Says:

Hi, Gwyn! Thanks so much for sending me your question.

In short, this is a survivable injury.

You don’t specify in your question whether this police officer is shot in the right or left chest. Right chest would probably be preferred as there are less vital structures on the right side of the chest then the left.

ambulance1You give your victim immediate first aid and EMS responds quickly. Keep in mind that you’re going to need a paramedic to respond to give more advanced field procedures. A basic EMT is limited in what they can do— CPR, wound dressings, assisting the patient with some of their own medication administration. Depending on the state, some EMTs can start IVs, so if your novel is set in a specific location then I would research this for that area. Assuming he has a paramedic respond then he’ll get an IV, IV fluids, oxygen, and possibly pain medications. Of course, a set of vital signs and cardiac monitoring.

In an urban setting, a drive time of fifteen minutes to the hospital seems a little long. If a rural setting then you’re probably fine but you might need to adjust there as needed.

A bullet passing through the chest is likely going to puncture and deflate the lung. This character will need a chest tube to get the air out of his chest and reinflate the lung. A chest tube can be placed in the ER. This patient would get a CT scan of his chest. If the medical team isn’t worried about any other injuries than this patient may not even need to go to the OR.

A patient with a chest tube will need to be admitted into the hospital. How long it takes the lung to reinflate depends on the size of the pneumothorax or the degree to which the lung has collapsed. Generally, a patient’s chest tube is connected to a drainage box that uses suction to help the lung reinflate. Patients with this type of injury will get daily (or every other day) chest x-rays to see how the lung is expanding. After the lung is fully expanded, the suction is stopped, but the box remains in place. This is generally referred to as placing the chest tube to water seal.

If the lung stays expanded to water seal for one to two days then the medical team would feel good about removing the chest tube. Then the patient would be observed for another one to two days to make sure the lung stayed reexpanded.

Pending any complications, you’re looking at a hospitalization of 4-7 days. Pneumonia is probably your more likely complication. Having a tube in your chest hurts. Because of this, patients don’t want to take deep breaths. This can lead to the smaller air sacs in the lung staying collapsed and trapping bacteria which could lead to pneumonia.

If you add a complication like pneumonia, then you’re easily adding another one to two weeks that he’s out of commission.

If you just stick with a “simple” collapsed lung I would say he’d be out of work for about two weeks. He won’t be physically 100% of what he was before the injury but he should feel back to his physical baseline in about a month.

I would say he can work, but he’s going to have some physical limitations. It would be up to his department what his physical capacity needs to be before he can return to work. Half days at a desk job is not unreasonable for a few weeks.

He’d likely become short of breath during any exertional activity (like running after a bad guy). However, considering his physical shape, he should bounce back fairly quickly.

A nice overview can be found here.

Hope this helps and good luck with your novel!

Author Question: Complex Traumatic Injury

Rachel Asks:

I love your blog, and I have a fictional medical question for you.

motorcycle-654429_1280I have a young teen character in the near future (about 2075) who is a motocross racer. She has a horrible crash near the end of her freshman year of college and suffers a large injury – she has to stop school.

I want her to recover in 3-6 months, well enough to go to school, and show up full of plates and wires. I was thinking a severe shoulder fracture would do it, and assuming she got good enough PT, she could eventually race again (and even move onto a more demanding kind of racing.)

Is this a likely enough scenario? What would be a typical range of wires and plates to put in? I want a specific number for her to obsess about as she overcomes her fear of biking. Other injuries you could suggest? What about the recovery timeline? I need her off the bike for about 6-9 months, but some of that could be psychological, not physical recovery.

In this novel, there is some integrated AI technology. Obviously, the answer can incorporate speculative medical advances, but I’d like to know what is typical today so I can make them sound convincing.

Jordyn Says:

My first impression is that the shoulder may not be the best option if you want lots of plates and screws. You have to consider the bones that make up the shoulder and how those injuries would be treated. The scapula is very hard to fracture and likely wouldn’t be repaired that way. I’ve only actually seen one scapula fracture in my entire ICU/ER career in the span of almost 25 years. Collar bones we basically let heal on their own without surgical intervention. Even the upper arm— at least in kids— is not even splinted if you can believe that (most often)! Ligament repairs, labral tear, rotater cuff repairs, etc, could potentially take your time frame (with some complications) but would not involve a lot of plates and screws.

If you wanted to stick with an upper body injury— you could do amputation and then have your character learning to use a prosthetic which might tie in nicely with your integrated AI technology.

If you want to stick with a ton of plates and screws, alternative injuries could be a pelvic fracture or a complex upper or lower (or both) leg fracture. For instance, you could probably Google– x-rays of pelvic fractures repaired using plates and screws or x-rays of lower leg fractures repaired using plates and screws as references to come of with a specific number for her obsessive counting, etc.

Hope this helps and good luck with your story!

Author Question: Surviving Stab Wounds to the Abdomen

Anonymous Asks:

I have a character in my story who is stabbed three times with a three inch, narrow blade trench knife in the abdomen. I’m trying to avoid the guts or arteries and make it as non-lethal a spot as possible. He is a doctor and also a spy. I would like him to live and make a complete recovery.

He is two hours away from a hospital and has a friend to help him get there. Here are my questions:

1. Would it be feasible for him to live that long while he gets to the hospital for treatment?

2. Would he want to leave the knife in during travel time so he doesn’t bleed to death?

3. Or do I need to rework the scene so he’s closer to the hospital? If two hours is too long, what’s the maximum time he could have in travel before it’s too late?

Jordyn Says:

anatomy-254129_1280This is an example of all things are possible, but not necessarily probable. Of course, people survive devastating injuries every day. Miracles do happen. This is the category I would put your character in to.

The largest problem with him surviving these injures in the length of the knife and how many stab wounds he has. Three inches is long when it comes to knife wounds— particularly if the full length is buried into the abdominal area. We have to operate on a worst case scenario until the patient proves otherwise. Looking at the picture to the right, you can see all that is located in the abdomen and how likely it is that something devastating to this patient would be punctured or nicked.

If you want to keep the scenario as is, then I would have all the punctures be to the lower abdomen and to either side. This could puncture the intestines and bladder. These would need to be surgically repaired, but should be survivable (if the bleeding is minimal) for a couple of hours.

You’d definitely want to avoid the left upper and right upper abdomen which house the spleen and the liver. If these are punctured, your character would likely bleed out within two hours. Also, more midline to the abdomen is the descending aorta (a very large blood vessel), which also would lead to rapid hemorrhage and low survivability.

Leaving the knife in is up to you as an author. I could see his friend doing either thing. In a panic, he removes the knife. Or, maybe he has some medical knowledge where he thinks leaving it in place might be a good idea. I would pick whatever increases the tension for your scene.

Two hours is reasonable if you pick the injuries I describe above. I would caution you, though, to give the reader an image that there is little bleeding and the pain is somewhat tolerable. Rapid bleeding, a hard distended belly, accompanied by signs of shock (rapid heart rate, rapid breathing, sweating, paleness, clammy skin) would be poor prognostic indicators for surviving two hours.

Hope this helps and good luck with your novel!

Treatment for Amnesia

Marissa Asks:

How do doctors proceed if they suspect amnesia? In my novel, the patient was brought to emergency after being found on the side of the road (in the snow.) The patient shows signs of physical torture: multiple rapes, bruises, lacerations, glass embedded mainly in his hands, hypothermia, and a cold (because obviously my character needs to be ill on top of everything).

burnout-384086_1920The patient has just woken up and had a panic attack. Been settled down. You asked for his name and he seemed uncertain as he gave his first name. You asked for his last name and the patient shook his head. What next? I mean obviously the glass would have been removed from his hands and a drip put in for painkillers but what next? Who does the nurse call? Or what does she ask now? And if memory loss is confirmed, how do they find out it’s amnesia like which SPECIFIC tests do they do? Who is contacted and brought in to liase?

I just sort of need a timeline rundown because my character is going to be going through that.

Jordyn Says:

Thanks so much for sending me your question. First of all, it sounds like this patient has a period of time where he is unconscious in the ER. You make it sound like he wakes up on his own and not in response to an exam by a doctor.

So an unconscious patient found with these injuries would have a CT scan of his head. Hypothermia could be determined simply by taking the patient’s temperature and warming him up with something as simple as warm blankets to more complex as heated IV fluids. Regarding the IV drip for pain— this is actually unlikely in the ER. This is referred to as a PCA pump (patient controlled analgesia) and I’ve never seen them used in any ER setting. Would we treat the patient’s pain? Yes. But, you might be surprised that we may choose not to use a narcotic (for many reasons) and instead try something like Toradol which is an IV form of an NSAID (which is in the same drug class as Ibuprofen.)

The glass embedded in his hands would be removed. The wounds irrigated and stitched closed if necessary. The lacerations would be treated the same way. Keep in mind, not all lacerations can be stitched closed if they’ve been open too long due to the risk of infection.This patient would also receive a tetanus booster if he hasn’t had one in the last five years (even if he can’t remember the last time he had a shot.) If anything looks infected, he would receive IV antibiotics.

If the patient wakes up and doesn’t know who he is (and doesn’t have any form of identification on him) then we would involve the police. Likely, they are probably already involved considering the circumstances— that he was found unconscious and beaten. Plus, you mention that the character has been raped several times so a sexual assault kit should be collected, but the patient’s consent is required, so we’d ask him if he wants this when he’s awake. Yet another reason the police would be involved.

If the doctors think the amnesia is related to a brain injury from the beating, they may just see if it improves with time.

I think it’s reasonable to admit this patient to the hospital and I speak a lot here about how it is actually rare to admit a patient with concussion, but considering the amnesia (it sounds like you want it to persist), the beating, the rapes, the wounds to his hands (as well as additional lacerations), and the hypothermia then some watchful observation is warranted. The doctors could consider a neurological and/or some type of psychological evaluation considering the circumstances of the case to see if his memory loss has a non-medical cause. Neuro might request an MRI of his brain to look for additional injuries not as easily discerned via CT scan.

In the end, if he never remembers, there’s little treatment to “correct” amnesia. This is good for the writer because you have a lot of leeway in what you want to happen to the character. Your time frame can be what you wish.

I think if he were stable in the hospital for a few days and the neurological/psychological evaluation didn’t warrant anything that required further inpatient treatment, he could be discharged home even if the amnesia persists with outpatient neurological follow-up and perhaps outpatient therapy if he consents.

Obviously the police would be very involved with this case.

Author Question: Car versus Pedestrian

Alex Asks:

My character suffers the following injuries. I want the injuries to be severe enough that they require immediate surgery, but also that he recovers after about a month in the hospital and a stay in rehab.

carpedistrian1. Character is standing in the road, tries to run but is hit by the car front on.  Body smashes into the windscreen, sending him up into the air.

2. Hits his head on the pavement on landing and suffers broken bones as a result.

3. He blacks out from the impact and wakes up several hours later. In this instance, would he be able to survive for several hours with the kinds of injuries he could have?

4. Possible injuries I thought he could have included: bleeding on the brain, broken leg/s and/or arms, fractured ribs which could cause a puncture to one of his lungs.

5. As a result he suffers from retrograde amnesia when he wakes up at the scene because of the injuries to his brain. Cannot remember his name/where he is or other events in his memory. Again here I am not sure what kind of specific head trauma could cause this.

6. After surgery to the brain, he is put into an induced coma to monitor the swelling. He will eventually wake up from this about a month later.

Jordyn Says:

The accident you describe would include some very serious injuries— perhaps not even survivable. It’s not just the injuries the character suffers getting thrown from the impact onto the pavement, but also the injuries he suffers from getting hit by the car. An impact that is so violent that it throws someone into the air would also likely shatter the windshield indicating to EMS responders that there was a lot of violent energy associated with this collision— which means bad things for the patient.

My first opinion is if you want this character to wake up in a few hours would be that he doesn’t fall directly on his head after he’s thrown into the air from the first impact. Overall, for your scenario, you might want to lessen the violence of this crash if you want him up in a few hours. It wouldn’t be surprising for this patient to require surgery to fix broken bones and/or internal bleeding.

A pedestrian surviving this crash is not impossible but it is more on the improbable side. This patient will have a lengthy hospital stay. May not wake up for days or months— not just hours. What you outline is a high speed impact to a pedestrian.

To answer some of your medical questions— surgery may be required for the bleeding on the brain depending on its location. All patients who have a brain bleed do not necessarily go to surgery. A punctured lung will require a chest tube to be placed which further complicates your patient’s medical picture. This patient would be placed on a breathing machine for sure to stabilize him until all these injuries could be sorted out.

Could a patient with a significant brain bleed be conscious at the scene after the accident? Yes. There is a specific type of brain bleed that fits this scenario called an epidural bleed. It does have a characteristic lucid period before the patient becomes unconscious again. It does require surgery to correct. If no surgical intervention is done then the patient will likely die. Honestly, as a writer, you have a lot of leeway in regards to what to do with amnesia. Any type of traumatic brain injury (and this certainly qualifies) could cause amnesia.

Medically induced comas are used frequently in medicine as a way to help control brain swelling. However, the medicines are not used forever. Peak brain swelling usually occurs 48-72 hours after the injury. After this time has passed, the medical team will evaluate when to decrease the medications keeping the patient in the coma. Keep in mind, even after these medications are discontinued, the patient may never wake up. Further studies would need to be done to determine the extent of the damage to his brain. These changes will evolve over time becoming more stable the more time that goes on.

My recommendation would be to lessen the severity of the crash. The car hits him, he hit the windshield, breaks it and then falls to the ground. This alone could cause a femur fracture and brain injury for which he could suffer amnesia and require surgery. If it’s an epidural bleed then he gets surgery, perhaps with some swelling and therefore the medically induced coma, but wakes up in a month. The leg is set in surgery with pinning or a rod. I think just having these two things is enough for your scenario.

All the rest might prove too complicating.