Author Question: Rehabilitation after Gunshot Wound Injuries

Sean Asks:

Hi Jordyn!

Looking for a little bit of help with some 9mm gunshot wounds. I was going for non-lethal aside from possible bleeding out and injuries that would have long recovery time.

I have a character get shot at point blank range in the lower right abdomen from the front. Then in the right shoulder/clavicle, also from the front, about five to ten feet away, breaking the clavicle. Finally, in the left calf from behind from ten to fifteen feet away, breaking the tibia which is made worse when the shooter grinds his foot into it.

I’m guessing the shoulder/clavicle and calf/tibia would require a sling or cast and a serious amount of PT. The abdomen wound I’m guessing would require some reconstructive surgery depending on if and how much the bullet bounced around?
I figured it would take her almost a year to walk without assistance from those.  Am I close in that assessment? Thanks in advance for ANY help!
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Jordyn Says:

 

Since this is largely a rehab question I reached out to Tim Bernacki, a great physical therapist, who I highly recommend from personal experience. If you live near Castle Rock, CO look up his clinic, Front Range Therapies.

Tim Says:

Generally, time frame of healing is 6-8 weeks for most things, especially soft tissue. All these injuries would require surgery. The clavicle fracture would require an open reduction/internal fixation (ORIF)—this means that there is an incision made and hardware placed to stabilize the fracture.

I wouldn’t know what is done if the clavicle is “shattered” and is in a multitude of pieces. The wound would have to be a glancing hit that results in a fracture. Anything more severe in the area could result in ruptured arteries, as well, and the person cannot die from this wound.

The tibia fracture also would require an ORIF—either plate, screws, or rod with locking screws. The difficult thing in all this would be that due to the leg recovery, the person will be using an assistive device, but probably cannot use crutches due to the clavicle pain. Perhaps a walker could be used. Depends on how conditioned the person is, how young, etc . . .

The leg injury would require limited weight bearing for 6 weeks I would guess. If all heals as expected according to x-rays, then they would transition into weight bearing as tolerated (WBAT). Probably would have a limp for several weeks after that. Likely wouldn’t run until four months following surgery if all goes well. The clavicle would probably have a sling for maybe 2-4 weeks (if no repairs to muscle or rotator cuff were done). After that, overhead reach would be most affected and for several months.

As for the abdominal injury, other than not bearing down with pressure for a short time, I wouldn’t think there are other issues to consider.

I’ve seen some gunshot wounds (GSW) where the bullet enters, hits a long bone, changes course and travels along the bone. This assumes the round is a practice round (full metal jacket) and not a hollow point. Hollow point bullets or defensive rounds open up when they hit something, resulting in a much-enlarged object/wound. I’ve seen rounds left in place because taking them out was unnecessary and I’ve seen rounds removed because of the location. Sometimes there are exit wounds and sometimes there aren’t depending on what stops the round. Sounds like there wouldn’t be an exit wound with the clavicle and leg but could be with the abdominal (perhaps in the low back).

Hope this helps and good luck with your story!

Author Question: The Perfect Skull Fracture

Ethan Asks:

I’m looking for the Goldilocks of skull fractures. My main character is a college age male that got into a fight. I’ve tried doing my own research but I’m second-guessing myself on which part of the skull to hit. I’m looking for a crack (not a shatter), minimal blood loss, he stays conscious for ten minutes or so, and a hospital stay of about five to seven days. I’m guessing there’s no way to avoid a concussion, as long as there’s no permanent brain damage I can work with it. Is such a skull fracture possible? If so, where on the skull?

Jordyn Says:

Yes, there is such a skull fracture that I think would fit your scenario perfectly.

In a small amount of cases, patients who receive an injury to the side of their head causing a fracture of the temporal bone can tear their middle meningeal artery causing an epidural bleed.

An epidural bleed/hematoma is considered a neurological emergency. Most of these patients will require surgery to save their lives. With epidural hematomas, the patient can have an initial loss of consciousness followed by a distinctive lucid period, and then worsening neurological status after that.

This article gives a nice overview of the condition and treatment for epidural hematomas. Also, this is a good article as well.

Hope this helps and best of luck with your story!

Author Question: Details for Chest Tube Placement

Rachael Asks:

I’m sure you get questions on this all the time, but I was wondering what insight you can provide on traumatic wounds. My project is science fiction and the characters in question have enhanced healing and a sped up metabolism which I’ve just been using as my cure-all, smooth-over for any inaccuracies thus far. But then I found your blog- which has been incredibly fascinating and entertaining.

The first question I had which led me here was in general for a gunshot wound to the chest though not involving the heart. Namely, the various potential complications, the meds, supplies, or procedures that may be employed, and the sorts of phrases and terminology and reactions that may be overheard from the staff working on the patient. I’ve read on the risks of things like a sucking chest wound and consequential lung collapse, punctured lung, of course blood loss, but I still am at a loss for particularly the things the medical staff on hand would be saying or doing. (Bonus points if you have any tips for the internal monologue for the victim besides “ow.”)

Jordyn Says:

Hi Racheal! Thanks for sending me our question.

Your question is hard to answer. You don’t give specifics of the injury though it looks like you’re leaning toward a collapsed lung. There are a couple of ways you can research the feel of an emergency and that is by watching reality based (non scripted) shows that center on emergency medicine or look for teaching videos (or live videos where they capture the procedure on a real patient on You Tube).

For instance, a patient with a collapsed lung will likely need a chest tube placement. You can search You Tube for “placement of a chest tube” and see what comes up. The below video is pretty good as it gives lots of technical detail on what the physician is doing, seeing, feeling, and even what medicines might be prescribed for the patient. However, it does lack a lot of language of what would be said to the patient during the procedure.

The next video shows more patient interaction and what might be said. Between these two videos you could probably extrapolate together a scene. I will say that typically patients are connected to a larger suction device, but what the below physician is connecting to looks to be a more portable device so the patient can be up and walking. Also, a patient with a tension pneumothorax who is crashing may not receive local anesthesia and may even be unconscious.

Your best option, once the scene is written, is have a medical person who actively is practicing in the field review it. If your scene is written from the POV of the doctor placing the tube, it would need to be more technical versus if you’re writing it from the POV of the patient. You can also search Google for patient experiences of having a chest tube placed to get a feel for the inner dialogue you’re looking for.

Hope this helps and good luck with your story!

Author Question: Blood Types and Blood Transfusions

Ryana Asks:

I want to do a story set in WWII and one of my climaxes is when a Jewish soldier gives blood to save a German soldier’s life (or vice versa). My question is this: do different races have different blood types? Like, do Jews have a blood type no one else has? I don’t want to do something medically incorrect just because I think my story is good.

Jordyn Says:

There are eight different blood types and all ethnicities/races can have one of these blood types though some are more prevalent in a race than others. Here is an interesting link where the Oklahoma Blood Institute looked at what blood types certain races were and their break down.

I think the harder part of your question is would these two soldiers, by chance, have the same blood type where it wouldn’t cause a life threatening reaction in the soldier receiving blood. I was able to Google this question and found this link. As you can see, the best odds are if both soldiers are O-positive and yet that random chance that both are the same blood type is only 38%. The next highest is if both are A-positive at 34%. The other blood types fall precipitously after that. Of course, if the soldier giving the blood is O-negative (this is the universal donor) then there should be no reaction regardless of what blood type the receiving soldier is. On the reverse side, the universal recipient (someone who can get anyone’s blood) is AB-positive.

It would actually increase conflict in your story if the soldier receiving blood DID have a transfusion reaction. This type of reaction would be called a hemolytic transfusion reaction. This article reviews some of the varied responses a patient can have. Of course, you’d have to consider the time frame of your piece and what treatment would have been available then.

Hope this helps and good luck with the story!

Author Question: Multiple Survivable Stab Wounds

Joseph Asks:

I am writing a story inspired by the Saw franchise in which a man is forced to stab himself with three Swiss army knives. The knives will remain in. For the best chance of survival, should all the stabs be in the lower abdomen, or also bladder and/or hands/forearms?

I’ve heard the hands, forearms and lower abdomen are the three safest places to survive a stabbing, although of course technically there is no safe place, but those three areas avoid major organs/arteries/blood vessels. Though I’ve also heard stab wounds to the extremities i.e. hands can cause lasting disabilities. Where should he stab himself and how long until he is expected to die? He will be able to call an ambulance immediately, and maybe could use some cloths nearby to help put pressure on the wounds, assuming the pain is not debilitating.

Jordyn Says:

Hi Joseph!

Thanks for sending me your question.

I would agree with most of your assumptions as far as the extremities in general and the lower abdomen. You don’t include the legs. I think another relatively *safe* area would be the front of the thigh into the muscle or the back of the calf. Anywhere in the extremities where there is a large muscle mass. You could browse anatomy pictures of the extremities looking for diagrams of where the arteries are located to make sure you avoid them.

The lower abdomen is a good choice as well for suvivability. The problem can be puncturing the intestines and spilling gastric contents into the the abdominal cavity. If this happens, this can set up infection and sepsis though this would take a couple of days. You mention in your question that your character will be able to call for an ambulance immediately, not sure if that’s what you intended to say, as a delay in calling for an ambulance would definitely increase the conflict in your story.

Next to bleeding out, developing infection and sepsis would be the greatest risk of death for this character, but would likely take 2-3 days to develop.

Any stab wound to the hands or feet could be a set up for a life long debilitating injury. Many of these can be repaired, but I personally ruptured a tendon in my hand over twenty years ago and have limited range of motion to that thumb. The decision to make as the author is what, if any, long lasting effects you want the character to suffer.

Hope this helps and best of luck with you novel!

 

Author Question: Stab Wound to the Lower Abdomen

Katerina Asks:

My character, Faith, is stabbed with a switch blade (about  8.5 cm long)  in the lower abdomen. I have three questions about this.

1. Can she die from this and how long would it take?
2. Would she have to go to the hospital?
3. If she survives will there be any permanent or semi  permanent  damage?

Jordyn Says:

Hi Katerina! Thanks so much for sending me your question.

You don’t give specifics on exactly where in the lower abdomen your character gets stabbed (left, right, or mid line). If stabbed in the lower abdomen, there are fewer things that can be hit that will cause you to die immediately— generally from blood loss. Though there is that descending aorta to worry about.

The lower abdomen mostly contains intestines, the bladder, and reproductive organs for the female. A person can die from injury to these body parts– most likely from infection leading to septic shock. This would be unlikely should your character receive medical care shortly after the injury.

If you choose to go this route, I would say death from sepsis could be as early as 48-72 hours to as long as a few weeks. On the early side if the character did not receive any medical treatment and there are some nasty germs either on the knife or the intestines are punctured leading to contamination of the abdominal cavity and no surgical repair or antibiotics are given.

Longer if there is surgery and antibiotic therapy but the person is infected with a resistant strain of a bacteria or fungus, or is immunocompromised, etc.

A stab wound of this type should be evaluated in the hospital. Again, this would be up to you as the author and what kind of conflict you want to have for your story.

It’s hard to say if this character would have any lasting effects from the wound as you don’t give specifics as to the injury.

Best of luck with your story.

Author Question: Pedestrian vs. Truck 2/2

Today, we’re continuing with Luna’s question. You can view Part I here. In short, a 24 y/o woman has been hit by a truck throwing her into the air. When she lands, her head hits a concrete divider.

What will the doctor check or say when she first arrives at the emergency department?

If EMS care has been provided as I outlined in the previous post, we would do the following in the ER:

  1. Check vital signs and level of consciousness. If vital signs are abnormal, we would address those immediately. For instance, if her oxygen level is low, then we’ll provide more oxygen and evaluate whether or not the patient needs to be intubated (a breathing tube into the lungs). EMS may have already done this. If so, we’ll check the placement of the tube. If her blood pressure is low address that by giving either more fluids, blood, and/or a vasopressor (which is a medication given via a continuous drip to raise blood pressure). Of note, sometimes giving lots of IV fluid with head injuries is problematic.
  2. Draw lab work. In this case, we would check multiple labs. Blood counts, chemistries, and labs that look at how well the blood is clotting.
  3. Radiology studies. This patient automatically buys herself a full spine series (looking for fractures in the spinal cord) and a head CT (that would look for bleeding– and other things). Other labs and studies would be ordered depending on what other injuries were found. As previously stated, this patient would likely have more than just the head injury. A chest x-ray as well particularly if intubated to check placement of the tube.

Is surgery needed? 

This would be up to you as the writer. Would there be a case in this scenario where surgery might be indicated? Yes. Hitting your head into a concrete barrier could definitely cause some fractures in the skull where bone fragments could enter the brain. This patient would get a neurosurgery consult for sure.

Does she require blood transfusion for the surgery? 

Whether or not a patient gets blood is largely dependent on what their blood counts are. We look at this by evaluating a patient’s hemoglobin and hematocrit or H&H in medical lingo. If low, the patient gets blood. In trauma patients where there is a concern for bleeding, we draw blood every few hours to trend this lab. If it’s dropping, we know the patient might be bleeding from somewhere.

What machines would be used to keep her alive?  

In this case, likely a ventilator (or breathing machine).

How long will she be in the hospital? I am writing for two days.

Unfortunately, I think this patient would be hospitalized much longer than that. A brain injured patient that requires brain surgery would likely be hospitalized for a week or more. A week on the short end if they wake up and are neurologically intact meaning that they can speak, walk, and talk. That they know who they are, where they are, and what time they are in. Also, are their cognitive abilities intact (memory, ability to do simple calculation, etc). If this patient had a simple epidural bleed, then perhaps home in a few days if the above is normal.

The reason I say a week for this patient is the concern for brain swelling surrounding this type of injury. Brain swelling peaks around 48-72 hours and patients generally get sicker when that happens.

Thanks for reaching out to me, Luna! Best of luck with this story.