911 S2/E2: Determining Death

In Episode 2 of this season’s Fox series 9-1-1, a devastating earthquake has hit LA county.

The team is searching for victims when they come upon a patient where only her lower legs are visible. The paramedic reaches down and assesses her pulse at her foot and determines that she’s dead. Time to move on.

Can you feel someone’s pulse in their foot? Yes, you can. He’s palpating what’s called the dorsalis pedis pulse.

Should it be used to determine if the patient is dead? To this, I would say no. The problem is, when the body goes into shock, it shunts blood toward the central aspects of your body to ensure blood flow to your vital organs so even though the person is alive, you may not be able to feel the pulses in the feet. This is why when checking for life, the use of central pulses is encouraged— for instance the femoral or carotid pulses. Also, this victim could just have two broken legs with compromised blood flow to her feet causing the lack of pulse.

However, I’m not going to give them too much grief for this. In a mass casualty situation, sometimes you do just need to move on and save who you can.

Author Question: Stab Wound to the Abdomen in a Young Girl

Loinnir Asks:

There’s a scene in my story where one of the main characters, a short and slightly underweight 13 year old, is stabbed in the abdomen (I was thinking the epigastric region) with a 4-5 inch blade which is almost immediately ripped out by the perpetrator. Around 25-30 minutes pass before she arrives at the hospital (she is transported by car, not an ambulance as the witnesses don’t have any way to call one).

So, I was wondering how likely she is to survive, the type of treatment and expected length of recovery, and what would the protocol be for the witnesses (her five friends, all minors)?

Jordyn Says:

Thanks for sending me your question.

I think the biggest risk in an underweight (thin child) being stabbed with a 4-5 inch blade (which is fairly long) in the epigastric region is hitting the descending aorta (or one of the large veins). Particularly if the blade is pulled out, there would be little to stem the bleeding. Of course, it would depend on the angle and depth of the blade but this would be one of the more concerning injuries. If the blade is angled up, you could also hit the diaphragm, a lung, and possibly the heart. Angle the blade to the side and you have the spleen on the left and the liver on the right.

Biggest risk of death for this victim would be hemorrhage. Considering she is being transported by car versus ambulance, she would die in just a few minutes if her descending aorta or heart were hit. A lung injury could be survivable if care is given within thirty minutes depending on how much of the lung is deflated.

If you want her to live, I would also avoid hitting the liver or spleen on either side as she would bleed to death before getting to the hospital.

Getting stabbed in this area could also injure the small intestine. This is probably the more survivable injury. It would require surgical repair and a short hospital stay if the surgery went well and there was no other damage. They would have to ensure her bowels were working, she was passing gas, and could tolerate food and fluids before discharging home.

Medical treatment in the ER for a stab wound would be a set of vital signs, continuous monitoring of ECG, oxygen levels, and breathing. IV placement (likely two—one in each arm in the antecubital space), normal saline fluid boluses, labs (particularly those that measure blood levels and organ function of the abdomen) and blood if needed. They’ll check her urine for blood and if she’s menstruating she will get a pregnancy test. She would likely get x-rays of her chest and abdomen as well as a CT scan of her abdomen checking for injuries. Antibiotics would likely be warranted if her intestine had been perforated. Then to the OR to repair any injuries.

I’m not sure what you’re asking as far as the five minor witnesses. I checked with my brother who works in law enforcement and he said there are no legal issues in interviewing a juvenile witness. If your question is concerning medical care, I don’t see a reason for these kids to be evaluated if they are uninjured. At the scene, they would likely be held until parents arrived to pick them up.

Best of luck with this novel.

Author Question: What Kind of Car Accident Matches these Injuries?

Mary Asks:

I have a couple questions. My young adult characters (a total of six— four of them intoxicated) were involved in a car accident. The two sober ones were in the first vehicle. My plan was to have the driver suffer from a broken wrist, maybe a bump on the head, nothing too serious (this can change if it needs to). If he is that okay would it be unrealistic to have his passenger hit her head hard enough to lose consciousness and suffer memory loss when she wakes up? I was thinking of including pretty severe amnesia, but as for the other four characters, would their level of intoxication let them walk away with little to no injuries, or would they still arrive in the ER with at least the unconscious passenger?

Jordyn Says:

There are so many variables in car accidents that you could basically do whatever you wanted, but I’ll give you some guidelines.

If you want the injuries to be less severe, I would not have a very serious car accident. For instance, your two sober characters in the first car should not be traveling probably over 45mph. Are there air bags in the car? Did they deploy? Typically they’ll deploy in a front end collision. Now air bags are not like soft little pillows when they inflate so facial injuries are not uncommon with air bag deployment so your driver breaking his wrist (if he were bracing the steering wheel in anticipation of the accident upon impact) with a bump on his head would be reasonable if he were seat belted into the car.

The sober passenger— I’ve never really seen “pretty severe amnesia” in head injuries unless the brain injury was very significant (like brain swelling, bleeding requiring intubation, medical coma, etc). This could be achieved if this passenger was not wearing a seat belt and maybe came up over the top of the air bag into the windshield. Or, for some reason, the air bag failed to deploy and they hit the dash board or they’re driving an older car without air bags.

Generally people with amnesia related to a “simple” concussion will remember what happened to them in a few hours— generally after sleeping so everything can “reset” itself. Most often, in the ER, we observe them until they are at their “neurological baseline” which means they basically have to be the same way they were before the accident as far as knowing who they are, where they are, and what time it is, and somewhat remember what happened. Also, their physical symptoms will have to be improved (little to no headache, no repetitive vomiting or nausea, good motor function, and can walk with little to no dizziness).

So to have “pretty severe amnesia” which I think you mean to have the amnesia to persist over days or weeks then I think this character would need a more severe head injury— which could probably be achieved if the passenger went through the windshield because she wasn’t wearing a seat belt.

The drunk kids— with an offset front end collision of around 45 mph and they were all seat belted into the car with air bag deployment then I could see them walking away with little to no injures. Likely, EMS would transport them to the ER for a medical exam because 1) they are minors (I’m assuming under 18) and 2) they’re drunk and could be responsible for an accident. The police might be interested in a legal blood alcohol levels which can be very tricky (for instance, our ER doesn’t do them. We’ll do a medical one, but this isn’t released to the police). Now, could a prosecutor later obtain those medical records through the courts? Probably with a warrant.

Hope this helps and best of luck with your story.

Author Question: Gunshot Wound Near Clavicle

Sarah Asks:

In my novella, the main character is shot directly below the left clavicle by a sniper rifle. The bullet misses the bone, but would it have hit the subclavian artery or another artery? And if so, how long would it take for her to bleed out? She receives medical help from an off-duty paramedic within three to five minutes. Thanks!


Jordyn Says:

I reviewed a couple of anatomy pictures and the subclavian artery appears to sit higher and slightly above the clavicle or collar bone. When looking at anatomy photos, red indicates arteries (as they are taking oxygen rich blood away from your heart to the rest of your body) and blue indicates veins (bringing oxygen poor blood to your heart and lungs for more oxygen).

That being said, the left chest has all sorts of major veins and arteries. A bullet can always miss these structures— we all hear those rare stories, but I generally encourage authors to stick to the right chest for a more believable scenario if they want the character to live. Ultimately, it is your choice.

The subclavian vein, which is nestled under the artery, could definitely be nicked or severed by a gunshot wound to this area (either the right or left side). Central lines are often placed to the subclavian vein which is accessed just benenath the collar bone.

If the bullet hits the subclavian artery, the character would bleed out fairly immediately— in roughly under two minutes without any medical intervention. Your paramedic arriving in three to five minutes would likely be too late. Direct pressure to the area will help. It is hard to stem bleeding from an artery this size, but pressure could help delay the onset of death for another few minutes.

If the bullet hits the subclavian vein, the bleeding will still be brisk but could be more easily controlled with pressure than bleeding from an artery.

If you want an injury that will bleed, but would likely be survivable, I would pick the subclavian vein with people at the scene immediately applying direct pressure to the gunshot wound.

Hope this helps and best of luck with your story!

Dr. Strange Should Know Better

If you haven’t seen the movie Dr. Strange, you have been warned that this blog post will contain spoilers to the movie.

Dr. Strange, released in 2016 as part of the Marvel Universe, features a stereotypical, obnoxious, arrogant, and rich neurosurgeon. He is greatly skilled, but is known to turn down patients in order to keep his perfect surgical record. Unfortunately for the character, he is in a terrible car accident and both his hands sustain multiple fractures that cause permanent nerve damage and therefore lead to the end of his promising career.

Dr. Strange is like many patients when the medical establishment can’t offer complete healing. He begins to investigate alternative/investigative medicine for treatments. He hears from a physical therapist that a patient with a complete spinal fracture is up and walking around. Dr. Strange responds to this by saying, “Show me his file.”

I’ve said all along in this blog that medical people in films, television, and novels can do bad things. Your job as the writer is to let the reader know that you know that the character is misbehaving in his role. This allows the reader to know you’ve done your research and they can trust you as an author.

Dr. Strange asking for this patient’s chart if flat out a HIPAA violation. He never cared for the patient and he has no right to know what’s in his medical record. There are consequences for HIPAA violations and having the character suffer these is a great way to add tension and conflict to the story.

A second medical violation in the movie is the treatment of Dr. Strange’s chest wound. He suffers a blade wound to the chest and transports himself back to his old hospital to be treated by a colleague. There are a few problems with this scene.

Problem #1: That there is a sterile operating room in the ER. No, this isn’t standard. Can sterile procedures be done in the ER? Yes, but not a sterile operation as in the OR.

Problem #2: Wrong ECG rhythm. Dr. Strange has diagnosed himself with a pericardial tamponade. A cardiac tamponade is where fluid is collecting in the sack around the heart thereby impinging on the heart’s ability to pump blood.

The rescue procedure for this is a pericardiocentisis— or removal of the fluid from around the heart. His love interest confirms the diagnosis by percussing his chest. This is probably the least reliable way of diagnosing this problem. Any well equipped ER should have some sort of bedside ultrasound to aid in the diagnosis. The ECG monitor first shows a rhythm of bradycardia— the heart beating too slowly. This again is one of the least likely rhythms related to this condition.

Problem #3: Wrong placement of the needle. In the movie, the doctor is shown placing the need straight into the chest. It should be at an angle pointed to the left shoulder which this nifty video on You Tube shows.

Problem #4: Shocking asystole: I’ve blogged a lot on this. You cannot shock asystole. It won’t improve the outcome for the patient and is contraindicated. First treatment is high quality CPR and a dose of epinephrine or adrenaline. Also, this is not the correct paddle placement for defibrillation. It should be just to the right of the patient’s sternum and over the apex of the heart or more to the left side. They also cannot be placed over clothing.

Problem #5: OR is next. Most likely a patient like this with penetrating trauma to the chest would likely go to the OR, or at least some follow-up radiology studies. Not just stitched up and sent on his way.

Author Question: Can Onset of Paralysis be Delayed after a Fall?

Kaylee Asks:

In a book I am working on the main character falls off of a one-story wall injuring his back. Could he be paralyzed? If so, would it be possible for paralysis to set in an hour or two later? Would he be able to remain conscious and still walk for about an hour? He is a spy, mid 20’s, strong, and loves to run.

Jordyn Says:

In my experience, I’ve never seen a delay in onset of paralysis. Usually, it is immediate. I’ve not personally seen people with devastating paralysis from a fall from this height. Broken legs/arms, lacerations, and concussions . . . sure. Could a spinal cord injury happen? Of course there are always outliers. If you did write this, it would help believability if the character fell directly onto their head (called an axial loading injury) or onto another hard object (like a rock or something with a hard edge) to increase the chance of a complex fracture causing paralysis.

I did some hunting regarding spinal bones specifically. This article says three meters (which equates to about 10 feet or one story) can cause spinal fracture, but just because you break the bones doesn’t necessarily mean paralysis. A person with a stable fracture of their back can be up and walking around. I’ve seen this plenty of times.

I  did find one article where a woman did have delayed onset of paralysis of four days, but if you read through the article she had a significant mechanism of injury and died as a result of complications of her injuries.

Best of luck with this story!

 

Author Question: Frozen Body

Susan Asks:

I just stumbled on your site while doing a search, and I wonder if you can answer this question. The victim in my latest book has been pushed through a hole in an ice-covered lake. She drowns, and her body slips under the ice. Her body is not found for two days. Would the body literally be frozen, to the point that it would have to be thawed before an autopsy could be conducted? Or would it just be really, really cold?

Jordyn Says:

Hi Susan! Thanks for sending me our question.

My opinion is that the body would not freeze and would not need to be thawed for autopsy.

In researching this— it appears that water underneath an ice sheath on a frozen lake (though still really cold) is not at 32 degrees F but could be as warm as 40 degrees F. Since fish are cold-blooded and will take on the temperature of their environment and their tissue doesn’t freeze– then I don’t believe a deceased human’s would either.

Best of luck with your story!

Author Question: Law Enforcement Shooting with Vest in Place

Carol Asks:

I have a cop who is involved in a shooting. She’s wearing a vest and is hit outside the vest’s protective area. I need her hospitalized long enough that the shooter (who she killed— they shot simultaneously, more or less) to have been claimed post autopsy. I can’t have her debilitated for months— just a week or two. Where would I shoot her? Hip? Leg seems hard to hit and shoulder does too. I don’t want her disabled, nor do I want a months long rehab.

Jordyn Says:

What I would recommend is a shot coming through the side, under the armpit, causing the lung to collapse. I would pick the right side over the left— there’s just a lot more vasculature on the left that could prove deadly/problematic. If her right arm was raised and she was say . . . turning into the shot . . .  it could leave her vulnerable.

She would have difficulty breathing. How difficult would depend on how quickly the pneumothorax (air moving into the chest and deflating the lung) expanded. She would be transported to the ER via ambulance and receive an IV, oxygen, and vital sign monitoring.

A chest tube would be placed, likely after a quick chest film, unless she is in significant distress to re-expand the lung. If in significant respiratory distress or cardiovascular compromise then she would get a rapid needle decompression to buy some time or some facilities will go straight to chest tube placement. For a “simple” pneumothorax she would be admitted into the hospital (regular floor— not ICU) and observed.

Generally, depending on the size of the pneumothroax, it’s a few days to get the lung to re-expand, a day or two with the tube to “water seal” to make sure it stays up without suction, and then the tube would be removed. Maybe one or two more days after that to make sure all was well.

If she’s young and healthy she should recuperate pretty quickly, but would still be winded, perhaps easily fatigued for another week or two.

Hope this fits your time frame.

Author Question: Gunshot Wound to the Chest

Virginia Asks:

I’m putting the final touches on a romantic suspense novel in which my hero is shot. The most important part of this is that he has to continue to function until he saves the day, then falls and has to be treated. The wound cannot be bad enough that he can’t pass the physical and qualify to become an FBI agent within a few weeks.

My fit male character (34 years old) is in a shootout. He’s shot with a 9mm handgun but the bullet ricochets, grazes his chest, and fractures a rib. He doesn’t notice initially. He begins to feel some pain after about five minutes. Then feels woozy and has a head rush. I want him to fall after the action is over, but be able to talk a little with some struggling.

He’s far from a hospital when he’s shot, but a military medic is there with his kit. The hero can be medevaced to a hospital on a military helicopter. What would the medic do in the field? I don’t want the bullet to penetrate the chest wall, but would the medic check for pneumothorax and if so how?

What would happen at the hospital? How long would he be hospitalized?

I’ve read and re-read about pneumothorax and hemopneumothorax, but think that might require too much recovery time and be too much for him to qualify and be able to pass the physical. I’ve done some research on pulmonary contusion but am a bit overwhelmed with the possibilities of the use of continuous positive airway pressure and high-frequency chest wall oscillation. And the long term recovery.

Since I really don’t know what would be best as a gunshot wound that my hero can recover from and pass a physical in a few weeks, I really need some guidance and specific information that can easily be explained in a romantic suspense novel. I’m hoping this “bullet grazes the rib” scenario is workable. If not, what should I consider instead?

Jordyn Says:

Thanks so much for sending me your question, Virginia.

I think the simplest thing to do is to have the bullet graze his chest. It could potentially hit the rib, break it, and ricochet away. Leaving a nasty gash with a broken rib underlying but nothing else injured. Generally, a fractured rib will heal in 4-6 weeks so he will have pain and limited movement until then. The worst pain will probably be in the first 1-2 weeks and then should taper off after that.

As far as the military medic assisting off duty. I think it’s fine if he has a small first aid kit that he could dress the wound with. He likely would not be carrying an oxygen tank, etc. So the dressing to control bleeding is necessary. Lots of emergency medical types might have a small kit in their car (I do), but not an oxygen tank or a way to deliver oxygen to the patient.

The military medic could check for a pneumothorax by listening to your hero’s breath sounds. Clear and equal breath sounds bilaterally generally indicate no pneumo (though a small one could still be present). It will hurt to take deep breaths if his rib is fractured.

If he’s transported by a military medevac then they could start oxygen, an IV, and give some IV fluids. Place him on a monitor to keep tabs on his heart rate, breathing, oxygen levels, and blood pressure.

In the hospital, he’ll get chest and belly films and possibly a CT of his chest and abdomen. If it seems like a fairly benign wound, the wound could just be irrigated with a lot of saline and sutured closed. He needs an updated tetanus shot if he hasn’t had one in over five years.

If his breathing is good and he suffers just one cracked rib, there is likely not enough injury criteria for him to be admitted into the hospital. He’d likely be observed in the ER for several hours to make sure everything is okay. He’d be sent home with a short course of narcotics (like three days) and instructed to take over the counter pain relievers to help with the pain as well. He should have limited activity but not be bedridden. He’d be encouraged to take deep breaths (usually at every commercial break if watching TV) to prevent lung complications because patients don’t like to breathe deep when they have a cracked rib.

Hope this helps and good luck with your story!

What is the Glasgow Coma Scale?

Often times on television and in movies, you’ll hear a medical character exclaim, “His GCS is 5!” or some other variation. What is this score? What does it mean for the patient?

The Glasgow Coma Scale (GCS scale) is one way to gauge the significance of brain injury. There are three components to the measurement. Eye Opening. Verbal Response. Best Motor Response. In general, the highest score is 15. The lowest score is 3. You can be dead and still score a 3 so the higher the score the better.

Eye opening looks at four components and each is given a score:
4: The patient opens their eyes spontaneously.
3: The patient opens their eyes after being spoken or shouted to.
2: The patient opens their eyes to a painful stimulus.
1: No eye opening at all.

Verbal response looks at five components:
5: The patient knows person, time and place.
4: The patient can speak but is not oriented.
3: Speaks unintelligibly.
2: Moaning.
1: No verbal response.

Best motor response looks at six components:
6: The patient can obey a two part request such as touch your nose and then your shoulder.
5: The patient moves to push away a stimulus. For instance, if I’m starting an IV in your left hand, you take your right hand to push it away. This is called localizing pain and the patient usually needs to move across their midline or above their clavicle (if the stimulus is placed to the head) to score here.
4:  Pulls extremity away from pain.
3: Abnormal flexion.  Also referred to as decorticate posturing.
2: Abnormal extension. Also referred to as decerebrate posturing.
1. No motor response.

Initially, we might look at the overall score to determine whether or not a patient needs to be placed on a breathing machine. Generally, a score equal or less than eight is used as a cut off point. The lower the initial score, the more likely the patient will be intubated. Over the long term, the GCS can be used to trend improving or worsening neurological status.

Have you ever heard this scale used on television or in a movie?