Trauma

Author Question: Gunshot Wounds and Rib Fractures

/ Jordyn Redwood / Leave a comment
Shanda Asks:

I have a scene where (in my mind at least) someone very physically fit is shot in the torso as they dive to save another from being shot. They then land excruciatingly hard on the edge of raised concrete (think like the front of an outside step) and break three ribs but that injury goes unnoticed as a result of the gunshot wound.

human-skeleton-163715_1280So my questions are as follows:

1. Would it be possible for someone to pick up the injured and run say a mile or two to get them to where help is waiting?

2. Could it be possible to have surgery for the gunshot would and the rib injuries be missed and hours later cause internal bleeding?

3. What would be the typical recovery time for the first and the latter?

4. Would it be realistic that after the second surgery (for the internal bleeding) the patient could not wake up for days having had two trauma surgeries so close together?

Jordyn Says:

Thanks so much for sending me your questions.

1.  Can someone carry an injured person one to two miles for treatment? It would depend on the physical characteristics of the character who is lifting the other person. Carrying someone one to two miles is a long way. I could possibly imagine a man doing this for an injured female and possibly a very fit male for another male, but a female doing this for a male might be stretching it. It would have to be a very fit female character.

On the other hand, could a character with these injuries get themselves to the hospital? The three cracked ribs are definitely going to slow them down and it also depends on what the gunshot wound has injured which you’re not clear on here. If the gunshot wound deflated a lung then they are going to have a lot of trouble breathing.

2. Could the broken ribs be missed on the first medical exam? Probably no. Any patient with a gunshot wound to the torso is going to get plain x-rays of the chest and probably a CT scan of the chest as well— both of which would show the rib fractures. So in the setting of modern medical care it would almost rise to the level of negligence to miss the rib fractures with a gunshot wound to the torso. I don’t see that happening.

3. To determine your typical recovery time I really need more information on this gunshot wound. Where was the character shot and what was injured specifically? The rib fractures themselves will take 4-6 weeks to heal. Rib fractures are very painful and could inhibit breathing based on their location. Also, successive ribs that are broken in more than one place can create a free floating segment that can be very detrimental to breathing as well.

4. A patient could still develop internal bleeding and need to go back to surgery even if the rib fractures are found right away. This would not be a rare event. It is reasonable for a patient to not wake up for a couple of days if they suffered a code during the second surgery due to extreme blood loss and had flat lined for a period of time.

Even the stress/shock of the surgeries close together might be enough for the brain to check out for a time. The problem with a comatose patient is they have to be in the ICU, on a vent, with a tube in every orifice as they say. For instance, a patient can’t be out cold and have no way to pee— so a catheter has to be placed so the urine can come out.

Going down that road can get very complicated for a novel depending on whose POV you’re telling it from.

Best of luck with your novel!

Murdering a Television Scene

/ Jordyn Redwood / Leave a comment

The ABC drama, How to Get Away with Murder, is a series not for the faint of heart. The show centers around defense attorney Annalise Keating (great acting by Viola Davis by the way) and how murder victims keep popping up around her where she may or may not be involved.

The second season opens with an intense scene where Annalise has been shot in the chest and subsequent episodes deal with the events leading up to this one scene. Just who shot her and why did it happen?

Of course, this is a great time to do some medical analysis of her EMS rescue. What’s follows is a conversation between two medics who are taking her to the hospital.

Medic One: Starting a 16 Gauge IV. Lungs are clear. Need another blood set for a second IV and a BVM. Blood pressure 70/palp. Pulse is thready.

Medic Two: Feels tachycardic. I’m seeing some JVD. Might have to do a needle thoracostomy. Need to get ETT right away. Diminished respirations. Chest is clear. Equal breath sounds but respiratory effort decreasing.

Just what does all this medical mumbo jumbo mean and is it medically accurate? Well, kind of.

When dealing with a trauma patient, getting IV access is paramount. Usually two lines of a large bore gauge is necessary. A 16 Gauge is a large size. And working to get two lines in is accurate.

What does BP 70/palp mean? Likely, you’re used two seeing two numbers in regards to blood pressures. Something like 120/72. The top number is what’s referred to as your systolic number– or the pressure inside your arteries when your heart is contracting. The bottom number, or your diastolic number, is the pressure in your arteries when the heart is relaxing. To get both numbers, you have to be able to listen to the blood pressure by using a BP cuff and stethoscope at an artery point– usually at the antecubital space (the crook of your arm.) The first time you hear the heart beat– that’s the first number. The moment you can’t hear it anymore– that’s the bottom number.

In EMS, active resuscitation scenes are really loud and it’s hard to hear. There is  technique where you feel for the blood pressure but you only get one number– the systolic one. In this technique, you feel where the radial pulse is (at your wrist) and pump the cuff up until you can’t feel it anymore. As you let the air out of the BP cuff, you record the number where you first feel the pulse. In this case 70– which is low. But, that’s why there is only one number and the “palp” denotes it was felt or palpated.

Pulse being thready– means it feels thin and weak. Also appropriate for someone experiencing blood loss related to a gunshot wound. As does what the second medic begins to say– feels tachycardic which means the patient’s heart rate is increasing– which is also a sign of blood loss.

The main medical inaccuracy with this scene is the procedure one medic says they might need to do– a needle thoracostomy. Just what is that?

A needle thoracostomy is done to pull air from the chest that has caused a lung to deflate– here from a gunshot wound to the chest. It is a rescue measure– meaning it will buy you some time until the patient can get a chest tube placed in a hospital setting.

But note what the medics say over and over– her breath sounds are equal. These comments denote that her lungs are filling as they should. If one lung was “down” or deflated from the gunshot wound– the breath sounds should be unequal. Generally, you can’t hear breath sounds on the side of the chest where the lung is deflated– or there is very little air moving on that side.

The writer has also picked the wrong procedure. When one medic comments– “I’m seeing some JVD.”– this usually denotes an obstruction somewhere in the chest (like a deflated lung or blood collecting around the heart) and blood is having difficulty flowing as it should and so the blood is backing up into the veins. JVD= Jugular Venous Distention and is when the jugular vein is easily seen at the side of your neck because it is filling up with blood.

Since the medics state her breath sounds are “clear and equal” then we know the problem is not with her lungs but could be with her heart.

The rescue procedure for blood collecting around the heart is called “pericardiocentesis”.

Again, Hollywood, I am available for medical consultation. Let’s rescue our characters using the right procedures.

If you’re interested in seeing a video on needle decompression (the first) and/or pericardiocentesis (the second)– then watch the videos below. They aren’t gory.

Unbelievable Real Life, Believable Fiction

/ Jordyn Redwood / Leave a comment

When I hear a reader say: “That’s not realistic; all of that couldn’t happen to one character.” I think, “That reader has skirted through life with little trial.”

Spring 2009, a cop barreled into our car, injuring my oldest daughter, my son and myself. My husband and our youngest daughter escaped uninjured. The two kids healed; I suffered a shoulder and cervical injury. Actually, those injuries initially occurred when I was in a bicycle accident (a driver ran a stop sign); the car accident worsened those injuries.

A few months following the car accident, my husband’s biopsy on an enlarged lymph node was negative, but a few months later he was diagnosed with head and neck cancer (the biopsy results were wrong). In 2009 and 2010 he endured two surgeries and cancer treatments.
During this same time, our son battled a mysterious illness I suspected was Lyme disease since he had fourteen Lyme’s symptoms, but Curtis didn’t test positive so no physician would listen—see Brandilyn Collins’ posts May 2011 titled: The Lyme Wars. Most Lyme’s patients don’t test positive.
For the love of hockey, Curtis fought the pain and continued to play; unfortunately, he suffered a shoulder separation during a game. In a sling for that injury, he had a MRI on a large cyst behind his knee; it tested benign. Hoping I was wrong about Lyme, I agreed to allergy injections to treat Curtis’ allergy-like symptoms. Days after the injections started, he developed a systemic rash. The allergist responded, “There’s an underlining cause.” So, I told an infectious disease MD, “Don’t think of me as a mom; as an EMT I’m telling you this patient has Lyme disease. Please help him.”
After several months of Lyme’s antibiotics, Curtis improved but still battled bilateral knee and ankle arthritis. My orthopedic surgeon (explanation later in this paragraph) diagnosed Curtis with Lyme arthritis saying, “Bring on the CDC; this kid has Lyme disease and I’m treating him as so.”
During the several months of Curtis enduring tons of doctor appointments (pediatrician, allergist, dermatologist, infectious disease, rheumatologist and orthopedist) plus countless tests, my shoulder worsened to the point I needed surgery to repair a labral tear. To date, Curtis still suffers with Lyme arthritis and may for years. Unbelievably, fall 2011 he suffered a severe concussion from head trauma in a hockey game and was out of school for three weeks.
As for my daughters: In 2010 my oldest was being recruited by countless college swim coaches. They were in and out of our home and Sabrina traveled on college recruiting trips; exciting yet stressful. My youngest, Fiona, dealt with anxiety from watching her family endure this mess.
How can one family battle all that in two years? For starters, God carried the five of us. Plus, Leo and I are well practiced in dealing with life’s mountains. Leo’s brother committed suicide when I was pregnant with Sabrina; I went into labor at the funeral. When Leo was sixteen, his dad suffered a heart attack; Leo drove him to the hospital in time. At age seventeen, I lost my family when my dad was killed in a bicycle accident. Also, Leo and I lost three babies, one of them in my second trimester due to a disease that prevented the development of limbs and caused a miscarriage.
My attitude during 2009-2010 was calling the five of us: “As the Bensons Turn.” Laughter, a positive attitude and our faith, plus the love and support of our family and friends, carried us through.
All that said (whew), next time you think something is unrealistic, really ask yourself – “Is it?”
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After majoring in communications and enjoying a successful career as a travel agent, Dianna Torscher Benson left the travel industry to write novels and earn her EMS degree. An EMT and Haz-Mat Operative in Wake County, NC, Dianna loves the adrenaline rush of responding to medical emergencies and helping people in need, often in their darkest time in life. Her suspense novels about characters who are ordinary people thrown into tremendous circumstances, provide readers with a similar kind of rush. Married to her best friend, Leo, she met her husband when they walked down the aisle as a bridesmaid and groomsmen at a wedding when she was eleven and he was thirteen. They live in North Carolina with their three children. Visit her website at http://www.diannatbenson.com

Fractures: General Guidelines

/ Jordyn Redwood / Leave a comment

Fiction, particularly the thriller genres, generally require a character to sustain an injury. These can run the gamut from minor to life-threatening.

Today, I’m going to focus on a couple of general guidelines if you injure a character with some type of fracture.

Though it may be hard to break a bone, sometimes it seems the most minor accidents can cause a fracture. My mother once slipped off a small rock onto the side of her foot. Her foot was bruised and mildly swollen and in my nursing wisdom (I was only in nursing school at the time), I said, “There’s no way you broke it slipping sideways off a rock.” Needless to say I was wrong. Yes, broken foot.

Guideline #1: The amount of swelling is not indicative of fracture. Ankle injuries are classic for this. Patients come in with a horribly swollen ankle, convinced they broke it. My guess in the pediatric realm (up to age 21), the ankle is 95% of the time sprained and not broken. Arms that have an obvious deformity and you can see the limb is broken before you get an x-ray, have little swelling in comparison.

Guideline #2: If something is broken, generally the joint above and below will need to be immobilized (or very close to the next joint). Someone asked me once if a person broke one bone in their lower leg, could they drive? There are two bones in the lower leg: the tibula and the fibula. Depending on how close the fracture is to the knee, the ankle and knee will have to be immobilized. I don’t know how many people can drive with a straight leg.

Guideline #3: Splints are placed first. It is rare to put a cast on in the emergency department. The reason splints are placed first is to allow for swelling to come and go. A splint is generally fiberglass sheets secured in place with an ace wrap. This allows for expansion during swelling. Then in 7-10 days, the patient is referred to an orthopedic doctor for cast placement.

Guideline #4: A good rule is that a cast will be in place for 6-8 weeks. Now, this is highly variable and if an author said the cast needed to stay in place for nine weeks, it probably wouldn’t drive me nuts enough to go check it out. However, a cast on for two weeks is unlikely. You should consider this guideline because it will effect your character for that length of time and inhibit their mobility. Maybe, this is something you want as the author.

Guideline #5: My observation: these bones/joints have a higher incidence of requiring surgery: ankle, elbow, and femur. Now, you can make any fracture bad enough to require surgery but these ones can be more common to require the OR.

What other guidelines would you like to see?