Head Injuries: Jason Joyner

There was that time when the editor saved the medical professional.

As a physician assistant, I enjoy having medical aspects in my story. But even medical folks can slip up and have errors in our fiction.

I have a scene where my heroine gets head trauma and wakes up later in the clutches of the villain. The freelance editor, Ben Wolf, wondered about that. He had read that if there was significant time of loss of consciousness (LOC), then it suggested a serious injury that would be hard for the victim to bounce right back from to be active.

One of my pet peeves is when characters are injured and recover too fast, so I had to look into this again.

Basically, my heroine suffered a concussion, also known as a Traumatic Brain Injury (TBI). Symptoms of a concussion can include headache, confusion, dizziness, visual changes, a blunted affect, and may or may not include LOC. (People always flash lights in pupils to check for concussion. If the pupils are affected, it is a serious sign and they won’t be up and active soon.)

LOC usually is only for a few minutes, and as my editor noted, will mean a much more severe injury if it lasts for hours.

Blast. Foiled by the editor.

Except, you can use the amnesia angle.

A concussion with LOC may have retrograde (before the incident) or antegrade (after the incident) amnesia. According to one research article, the antegrade amnesia can last for a few hours after the incident. I can attest – I had a concussion in 5th grade and couldn’t remember a couple hours afterwards.

So if you need your protagonist to be out of it for a while, keep the actual LOC on the short side and use the amnesia angle to get you where you need to be. The victim may be incoherent, unsteady, with a blank expression during this time. Use these symptoms to add drama to the situation.

When your protagonist comes to, it is actually the end of antegrade amnesia. I remember with my concussion it was like I “woke up” after lunch during our quiet reading time at school. I was confused, unsure of what happened. I could remember part of the morning, but about two hours was blank. I even found a goose egg on my head later, but I didn’t know how it got there.

So that was my work around. My heroine didn’t have LOC the whole time. But there was enough injury to cause confusion and amnesia, keeping her from attempting escape. There you go Ben. A few minor tweaks, and all is well. Except for my heroine, who’s tied up and threatened. But that’s another story.

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Jason loves good stories and wants to use words to make a difference. When he’s not writing, playing soccer, or losing in fantasy football, he works as a physician assistant in southeast Idaho. He also tries to keep up with his awesome wife, three high-energy boys, and his little princess. He writes suspense and YA supernatural, and likes to use his medical experience to punch up the stories. You can find him on Twitter @JasonCJoyner or his blog at www.jasoncjoyner.com/blog.

Author Question: Brain Bleeding 1/2

I’ll be handling Christy’s question in two parts. Part one today.

Christy Asks:

A bullet grazes my hero’s brain. He’s taken to the hospital where he has an intracranial hematoma.Would he be in a medically induced coma after this? If so, for how long? When do doctors decide to take someone out of a medically induced coma? What would a victim be like after the fact? Sedated? When would they know the extent of the injuries?

Jordyn Says:

It depends. Let’s start from the top.
A bullet grazing someone’s brain. Okay—well in order for it to even hit the brain it has to come through the skull. So, it’s not going to be a minor injury considering that. Not like a bullet grazing your arm.
An intracranial hematoma means you have bleeding on the brain but you haven’t really specified the area. For instance, epidural hematomas occur between the dura (which is a tough membranous covering) and the skull. These are almost always taken to surgery.
In a subdural hematoma the bleeding occurs between the dura and the arachnoid layer. These are not always evacuated by surgery. It depends on their size. Intracranial bleeding can mean a lot of things—that the bleeding is just within skull (which includes the two things I’ve mentioned) or in the brain tissue itself. Bleeding within the brain tissue itself is much harder to deal with.
Would he be in a medically induced coma? It depends. The decision to put someone in a medically induced coma is more based on whether or not the doctors think the brain will swell as a result of the injury and not necessarily because there was a bleed. For instance—epidural hematomas are generally taken to surgery and evacuated without the patient needing to be put into a coma.
If they think they see a significant amount of swelling of the brain tissue then a medically induced coma is more likely. A patient is generally placed into a coma through the period of peak swelling which is generally 48-72 hours post injury. The patient gets a special monitor (a bolt) that monitors their brain pressure (or ICP—intracranial pressure). 
After that peak period of swelling comes and goes a decision will be made to wean the patient off their sedation. The pressure may stay high. If the pressure stays high the patient may proceed to brain death (caused by herniation or hypoxia related to the pressure), or significant brain injury, or recover. It may not be known for several months what the outcome is though generally if a patient is going to suffer brain death they will do it in that 48-72 hr window. Past that, if they live but the pressures have been high—more a vegetative state or significant neurological impairment. If pressures have stayed lower—the patient may recover okay.
I have seen miracles, though, too so this is not cut and dried.
As far as knowing the extent of injures—they’ll know that pretty quickly based on CT imaging. However, what won’t be known is the affect on the patient. People can have the same exact brain injury—some die—some fully recover so there is a lot of writing leeway here. It may not be known for years how the patient will recover or what their lives post-injury will look like. 
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Christy Barritt is an author, freelance writer and speaker who lives in Virginia. She’s married to her

Prince Charming, a man who thinks she’s hilarious–but only when she’s not trying to be. Christy’s a self-proclaimed klutz, an avid music lover who’s known for spontaneously bursting into song, and a road trip aficionado. She’s only won one contest in her life–and her prize was kissing a pig (okay, okay… actually she did win the Daphne du Maurier Award for Excellence in Suspense and Mystery for her book Suspicious Minds also).

Her current claim to fame is showing off her mother, who looks just like former First Lady Barbara Bush. When she’s not working or spending time with her family, she enjoys singing, playing the guitar, and exploring small, unsuspecting towns where people have no idea how accident prone she is. For more information, visit her website at: www.christybarritt.com.

Medical Question: Surgical Timeline

I’m pleased to have Amitha Knight back who will be hosting a medical question today and tomorrow about surgeries. Today, she covers the general surgical timeline and what the patient’s process is through the OR. On Friday, she’ll cover more in depth about brain surgeries.

RB asks:

In the book my one lead character, a Brain surgeon, will be performing two major surgeries during the life of the book, one on (an animal), and the other she will be performing a radical operation on the male lead.

Could you, in as short as possible, give me an overview of what happens during such a surgery. The big picture and any suggestions you could give me that would make the scenes believable.

Even if you can point me at a website where I can read up about brain surgery – any videos would help as well, I am not squeamish about blood etc… so don’t worry about that side (more fascinated by the whole process).

Any help would seriously be appreciated.

Amitha says:

While I saw lots of surgeries during my 12-week surgery rotation in medical school, ranging from cholecystectomies (gall bladder removal) to liver transplants to cardiac surgeries to breast implants, I didn’t see any brain surgeries. I especially didn’t see any veterinary surgeries so I can’t comment on that part of your question.

The reason I didn’t see the brain surgeries was that the surgeons wanted you to be there for the entire surgery and brain surgeries can take a long time. For example, I heard of one brain tumor removal taking 6 hours. A quick search of the web reveals people who report their brain surgeries having taken more than 12 hours–not sure if they’re counting recovery time. Performing and assisting surgeries for long periods of time requires stamina, dedication, and patience. Alas, our hospital didn’t have a surgical theatre like on Grey’s Anatomy where people could eat lunch, gossip, and come and go as they please while watching surgeries.

While I haven’t seen a brain surgery, the very basic timeline of surgeries are generally the same:

  • The patient is wheeled into the sterile operating room (OR) and transferred to the operating table. Everyone in the room (besides the patient) is required to wear a face mask, a hair covering of some kind, scrubs, and shoe covers.

  • The anesthesiologist sedates the patient (sometimes this is started in the pre-op area). During some brain surgeries, the patient is kept awake for portions of the surgery (so they can monitor the patient’s brain functions by having the patient do different things during surgery) while in others, the patient is intubated and kept under general anesthesia the entire time.

  • The patient is positioned appropriately for the surgery. Parts of the body that aren’t being operated on are covered up. The patient’s head is shaved (or at the very least the part that they are operating on I should think).

  • Meanwhile the surgical team “scrubs in” (i.e. they go to a separate room attached to the OR to thoroughly clean their hands/arms up to the elbows and then return to the OR where they are helped by surgical technicians and nurses into sterile gowns and gloves, all the while making sure not to touch anything that isn’t sterile). Sterile coverings (which are usually all blue) are draped everywhere so that people who are “scrubbed in” don’t accidentally touch non-sterile things. People who aren’t “scrubbed in” aren’t allowed to touch anything in the sterile field. Keeping things sterile and clean is key.

  • The surgical area is “prepped” (i.e. cleaned).

  • Surgeons and surgical techs do a “time out” and double check the patient’s name and the procedure being done and the area being operated on.

  • The first incision is made.

  • The surgery is performed. Tools are all counted by the surgical tech. (During long surgeries, this may happen several times throughout.)

  • The surgical site is “closed” i.e. stitches are put in, the wound is dressed.

  • The patient is wheeled to the post-operative area (“post-op”).
Have you ever written a scene that involved the operating room?
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Amitha Knight is a former pediatric resident turned writer of middle grade and young adult fiction. She’s also a blogger, a book lover, an identical twin, and a mom. Follow her on twitter @amithaknight or check out her website: http://www.amithaknight.com/.