Author Question: Treatment of Teen Suicide Victim (1/2)

Pink Asks:

Hi there! I’m so glad I’ve found your site and thanks for taking the time to read this. Ok, here goes.

I’m writing about a fifteen-year-old boy who is being abused physically and sexually by his father. One day at school, he tries to commit suicide by slitting his wrists. He becomes scared by the amount of blood, so he leaves the restroom to try to find help. He is found by his teacher and passes out. Now, I know with any kind of suicide attempt, the police are always contacted, and given the all clear for the paramedics.

Jordyn: I think it would depend on the city, county, school district (and whether or not there was a school resource officer) as to the level of police involvement if he just really needs medical attention. I would advise that if this is written about a real place you ensure they have co police response because a paramedic team would be able to handle this call.

Pink: What will the ED staff do to stabilize a patient who has slit their wrists? Is surgery necessary if the wound is pretty deep?

Jordyn: We always look at airway, breathing, and circulation first. If the patient is talking to us then we can quickly check off the first two as at least functional for the time being. As far as circulation the priority is to stop all active bleeding first by direct pressure. Also, does the patient exhibit any vital sign measurements that show he’s suffering from blood loss—which in this case could be increased heart rate, low blood pressure, and also low oxygen levels.

After that, the medical priority for this patient is to further control the bleeding and determine how much blood he’s already lost. Direct pressure is the method used to control the bleeding. Blood work would be done to look at his blood counts to see if he needs any blood replacement. Next would be to look at if he damaged any arteries, tendons, ligaments or nerves during the attempt. Generally, an exam of the function of the fingers can reveal if there is a concern there. For instance, do his fingers have full range of motion? Do any fingers have areas of numbness? Arterial bleeding is very distinct so it’s usually obvious if an artery has been severed. If he has damaged anything that would limit the function of his hand then he would need follow-up evaluation by a hand surgeon for surgery. If there is no damage to the structures as listed, there is a possibility the wound could be closed in the ER as a simple laceration repair.

Pink: Upon discharge, what will the patient be given to take home for treatment of their wound (the slit wrist)?

Jordyn: If the patient gets a simple laceration repair (merely closing the skin even if it takes a lot of stitches) then pain could be managed at home with over-the-counter pain relievers like Tylenol or ibuprofen. If the patient requires surgery, a short course of a narcotic may be given for pain control,    but we also have to look at other factors to determine if this would be wise for the patient (are they a current drug addict or is there continued concern for suicide attempt). If the patient has surgery, then it is up to the surgeon to determine the patient’s home pain relief.

Pink: If a nurse or doctor notices any bruises on the patient’s body, can they examine an unconscious patient?

Jordyn: Yes, an unconscious patient’s skin can be externally examined. In fact, it is often protocol to do so because we are looking for clues as to why the person is unconscious.

Well continue this discussion next post.

Author Question: Tawse Hand Injuries

Anonymous Asks:

I’m really glad I found your blog! I don’t know whether this is the sort of question you’ll answer on the blog, since it’s “injury to order”, but I very much hope so as I try to be scrupulous about my research and want to get this right.

I have a male character in his mid-30s. He’s right-handed, and his left hand is permanently damaged. It can be either a birth defect or something that occurred when he was young (before the age of ten). I’m completely open to what the injury is— I would like him to have at least limited use of his hand, and it would be a bonus to have a childhood surgery and/or to have him use a splint or brace in adulthood (even only occasionally), but none of this is required.
However, what’s fixed is that he believes the injury was caused by parental abuse— specifically, being whipped across the palm with a leather strap known as a tawse.
Because he’s mentally conflating his actual injury with the abuse, those two things don’t have to match up. It might even be better if someone in his adult life said “could being hit with a strap really cause that damage?”, but I do want to know exactly what the issue is so I can depict it accurately.

Many thanks for anything you can suggest!

Jordyn Says:

Thanks for sending me your question.

I love “injuries to order”. Sometimes it’s easier to fit an injury into what the writer wants than framing the writing to a particular injury the author wants to write about.

I’ve never heard of a tawse and its use in corporal punishment. For readers, a tawse is a piece of leather with split end. You can find some representative images by following here. Just reading about this device being used– it would easily cause soft tissue damage– bruising (even though they were seemingly designed to not bruise), swelling, and if used with enough force– fractures. I think continued, persistent use could potentially even cause nerve damage. I looked specifically for articles dealing with “tawse hand injuries” and really didn’t have much luck.

The reason I list these potential injuries is so that you can “pick your own” injury within these guidelines. I’m including a couple of links to websites that list several congenital malformations of the hand. Read through them and see if any connect with you and the goals of your story.

http://emedicine.medscape.com/article/1285233

http://www.hopkinsmedicine.org/healthlibrary/conditions/plastic_surgery/congenital_hand_deformities_85,P01120

https://my.clevelandclinic.org/health/articles/congenital-hand

Hope this helps and best of luck with your story.

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!

Author Question: Scythe Wound to the Chest (2/2)

We’re continuing with Sue’s question regarding a scythe injury to the chest to a seventeen-year-old male. You can find Part 1 here.

Sue Asks:

I have a few follow-up questions regarding the surgery. Is it possible for a thoracotomy to be done by two people? The hospital in my story is severely understaffed and only two doctors are available to perform the surgery. There are not enough nurses on staff either, and it’s the middle of the night. Is that feasible or should I tweak the story so more people are available to make sure the teen makes it out alive?

And lastly, what kinds of medications would be pushed through the IV to sedate and/or paralyze him for surgery?

Jordyn Says:

This was a great question to ask my OR expert friend, Kim Zweygardt, who works as a CRNA.

Here are her thoughts.

Most hospital’s policy states that an RN must be in the room for assessments and patient safety. The bare minimum OR staff would be a circulator (RN), scrub tech, anesthesiologist, and surgeon. If you want chaos in your story— take out the scrub tech because the doctor will have to figure out the instruments for himself versus calling out and them being handed to him.

A patient this unstable would be intubated in the ER. Generally they are given a pain medication (Fentanyl), a benzodiazepine (Versed) for the amnesic effect, and the paralyzing agent will vary but Succinylcholine was common in your time frame of 2006.

Once in the OR— they would give him anesthetic gases to keep him down. I don’t see your scenario playing out without a anesthesiologist on hand.

Hope this helps and best of luck with your novel.

Author Question: Scythe Wound to the Chest (1/2)

Sue Asks:

The year is 2006 and a seventeen-year-old male gets stabbed through the right side of his chest all the way through to the back, but the blade (a hand scythe) that could potentially stop him from bleeding out gets removed. Naturally, he starts bleeding out.

I already know a lot about what goes into stabilizing him: Checking the ABCs, IVs for blood and fluid replacement, intubation (an endotracheal tube), but my question is, what is the exact treatment for this type of injury in a surgical theatre? What are the indications that he may need a thoracotomy or a lobectomy? Or is it as simple as a chest tube to treat the hemopneumothorax, connecting him to a ventilator, and then suturing the lacerations in his lung?

Jordyn Says:

Thanks so much for sending me your question, Sue. Very intriguing scenario you have here!

Let’s first clarify some of these medical terms for readers. A thoracotomy is a surgery that involves removing the lung. Lobectomy can be removal of any lobe of organs such as your thyroid, liver, or lung. In this case, you’re referring to the lung. A hemopneumothorax is a collection of blood and air inside the chest wall that is usually relieved by placement of a chest tube. Pneumothorax is an abnormal collection of air in the chest between the lung and the chest wall– also typically relieved by placement of a chest tube (though some very small ones may just be watched).

I asked a physician friend (thanks, Liz!) her thoughts on your questions.

She says the following:

Since the patient is unstable, he needs a thoracotomy by default. Other indications for surgery would be blood draining from the chest tube at greater than 100 milliliters per hour. The lungs cannot be sutured. Generally, bleeding vessels are either tied off or cauterized and the bronchi (the larger breathing tubes) are repaired. If the lobe is severely damaged then it does get removed.

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?

Should You Videotape a Healthcare Worker Without Their Consent?

Recently, I became aware of a story that broke my heart. Perhaps you heard of it, too. A WWII veteran called for help multiple times and when the call light is finally answered, the nurses delay giving him lifesaving measures and are even seen laughing at his bedside. Two nurses, appropriately so, lost their licenses. You can view the video and read about the story here. Also, this case that just aired on ABC news within the last few days of elder abuse by nursing staff  caught on hidden camera as well.

This is a very touchy subject and I don’t necessarily have a strong statement to make, but I do have a cautionary tale. I understand both sides and I’m glad these nurses were caught so that no other patient suffered needlessly. However, I also know that I would feel completely violated if I was videotaped or recorded without my knowledge.

When I worked as a Pediatric ICU nurse, a family chose to videotape the staff without their knowledge. The family was critical of the staff in general and it really was a no win situation. Then news came out that they had been videotaping the patient’s care. Our managers at the time approached them and requested they stop. In all the footage, and I don’t know how much there was, the staff wasn’t seen doing anything inappropriate.

In writing fiction, we always talk about increasing tension and conflict. I can tell you from personal experience that this will definitely do it.

In real life, if you or a family member make a decision that this is a necessary step to take, I would ask yourself why you’re making this choice. Considering this means you already think something is wrong. If that’s the case, is this the right doctor or hospital to be working with?

Taking this step is very serious. At the very least, it will likely destroy any trust between you and the medical staff. Sometimes, that’s hard to get back. Legally, you should discuss whatever option you’re considering (secretly recording a conversation, etc) with a lawyer. Different states look at this issue differently. There might be a hospital policy in place against. There are patient privacy concerns (the recording picking up another patient’s information). Also, it might actually have the reverse effect. When medical people know they are being more scrutinized, the added stress can make it more likely for them to make a mistake.

I think several things can be done before this to allay or address a family’s concerns. Any good hospital will take a family’s concerns very seriously. If they don’t, then there are places to go with your concern. For instance, concerns for elder abuse can be reported to state regulatory boards.

Here are my thoughts if you’re concerned your family member is not being taken care of appropriately.

1. A family member should be at the bedside 24/7. I know this may not be feasible for everyone, but having a family member at the bedside does keep staff on their toes. Ask questions. Keep notes. One problem I do have with the current state of medicine is that the providers don’t seem to read one another’s notes so important facts may not be shared. I had a personal experience with my husband with this very thing. If you can’t find someone to sit at the bedside, check in a couple of times per shift via phone with your loved one’s bedside nurse and try to be there in the morning when they make rounds.

2. Tell your nurse that you have a problem right when it occurs. State it clearly. Plainly. Rationally discuss what your concern is. If the response from the bedside nurse isn’t satisfactory, then ask to talk to the charge nurse. If that doesn’t help, ask to talk to the unit manager or nursing supervisor. You can speak to a patient care representative. If it’s a concern about the doctor, your bedside nurse should be the one who will advocate for you in that situation. Do not stay silent about your concerns. Big or small— please speak up.

3. You can request alternative staff to take care of your loved one. This is easier on the nursing side. Sometimes, your personality and the nurse’s personality don’t mix. That’s life. We don’t get along 100% with everyone. Is it a personality issue or do you think the nurse is providing bad care? Making a distinction between the two will help the charge nurse or supervisor decide what the best action is to take. For instance, a conflict of personalities, maybe it’s not best to put the same type of nurse in there.

4. Pay attention when you are admitted to the hospital about calling an RRT. An RRT stands for Rapid Response Team. Usually they are made up of a team of ER doctors, ICU doctors, and critical care nurses who will come to the bedside an do an independent evaluation of the patient and suggest a treatment course. Bedside nurses can call these, but many hospitals are making sure families know they can do this as well. The time to use this is when you feel your family member is getting sicker, but the bedside staff isn’t listening to your concerns in a way that makes you comfortable. It allows another set of eyes and ears on the patient and more medical opinions can be discussed.

5. If you’re a medical provider, you should report sub par staff to that person’s supervisor. This is all of our responsibilities. If you feel you can’t do that, then leave an anonymous message to your organization’s corporate compliance hotline. As they say, document and report.

What do you think about videotaping medical staff without their knowledge? Are you for it? Against it? Why?