Author Question: Treatment of the Burn Patient

Jennie Asks:

What happens when someone gets burned? What do the EMT’s do on the scene? The story line involves the explosion of a crosswired electrical box.  Two individuals are burned.

First, the man who threw the switch is thrown onto the floor and sparks are showering down on him and his clothes.  He is pinned beneath a shelf that he knocked over.  The second man takes his jacket and tries to put out the flames while others pull the shelf off the man on the floor.  The second man’s arm and hand are burned trying to put out the fire, and keep the sparks from falling on the man on the floor.

I have the paramedics taking the first man to the hospital. I describe very little about his condition. However, the hero is attended by the heroine who is an EMT. His burns are secondary. Would he have to go to the hospital?  Get a tetanus shot if he needs one?

Jordyn Says:

The first distinction to make is that there are several different types of Emergency Medical Service (EMS) providers and their level of responsibility to this patient will be different. An emergency medical technician (EMT) generally provides basic first aid, CPR, can administer oxygen and can assist the patient in giving some of their own medications (like an asthma inhaler or nitroglycerin tablets.) A paramedic does more advanced medical procedures and gives drugs. The level of your provider will need to be clear in the medical care they can provide.

For EMT’s, in general, burn care is as follows:

1. Remove clothing from the burn that is non-adherent.

2. Remove any constricting items. For instance, if the burn is on the ring finger, you would try and take the ring off.

3. Cover burn with a cool, wet, clean dressing. This will help control pain.

If you have a paramedic responding— it is possible that an IV could be started and the patient could get an IV narcotic for pain (something like morphine or fentanyl.)

If the character is burned by the electrical current, this poses a whole new set of problems. I get the feeling he is burned by the electricity because you mention that he has been thrown back. Electrical burns typically have an entrance and an exit wound like the hand and foot. The electricity enters one part but has to exit somewhere.

The other problem with electrical burns is that your heart pumps based on an electrical conduction system. An electrical burn can injure the electrical conduction system of the heart and we will look very closely at whether or not the heart sustained injury. This could be evaluated initially by a 12-Lead ECG and lab work that measures muscle breakdown specific to the heart. The issue with electrical burns is that the damage is often unseen because the electricity will injure you internally but we can’t see it externally except and the entrance and exit sites.

The other thought was the extent of your patient’s burns and this would make a difference in their medical care. Burns are generally calculated based on the percentage of skin that is affected. You can find examples of these tables by clicking this link. Adults and kids are calculated differently.

Burns <15% body surface area (BSA) would get cool, moist compresses. However, burns > 15% would get dry, sterile dressings. The reason for this is that burn patients have lost their skin integrity. Your skin helps your body maintain its temperature. Some consider it the largest organ in the body. When you burn >15% and apply cool, wet dressings, this can pull enough heat away from the patient to cause them to become hypothermic. We actually have to help burn patients maintain their body temperature by cranking up the heat in the room or using other warming techniques.

Your patient will have to go to the hospital. Initial ED treatment would be IV placement, fluid resuscitation (there is a formula we use for this and is dependent on the burn percentage), pain medication (like morphine), and likely consulting with a burn center to help determine his course of treatment. Tetanus shot would be updated if he hasn’t had one in the last five years.

Did you know that paramedic protocols are relatively easy to find online? For instance, this link shows all of the Denver Metro Prehospital Protocols. Referencing these will be one of the best sources for researching what type of prehospital care your character would receive for their given ailment.

***This content originally posted December 10, 2010.***

Button Batteries: Preventable Cause of Pediatric Death

There is nothing that will raise the ire of a pediatric nurse more than a preventable pediatric death. So, in an effort to educate the public, today I’m focusing on a very real danger in your home that could kill your child if ingested and that is the button battery.

battery-106353_1920Button batteries are those disc shaped, silver batteries that are found in hearing aids, watches, weight scales, and often toys. I would be surprised if you didn’t have these in your home.

Typically they are swallowed by younger children (age 1-3) who may or may not tell you what has happened. We can tell the difference between a button battery and a coin by a characteristic halo appearance of a button battery on x-ray. If you look at the underside of the battery, you’ll see this gap that will show on film.

If the battery becomes lodged in the upper esophagus, it leaks a highly caustic alkaline solution, even if the battery is spent, that begins to erode through tissue. This process happens quickly. I’ve seen these burns develop in just two hours. These burns can lead to scarring and long term complications— that can be a minor complication.

There is also a deadly complication. Even after the battery is removed, this alkaline solution can remain in place, eroding and burning away tissue. Typically, the cause of death in a button battery ingestion is hemorrhage because this solution eventually erodes through a major blood vessel. Even if the patient is in a hospital when the bleeding starts it is very difficult to repair.

For prevention:

1. Button batteries need to be treated as highly toxic objects. They should be kept out of the reach of children (even locked up) like other dangerous objects in your home.

2. Toys that have button batteries need to have screws that lock them in place. Toys should be checked frequently to be sure this compartment stays locked. Best case is not to have these types of toys in your house at all with younger kids.

3. Be aware of items in other environments that have button batteries. Button batteries are used in hearing aids. So be careful at grandma and grandpa’s house and have a discussion with any caregiver about the dangers of having these unsecured.

4. Give age appropriate education to other children in the home about how dangerous button batteries are. Tell older children to tell you immediately if they see a younger sibling with anything in their mouth that they’re not supposed to have. Have them show you toys when they break to see if the battery has become loose. If it’s not there— find it.

5. If swallowed, proceed immediately to the closest emergency department. I mean, really drive there now. You don’t need to call 911 but you do need to go. Do not delay being seen. Button battery ingestions are a true emergency. Your child should immediately receive and x-ray to determine the location of the battery. Treatment depends on its location.

6. If discharged home after a button battery ingestion, any bleeding needs to be treated as an emergency as well. If bleeding is significant then you should call 911 and be transported. Even minor (or spot) bleeding from the mouth needs to be evaluated emergently.

For additional cases and information you can read here and here.

As one of my physician co-workers said, “Respect the button battery.”

Please share this article!

Author Question: Medical Complications for Badly Broken Leg 2/2

Today, we’re continuing with Mareike’s question dealing with a character who has several medical complications from a broken leg as a result of a physical assault. You can read Part I here.

wheelchair-1629490_1920Today, I’m hosting Tim B. (my own physical therapist!) If you’re south of Denver and need an excellent physical therapist I’d be happy to refer you.

Here are Tim’s thoughts on the rehab aspects of this character. He also gives great insight into the medical treatment of such a fracture.

Welcome, Tim!

If a person has a compound, open, major fracture of the leg (the part between the knee and ankle), then the most likely treatment would be an ORIF (open reduction, internal fixation), or plates and screws. People with ORIF are then not given a cast.
If the fracture was comminuted (bone is fragmented versus a straight fracture), the typical treatment might be ORIF or an external fixator (halo). You can view this link for photos.

That person would then be non-weight bearing for at least 6 weeks (or more, depending on radiographic evidence of healing), then transitioned into partial weight bearing. They would use crutches or a wheelchair during the non weight bearing phase. The weight bearing phase would progress according to radiographic healing, more than anything else. There is no protocol, per se.

If a person is casted all the way to the hip, then there most likely would have been a fracture extending into the knee joint line, such as a tibial plateau fracture—which could be one of several fractures, including a compound fracture let’s say in the mid-shaft of the tibia/fibula.

Sometimes, an external fixator is applied (in the case of badly damaged and very swollen surrounding soft tissues). After swelling decreases, another procedure could take place (removal of external fixator and placement of internal plates/screws). A cast to the hip would not be used for a fracture below the knee, most likely. So the knee must be involved somehow for the cast to need to go all the way to the hip. Most people are issued a knee immobilizer after these fixation procedures. Perhaps in regions/countries where immobilizers and braces are not commonly found a person could be casted.

Compartment syndrome could be a result of the initial mechanism of injury—lots of soft tissue damage along with bleeding from the fracture—causing compression of the nerves and blood vessels of the leg. Or compartment syndrome might result from a cast that is too tight. Or a bedridden person who doesn’t move at all (same mechanism as a person developing a DVT due to lack of movement).

If blood vessels and/or nerves are compromised in the initial injury or by permanent damage from compartment/compression, the first attempt would be microsurgery by vascular/neurosurgeons to try and repair. Also, a release of the compartment would most likely take place.

Compartment releases are left open and frequent dressing changes take place until swelling comes down. It leaves a wide and long scar in the long run. It takes a little time to realize if it was successful or not (nerve and vessel repair). Perhaps a week later it would really be evident if the correction was successful, or if the leg/foot was “dying” due to lack of blood supply. Those dead areas would not be able to bleed, would probably start turning color, would start to smell, and might be numb.

PT would vary greatly.  Typically, non weight bearing to partial with appropriate crutch use while working the regions of the body surrounding the leg, including even the upper body for strengthening. Progression depends upon radiographic evidence of bone healing for the most part. Range of motion of the knee, ankle, and hip would be emphasized (for most people who have immobilizer but not casts).

Hope this helped and best of luck with your story!

Author Question: Medical Complications for Badly Broken Leg 1/2

Mareike Asks:

Greetings from Germany!

The character in question has several injuries, the most important of which is a severely broken leg (I’m talking cast all the way up to the hip). He got these injuries by being attacked and beaten up.

knee-1406964_1920I’m thinking open or compound fracture because then I can have him develop a bone infection. What I’m wondering is the order of things and how long it would take to develop what and how to recover, how long it takes, and so on.

I want him to either develop compartment syndrome and/or the above mentioned bone infection. From my understanding of the sources I’ve read, an infection can result from the treatment of the compartment syndrome, but not vice versa, so it would make sense to have that order, right? Those two are the main life/health threatening complications I could find while researching.

My ultimate goal is to write a story of recovery. Of the hardship, the struggle and pain, the setbacks. The physical therapy, the fear of whether or not he can go back to his old job.

Any resources you could point me towards when it comes to recovering from a very nasty break that might or might not require amputation or might lead to a disability would be greatly appreciated.

Jordyn Says:

Greetings from the USA! I’m going to give some thoughts on your question. I also consulted with a physical therapist since a large portion of your question deals with recovery and we rarely know what happens to patients in the long run.

I’ll give Tim’s thoughts on PT next post.

One thing I want to make clear is that treatment in the US is going to differ from medical treatment in Germany. If your novel is specific to Germany, then you really should run these thoughts by a medical person in your country. Some things should be similar, but some may also vary widely (like treatment of the actual fracture— use of fixators versus casting, etc.)

My first thought is it is really hard to get an open fracture of the leg from a beating. It’s not impossible, for sure, but we normally see injuries like this from mechanisms with a lot of velocity behind them— car accidents would be one example. So, sadly for your character, for this to ring medically true, I would probably add a weapon of some sort— like a metal pipe. And it’s more likely from repeated hits than just “one lucky” one.

The other thing is to understand the difference between compartment syndrome and the bone infection you mention which is called osteomyelitis. Compartment syndrome is a condition of swelling leading to a lack of blood supply. When you injure your body, it responds by swelling. Think of a sprained ankle.

Sometimes, this swelling can become so severe that is compresses on the blood vessels inside the extremity and either diminishes blood flow or cuts it off completely. This can be from just the injury, a cast or splint that is applied too tightly, or swelling after a cast was placed correctly.

Things begin to die when they don’t have blood supply. To alleviate the pressure, a fasciotomy is often done, which is a long cut through the skin and underlying tissue. It is a deep cut. If you Google pictures of a fasciotomy you’ll quickly get the idea. Not for the faint of heart. After this type of procedure, you have an open wound. Open wounds are always at risk for infection, but it doesn’t necessarily mean the bone would get infected.

Osteomyelitis is an infection of the bone. An open fracture (where the bone punches through the skin) can place a patient at risk for this type of infection. The dirtier the wound the more apt for infection. Wound infection does not develop immediately. Usually it takes 48-72 hours (24 hr at a minimum). Antibiotic therapy for osteomyelitis is extensive lasting 4-6 weeks. You can read an overview here.

Also, here is a link that deals with treatment of compartment syndrome.

With these injuries, coupled with the  added complications of compartment syndrome, fasciotomy, and/or osteomyelitis (or some other infection), your character is looking at 2-4 weeks in the hospital. He would likely go home on oral antibiotic therapy for his bone infection.

He’ll also need extensive rehab which Tim will highlight next post.

Author Question: Brain Infection

Dale Asks:

I have a character who ends up in a coma for three days. The character suffers from viral encephalitis which is brought on from huge amounts of stress, and I only have a little bit of info about this. I got the idea from a real life FBI profiler who went through this, but he only went into a few paragraphs of what it was like. I was wondering if you had any info about how someone would be cared for in this condition from the time of admittance to the time of release?

Jordyn Says:

brain-cellsTo start, let’s deal with what viral encephalitis is. Encephalitis is inflammation of the brain and/or spinal cord. Viral encephalitis means the infection is caused by a virus. When this type of patient presents to the ER, it may be hard to differentiate between encephalitis and meningitis. Symptoms of both encephalitis and meningitis can be fever, photophobia (sensitivity to light), headache, stiff neck, pain upon moving the neck, nausea and vomiting, and seizures. There are other symptoms as well. This is the short list.

One thing that struck me about your question is the stress aspect and why it made this FBI agent vulnerable. Stress weakens your immune system but wouldn’t be the cause of the encephalitis. There needs to be a causative agent (like a virus or bacteria) but he was likely set up to be more vulnerable by the stress he was under.

In the ER, we’ll draw blood to see if the patient’s white count and inflammatory markers are elevated. He may get a CT of the head. We absolutely will have to get a sample of spinal fluid through a lumbar puncture. Typically we have to collect a sample of the cerebrospinal fluid for testing before we give any antibiotics or antiviral therapy. Depending on the patient’s condition, it would be determined if they need admission onto a regular floor or the ICU.

If the cause of the brain infection is of a viral nature, the medical team will likely give symptomatic support as antibiotics are ineffective against viruses. There are anti-viral agents available, but this is up to the discretion of the medical team as to whether or not their use would be beneficial for the patient.

Symptomatic support in this case would be keeping the patient hydrated, controlling pain, and frequent reassessment of his neurological status.

For more information on encephalitis check out these articles here and here.

Author Question: Police Notification of Violent Injuries by the ER

Dale Asks:

I see in TV shows and movies people who are shot or stabbed go to get medical treatment and yet they never deal with the police. Or they refuse to go because they are afraid that it will get reported.  If a person is taken to the ER with a knife wound or gunshot wound, would the medical staff have to report it to the police?

Jordyn Says:

Police car lights close up. A group of policemen on the background.

Police car lights close up. A group of policemen on the background.

Yes, we have to notify the police if a person is shot or stabbed with nefarious intent. Knives can cause lots of wounds that aren’t criminally motivated. Think about the person slicing vegetables and cuts their finger. Knife wound . . . not criminally motivated. We wouldn’t call the police.

The most important aspect is whether or not the person is being truthful regarding their injury. It’s obvious if someone comes in with a gunshot wound that something criminal has likely happened.

If a person comes in with a knife stuck in their chest, we’re likely getting the police involved even if they say it was an “accident”. However, say a woman comes in with a defensive knife wound to the palm of her hand as she tried to keep her boyfriend from stabbing her, but she tells us that she cut it grabbing a knife from the bottom of a sink full of soapy water. If the woman doesn’t have any other suspicious injuries, we probably wouldn’t question her story.

In all honesty, we can only help patients as much as they are willing to help themselves. If they are truthful about the violence involved in whatever type of injury they have (particularly beatings from domestic abuse) then there is help we can offer them.

Ever wonder why you’re asked when presenting for medical care whether or not you feel safe? This is inherently because we know, as healthcare providers, that it is hard for victims to speak up. That question is your open door. If you feel you can’t answer honestly at the time, then look for a way to speak to your nurse or physician privately. Sometimes we try and facilitate a conversation like this by asking other visitors to step out of the room. If we do this, it should signal to you that we are suspicious that your injury did not happen the way you stated and we’re trying to find a way to help you.

It is true a patient might not seek medical treatment for fear of police involvement. The same can be true for child abuse injuries. A parent may not seek treatment or delay treatment for fear of being reported to child protective services and/or the police.

See how the different variables can vary to increase conflict in your story?

Author Question: Bullet Wound to the Chest

Gwyn Asks:

I’m writing a scene in which a cop is injured during a confrontation with a suspect.  I’d like to tell you about the scenario I have in mind and hopefully you can tell me how realistic it is.

ammunition-2004236_1920Cop, mid-thirties, in excellent health and physical condition is shot with a low caliber bullet from about 10 feet away.  The bullet hits his chest, goes through the lung and exits out the back.  He’s got colleagues nearby who administer basic first aid and the EMTs get there within 5 minutes.  Say about 15 minute drive to the hospital.  They radioed ahead so the hospital is expecting them and has an OR ready.

First of all, what are the chances of survival?.  Second of all, assuming survival, what are the chances (best case scenario) of full recovery – to the point he can return to active duty.  How long would the recovery time be, how soon would he get out of the hospital, and what complications — pneumonia, blood clots, etc should the doctors be worried about?

Finally, if a full recovery is highly unlikely, are there little changes I can make to the scenario to make it more likely?

Jordyn Says:

Hi, Gwyn! Thanks so much for sending me your question.

In short, this is a survivable injury.

You don’t specify in your question whether this police officer is shot in the right or left chest. Right chest would probably be preferred as there are less vital structures on the right side of the chest then the left.

ambulance1You give your victim immediate first aid and EMS responds quickly. Keep in mind that you’re going to need a paramedic to respond to give more advanced field procedures. A basic EMT is limited in what they can do— CPR, wound dressings, assisting the patient with some of their own medication administration. Depending on the state, some EMTs can start IVs, so if your novel is set in a specific location then I would research this for that area. Assuming he has a paramedic respond then he’ll get an IV, IV fluids, oxygen, and possibly pain medications. Of course, a set of vital signs and cardiac monitoring.

In an urban setting, a drive time of fifteen minutes to the hospital seems a little long. If a rural setting then you’re probably fine but you might need to adjust there as needed.

A bullet passing through the chest is likely going to puncture and deflate the lung. This character will need a chest tube to get the air out of his chest and reinflate the lung. A chest tube can be placed in the ER. This patient would get a CT scan of his chest. If the medical team isn’t worried about any other injuries than this patient may not even need to go to the OR.

A patient with a chest tube will need to be admitted into the hospital. How long it takes the lung to reinflate depends on the size of the pneumothorax or the degree to which the lung has collapsed. Generally, a patient’s chest tube is connected to a drainage box that uses suction to help the lung reinflate. Patients with this type of injury will get daily (or every other day) chest x-rays to see how the lung is expanding. After the lung is fully expanded, the suction is stopped, but the box remains in place. This is generally referred to as placing the chest tube to water seal.

If the lung stays expanded to water seal for one to two days then the medical team would feel good about removing the chest tube. Then the patient would be observed for another one to two days to make sure the lung stayed reexpanded.

Pending any complications, you’re looking at a hospitalization of 4-7 days. Pneumonia is probably your more likely complication. Having a tube in your chest hurts. Because of this, patients don’t want to take deep breaths. This can lead to the smaller air sacs in the lung staying collapsed and trapping bacteria which could lead to pneumonia.

If you add a complication like pneumonia, then you’re easily adding another one to two weeks that he’s out of commission.

If you just stick with a “simple” collapsed lung I would say he’d be out of work for about two weeks. He won’t be physically 100% of what he was before the injury but he should feel back to his physical baseline in about a month.

I would say he can work, but he’s going to have some physical limitations. It would be up to his department what his physical capacity needs to be before he can return to work. Half days at a desk job is not unreasonable for a few weeks.

He’d likely become short of breath during any exertional activity (like running after a bad guy). However, considering his physical shape, he should bounce back fairly quickly.

A nice overview can be found here.

Hope this helps and good luck with your novel!