Author Question: Pedestrian vs. Truck 2/2

Today, we’re continuing with Luna’s question. You can view Part I here. In short, a 24 y/o woman has been hit by a truck throwing her into the air. When she lands, her head hits a concrete divider.

What will the doctor check or say when she first arrives at the emergency department?

If EMS care has been provided as I outlined in the previous post, we would do the following in the ER:

  1. Check vital signs and level of consciousness. If vital signs are abnormal, we would address those immediately. For instance, if her oxygen level is low, then we’ll provide more oxygen and evaluate whether or not the patient needs to be intubated (a breathing tube into the lungs). EMS may have already done this. If so, we’ll check the placement of the tube. If her blood pressure is low address that by giving either more fluids, blood, and/or a vasopressor (which is a medication given via a continuous drip to raise blood pressure). Of note, sometimes giving lots of IV fluid with head injuries is problematic.
  2. Draw lab work. In this case, we would check multiple labs. Blood counts, chemistries, and labs that look at how well the blood is clotting.
  3. Radiology studies. This patient automatically buys herself a full spine series (looking for fractures in the spinal cord) and a head CT (that would look for bleeding– and other things). Other labs and studies would be ordered depending on what other injuries were found. As previously stated, this patient would likely have more than just the head injury. A chest x-ray as well particularly if intubated to check placement of the tube.

Is surgery needed? 

This would be up to you as the writer. Would there be a case in this scenario where surgery might be indicated? Yes. Hitting your head into a concrete barrier could definitely cause some fractures in the skull where bone fragments could enter the brain. This patient would get a neurosurgery consult for sure.

Does she require blood transfusion for the surgery? 

Whether or not a patient gets blood is largely dependent on what their blood counts are. We look at this by evaluating a patient’s hemoglobin and hematocrit or H&H in medical lingo. If low, the patient gets blood. In trauma patients where there is a concern for bleeding, we draw blood every few hours to trend this lab. If it’s dropping, we know the patient might be bleeding from somewhere.

What machines would be used to keep her alive?  

In this case, likely a ventilator (or breathing machine).

How long will she be in the hospital? I am writing for two days.

Unfortunately, I think this patient would be hospitalized much longer than that. A brain injured patient that requires brain surgery would likely be hospitalized for a week or more. A week on the short end if they wake up and are neurologically intact meaning that they can speak, walk, and talk. That they know who they are, where they are, and what time they are in. Also, are their cognitive abilities intact (memory, ability to do simple calculation, etc). If this patient had a simple epidural bleed, then perhaps home in a few days if the above is normal.

The reason I say a week for this patient is the concern for brain swelling surrounding this type of injury. Brain swelling peaks around 48-72 hours and patients generally get sicker when that happens.

Thanks for reaching out to me, Luna! Best of luck with this story.

Author Question: Pedestrian vs. Truck 1/2

Luna Asks:

I hope you can help me with my writing. I need some details for my character.

She is a 24 year old girl that was hit by a 4×4 pickup truck while crossing the road. She was thrown and her head hit the road divider. She was bleeding moderately (not too heavy) from her head injury. She was conscious when her friend sent her to the hospital where later the doctor said she had brain hemorrhage as a result from that accident.

Can I have the details for:

  1. Will she have shock and shortness of breath on her way to the hospital?
  2. What will the doctor check or say when she first arrives at the emergency department?
  3. Is surgery needed?
  4. Does she require blood transfusion for the surgery?
  5. What type of machines would be used to keep her alive?
  6. How long will she be in the hospital? I am writing for two days.

Jordyn Says:

Hi Luna! Thanks so much for sending me your question.

First off, this is a VERY significant trauma to this young woman. There are some specifics missing from your scenario that would be helpful in answering your questions such as how fast the truck was going when it hit your character. The fact that you mention that the victim was thrown indicates a higher rate of speed. Being thrown coupled with the fact that her head hits a very hard surface (the concrete divider) doesn’t bode well for your character.

From your questions, it sounds like you want this to be a more minor injury. If you want this to be a survivable injury (which could be doubtful) you would need to change the nature of this accident and make it less lethal. For instance, the character isn’t thrown a distance. The truck isn’t traveling at a high rate of speed. Or, your character is in a vehicle of her own.

I will answer these questions based on your scenario as is, but keep in mind, this is a very serious accident and if the character survived, she would likely have an extensive hospitalization.

Will she have shock and shortness of breath on her way to the hospital?

You don’t specify in your question whether or not 911 was called and the patient was transported via EMS to the hospital. I would recommend that you do this. You also outline in your scenario that her head wound isn’t bleeding a lot. This is another part of your question that will need some revision. Head wounds do bleed extensively and heavily. If you’ve ever seen a minor laceration to the head you’d be impressed. The scalp is very vascular (meaning lots of blood vessels supply the area and therefore a much higher rate of bleeding).

Yes, this character could be in shock likely related to the blood loss from her head wound, or her head injury, or psychologically from the fact that she’s just been hit by a truck. Keep in mind, the head injury may not be her only injury. Anyone hit by a vehicle and then thrown will likely have other injuries such as broken bones, possible internal injuries, other cuts, lacerations, and abrasions.

If the patient was transported by EMS, they would first provide for C-spine stabilization (placement of a C-collar and backboard) while simultaneously assessing her breathing. Whether or not she’s breathing would be up to you. I could see it either way in this scenario. If she’s not breathing, then they would assist with her breathing. In addition, they would control any visible bleeding by applying pressure and dressings. She would be placed on a monitor to track her vital signs. An IV would be placed and IV fluids would be started.

Since this is a lengthy question, we’ll conclude tomorrow.

The Good Doctor S1/E6: Killing Patients

At some point in every medical person’s career, we face a time when we think or may have altered the course of someone’s life either by a medical error causing serious harm or death.

Truth is, it’s a team effort to keep patients from suffering from these complications. We are all responsible for looking out for one another regardless of scope of practice. For instance, if an EMT sees something the doctor (or new resident) is doing wrong, they should speak up to prevent harm from coming to the patient.

In this episode of The Good Doctor, the staff is dealing with an MCI or Mass Casualty Incident. A bus full of wedding guests has crashed. After several of them are treated, it is discovered that a woman is missing at likely still at the crash site.

A resident leaves with an EMS crew (this in itself is highly unlikely) and finds the missing woman. On scene, the resident diagnosis her with a flailed chest and subdural hematoma (a collection of blood on the brain).

What is a flail chest? It’s when two or more consecutive ribs are broken on the same side creating a free floating segment of the chest wall. This can inhibit the patient’s ability to breathe and also puts the patient at a higher risk of having a pneumothorax (or air collecting outside the lung inhibiting the lung’s ability to fill with air.)

The resident chooses to intubate and then drill a bur hole into the patient’s head for the swelling. Upon arrival to the hospital, the ER doctor notices that the patient’s oxygen level is low (like in the 70s— normal of 90 and above) and pulls back the tube and the oxygen levels increase.

When someone is getting intubated, it’s natural to push the tube in too far and because of the anatomy of the lungs, it will pass into the right lung. It’s later noted in the show that because the resident intubated the right lung and that’s the side that had the failed chest, the patient suffered from persistent hypoxia (or lack of oxygen) and her brain died because of that.

Was this patient’s death preventable?

Putting aside that this patient could have been hypoxic during the time she laid for an extended period of time in the ditch, this death could have been preventable if the EMS crew, who would have been monitoring the patient’s oxygen level (and so should the resident if involved in transporting the patient) had spoken up about the dramatically low level.

When a person is intubated, these are the following checks that happen to ensure the tube is in the right place.

1. Does the chest rise and fall equally. In this patient’s case, the right side of the chest would not have risen that much if several ribs were broken and the lung was deflated which should prompt the doctor to do number two on this list.

2. Are the breath sounds equal? The patient’s lungs are auscultated (listened to with a stethoscope) to determine this. They should be equal. If not, then there is a problem with that patient’s lung (one is deflated, etc) or the tube is in the wrong position. At that point, the tube could have been adjust. If the patient’s breath sounds were severely diminished on the right side (especially after trauma) then a need decompression should have been done on that side as a rescue measure to try and reinflate the lung some.

3. Are the patient’s vital signs improving? This would be primarily the oxygen level. It can take a few second to a few minutes for the patient’s oxygen levels to reach normal but they should improve. If not, then something is wrong with the tube and it should be evaluated.

4. Is there the presence of carbon dioxide measured as end tidal CO2? There are quick measure devices in the field to check that carbon dioxide is coming up through the tube. This also ensure the tube is in the right place. In the hospital setting, we will watch this number continuously.

5. Ultimately, in the hospital setting, an x-ray is done to confirm proper placement in the field but if the above items or done, the tube (or endotracheal tube in this case) should be in the right position.

If the EMS crew would have spoken up and/or if all three of the crew members had been performing their job correctly by monitoring the patient’s oxygen levels (which is a very basic thing to be monitoring) then this patient’s death could have been prevented.

It’s up to every member of the healthcare team to ensure patient safety.

Author Question: Unconscious Teen Struck in Head by Baseball Bat

Ari Asks:

Hello and thank you for this blog. It’s a brilliant resource and I’m grateful to have the opportunity to reach out to a professional in this setting.

I have two scenarios in a novel I’m writing that I could use your help with.

First, a teenage boy is struck in the head with a baseball bat. He is knocked unconscious and falls into a coma. When he arrives in the ER, I would like some compelling dialogue between the first responders to convey his condition, rather than just typing it out in the slug lines. What are some of the measures that nurses and/or doctors would take in responding to this injury? Also, what type of jargon or verbiage would make this scene convincing to someone in the field?

Second, is the scenario where the doctor informs the parents of the same boy about his condition. In what setting would he/she do this? Or for that matter, who would be the person to inform the parents to begin with?

Thank you for taking the time to help writers do your profession justice.

Jordyn Says:

Hi, Ari. Thanks for reaching out and all your compliments regarding the blog. I’m glad you’ve found it helpful.

Typically, when a patient arrives to the ER via EMS, they give a report on their patient when they get to the assigned room. In this case, it might be something like this:

“This is John Doe, age 17, struck in the head with a baseball bat at 1600 today. Pt with immediate LOC (loss of consciousness). Was unconscious upon our arrival. Responds only to pain. We started an IV, drew labs, and started normal saline TKO (to keep vein open). His Glasgow Coma Score is eight (this is bad). Vitals signs are as follows: Heart rate 100. BP 124/62. Respirations 16. Pulse ox 100% on 100% non-rebreather. Parents are here. No chronic illnesses. No drug allergies.” 

The ER team will place him on a monitor, assess the status of his IV, and do a thorough physical exam of the patient including an extensive neurological exam. I would follow the link above and do some reading on the Glasgow Coma Scale and how it’s scored.

A Glasgow coma score of eight or less will likely lead to the patient being intubated because there is concern that he would not be able to maintain his airway.

Taking into consideration this patient’s mechanism of injury and the fact that he is unconscious, he would receive an expedited CT scan of his brain to look for injury— likely bleeding in this case.

Past this, it would be hard for me to talk to you about all the things the medical team would say. It’s your scene. If it is a compelling scene in the novel, I’d have a medical person review it.

Keep in mind the POV character you’re writing the scene from. If it comes from a medical person’s perspective, then the use of technical terms, etc is more warranted because they should sound like they know what they’re talking about. If the scene is from a lay person’s POV— then you can write more generally about the medical things being done.

Who informs the parents about their son’s condition? These days, parents are generally not separated from their child, even in instances where the child has lost their heartbeat. The parents likely followed the ambulance and would be updated upon arrival in the patient’s room. A nurse or a doctor can update the parents and give them the medical plan of care as outlined by the physician.

Hope this helps and happy writing!

Author Question: Pediatric Fall From Skateboard

Carol Asks:

A four-year-old falls off a moving skateboard onto a driveway (no helmet, or pads.) Someone was doing something he wasn’t supposed to do.

This is what I’m proposing happens to this child.

Result: Greenstick fracture in one of the bones of the forearm and possible concussion?

Treatment: Cast in ER and keep overnight for observation? Possible sedatives or stronger meds (like codeine) for pain that may make her sleepy?

Follow: Specialist?

Jordyn Says:

Thanks, Carol, for sending me your question.

I’ll answer in the same way you sent your scenario to me with my opinion.

Result: Yes, greenstick fracture is good. You can hit the link for further information. However, we don’t use this term (as least not in Colorado.) We say “buckle fracture” as in the bone buckles or squishes a little. Bones in this age group are very pliable. This is a very common fracture in kids. The fracture is not a line crack through the bone. Concussion, yes. And you’re right– this kid needs a helmet on!

Treatment:

Splint in the ER. Casting is rare in the emergency department. The difference between the two is a splint only has hardening material on one side and is secured in place by an ace wrap. This leaves space for the injury to swell and can limit the potential for developing compartment syndrome— though that would be rare for this type of fracture. Casting has circumferential hardening material— usually something like fiberglass sheeting that hardens. Also, some providers are just placing a removable type wrist splint on these fractures since they are very stable and the child will usually self limit activities until the pain goes away.

I’m going to assume your child/character has a mild concussion. No loss of consciousness. No amnesia. Maybe a headache, nausea, dizziness, etc. We would not give any sedative or narcotics to this patient— for the concussion nor for the fracture.

Ibuprofen is the preferred drug of choice for the fracture and even for the headache that might be associated with the concussion. Some providers are against ibuprofen in concussion because of a concern for increased bleeding (ibuprofen makes platelets less sticky), but that’s with multiple dosing. We give Ibuprofen often to kids with head injuries and they do fine. Acetaminophen can be given for headache and it will help with pain from the fracture, but it will do little to help the swelling of the fracture. This is why ibuprofen is preferred for broken bones because it helps with both pain and swelling.

Assuming this child has a normal neuro exam and is at their normal neurological baseline (meaning, they are acting as they normally do at home)— then they would be sent home. There is no reason to obs this kid overnight.

Follow up: With orthopedics in 7-10 days for reevaluation of the fracture with cast placement. Cast would be on for 4-6 weeks.

Hope this help and good luck with this story.

Traumatic Brain Injuries: Initial Treatment

Last post, I have a primer on traumatic brain injuries (TBI) that you can find here. Today, I thought I’d give an overview of the treatment guidelines.

Remember, the basis of treating TBI is manipulation of the three components within the skull: the brain, the blood, or the cerebrospinal fluid (CSF). Additionally, sometimes a portion of the skull is removed.

1. Manipulating Brain Tissue.

Removing brain tissue is an option and may be done to tissue that has died. Recovery of the patient is dramatically influenced by what part of the brain was removed.

Another management strategy is to put the brain at rest by placing the patient in a medically induced coma. Medication is used to heavily sedate the patient. Typically, the patient is on continuous EEG monitoring to ensure a minimal amount of brain activity is present. The purpose of the coma is to reduce the metabolic demands of the brain in hopes of keeping swelling down and allowing the brain time to heal.

Additionally a diuretic, either hypertonic saline or Mannitol, can be given to draw water out of swollen brain cells.

2. Manipulating Blood Flow.

This can entail a couple of areas. Remove blood that has collected in the brain. Sometimes when the brain is injured, blood vessels within the brain are ripped open. Two types of bleeding can occur between the brain and the skull: a subdural or epidural hematoma. A subdural hematoma occurs from veins. An epidural hematoma occurs from an artery. Depending on the size of the hematoma, a neurosurgeon may choose to operate and remove it. Sometimes bleeding occurs within brain tissue. This type of bleeding can be small and more diffuse. Although a risk for the patient it may not be an option to surgically remove it.

Another way to change blood flow is to manipulate the size of the blood vessels inside the patient’s head. This can be done by increasing the rate of the patient’s breathing on the ventilator thereby decreasing their blood level of carbon dioxide. When this level is lower, the blood vessels inside the patient’s brain shrink in diameter. This therapy is controversial and if done, only a mild drop in carbon dioxide levels is the goal.

Lastly, the blood pressure can be manipulated. A certain blood pressure or blood flow to the brain must be maintained in order to keep the brain alive. This is called the cerebral perfusion pressure (CPP) and is calculated by using the patient’s blood pressure and their intracranial pressure (ICP). Reducing the blood pressure is an option but you must maintain the cerebral perfusion pressure as well. This can be a challenging balancing act.

3. Manipulating Cerebrospinal Fluid (CSF)

A drain is placed to remove excess cerebrospinal fluid.

4. Removing a Portion of the Skull.

This is a viable option for management of brain swelling. A portion of the skull is removed (hemicraniectomy) to allow the brain room to swell. The portion of the skull that is removed is preserved by freezing so that is can be reattached at a later point once the swelling has eased.

Have you had a character in your novel with a traumatic brain injury? If so, what type and why did you choose it?

***Reposted from January 19, 2011.***

Traumatic Brain Injuries: A Primer

The brain is our most complex organ and perhaps the most difficult to help heal. The biggest challenge is its protective covering: the skull. Management of acute traumatic brain injury, or TBI, typically involves manipulating the three components within the skull: the brain, the blood, and the cerebrospinal fluid (CSF).

What is the purpose of each of these components? The brain is the body’s supercomputer. The blood delivers oxygen and nutrients to feed the cells or neurons. The CSF nourishes the brain, helps remove waste products, and keeps the brain buoyant.

What happens when something is significantly injured? It swells. Think about a time you saw someone with a really bad sprained ankle. What happened? It blew up like a balloon. The same thing happens to the brain with a traumatic injury. It swells.

Unlike an ankle, brain swelling is inhibited by the skull but the pressure inside the head can continue to rise if swelling is unchecked. Too much pressure inside the skull (it can’t move) and blood flow diminishes, thereby starving cells of oxygen, which then swell more.

We can measure the pressure inside your skull, or intracranial pressure (ICP), by placing a sensor into a ventricle (a ventriculostomy).  A normal ICP is 7-15mmHg. Cerebral edema can be insidious as swelling peaks 48-72 hours post injury. A patient can initially present following commands. Then in 2-3 days, develop cerebral edema to the point of herniation (which means brain contents shifting) and die.

What happens when a patient develops significant cerebral edema and ICP pressures skyrocket?

First bad thing: Blood flow is reduced. The brain is very sensitive to blood flow and greedy for oxygen. If there is diminished blood flow, neurons (brain cells) begin to die. If there is no blood flow, the brain will die. You may have heard the term brain death. This is determined by several factors but the definitive one is by taking the patient to radiology and doing a brain flow study. Roughly, a dye is injected into the blood and x-rays are taken. If there is no blood flow, the patient is declared brain dead.

Second bad thing: Brain contents shift into areas where they’re not supposed to be. This is called herniation. When neurons are compressed, they don’t function properly and will begin to die as well. When brain cells die, machines and medications have to take over their function to keep the patient alive.

Unfortunately, if brain death has occurred, the medical team will start discussing withdrawal of care with the family.

***Content reposted from January, 12, 2011.***