Rehab

Author Question: Medical Condition for Elderly Man to become Comatose

/ Jordyn Redwood / 2 Comments

Amanda Asks:

I have an elderly character who is about 90-years-old. As things stand, he is very sharp mentally and physically and fairly strong for his age. The story needs are for him to be in a coma, whether natural or medically induced, for several weeks.

My question is, is there a cause or condition that would make this plausible at his age, that he could still awake from when it’s time for him to re-enter the story? I did some preliminary poking around and it seems like medically-induced comas are less common in the elderly. What might happen to him to put him in such a state (naturally or medically), that he could still awake from?

It could be anything at all for the story. I just don’t know what’s feasible and what’s not. And how long can he be in the unconscious state before it becomes too unrealistic?

Jordyn Says:

Lots of things can cause someone to be in a coma caused by direct injury to the brain or something that would cause lack of oxygen to the brain.

One thing that is quite common in the elderly is a subdural hemotoma. Sometimes, if the clot is big enough, it will cause pressure and swelling on the brain enough to induce a coma. Usually, surgery would be used to drain a blood collection like this. One of the most common causes of a subdural hematoma in the elderly is a fall where they strike their head. As we age, our blood vessels become more fragile. If your character was also on a blood thinner for any reason— this would increase his risk for bleeding and potentially the size of the blood clot.

Any significant, direct injury to the brain can cause coma. A serious car accident. Falling off a ladder onto your head. Etc.

More medical causes, particularly in his age group, could be a stroke or a heart attack. A stroke causing a coma might be hard to write. In real life, it has a high mortality rate. Not to say it’s impossible but any direct injury in the brain (either through blood bleeding where it shouldn’t or the brain dying because of lack of oxygen causing death of brain tissue) is going to be hard to overcome with a mentally intact patient on the other end.

A heart attack, where he was deprived of oxygen for a period of time, could cause coma. Generally, over four minutes of down time without resusitative efforts is getting into the brain death arena. Even patients who are revived after four minutes will typically have brain death or proceed there. Of course, there are always outliers.

However, even a patient who gets immediate resuscitation (CPR at the least) can still proceed to coma once a pulse and good blood pressure are reestablished.

If I were you, I would pick either a subdural hematoma or a heart attack. I think this will be more likely to preserve the mental state of your character. If the heart attack, I would have it be a very short down time before he is treated and gets his pulse back.

Comas are very hard to write into stories. The length of time is up to you— that happens in real life. A coma of 1-2 weeks for these situations might be a little on the outside but possible.

The problem with a character in a coma for a lengthy period is that normal bodily functions must be tended to. We have to maintain the body functioning as close to how it does when we’re awake. So, the patient must be fed (either through a nasal, oral, or surgically implanted feeding tube). The character will still need to pee and poop— so a catheter can be placed to drain urine. We generally don’t like catheters to stay in long term because it increases the risk of infection for the patient and the elderly are more at risk for this.

Also, a patient in a coma is likely going to need ventilatory assistance and if they are on a vent over 7-10 days then generally there will be talk of putting in a trach.

The longer the coma, the more rehab a person will need. Even if in a coma for 1-2 weeks, the amount of generalized muscle atrophy will be significant. A character who is a 90 y/o who awakens from a coma after being bedridden for 1-2 weeks would probably go to inpatient rehab for several weeks/months and then outpatient rehab for a couple of months– and that might be underestimating. It’s just hard to recover from these types of injures as we age.

Hope this helps and best of luck with your story!

Author Question: Long Term Coma

/ Jordyn Redwood / Leave a comment

Tina Asks:

I’m a self-published author who has written two books from a YA fantasy series (The Arid Kingdom) and am now working now on a modern fantasy action novel.

I’d be really grateful if you could help me with some medical advice regarding this scene:

There is an accident during a concert. A girl who was singing on the stage has her head hit by a stage lamp. She falls unconscious and remains so for eight months.

Questions:
1. Some other character with an open injury (a dagger injury) will be in the same hospital. Will they be in the same ward?
2. After she wakes up, will she have some memory problems?
3. I expect her to have some mobility issues after staying in a lying position for such a long time, like she’ll have to learn to walk again. Will her arms present similar issues?
4. How long does the recovery stage last and how is that done?

Jordyn Says:

Let’s first tackle the character who is in a coma for eight months.

What a lot of authors don’t consider is that humans eat, poop, and pee so all of these things need to be provided for in the unconscious person. If she has perpetual unconsciousness, she would need to be fed by a tube. Also, she’ll still need to poop and pee and since she can’t walk to the bathroom then she’d be placed in an adult diaper (or a catheter placed for urine drainage especially in the beginning). There are other things medically we consider in a perpetually unconscious person– most importantly– can they breathe adequately. Some can, but most end up with a trach.

When she wakes up, will she have some memory problems? You have some latitude here as a writer. Could go either way. She’ll probably be fuzzy until she figures out what happened but as far as her retaining her past experiences/memories you can decide.

This character would have whole body muscle atrophy from being bedridden for eight months. So yes, arms will be weak as well. She would be easily fatigued. Even something basic like brushing her teeth will be taxing.

Once she does wake up and is considered stable, she would be transferred to a rehab center and then transitioned to outpatient therapy. How fast and well a person does in rehab can be largely up to them. If she works hard, has a positive spirit, etc she could progress quickly if she has no other injuries. However, considering her length of unconsciousness, I’d imagine rehab would take months. Maybe eight weeks on the short side. I consulted with a physical therapist on this and he agrees. Could easily be longer. Two to four months as a range.

The character with the dagger injury would likely not be on the same ward. The unconscious person would likely initially be admitted to the ICU. The dagger injury, could even go home if not surgical. If surgical– then a regular surgical floor unless extenuating circumstances required ICU admission. Depending on the hospital, some ICU’s are split between medical and surgical.

Hope this helps and best of luck with your novel.

Treatment of Car Accident Victim with a Brain Injury

/ Jordyn Redwood / Leave a comment

Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!

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

/ Jordyn Redwood / Leave a comment

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!