Author Question: Prioritizing Medical Care

Ethan Asks:

My main character was in a fight. He has a skull fracture with epidural bleed, a dislocated shoulder, and a twisted ankle. He arrives at the hospital unconscious. Would the ER try relocating the shoulder right away or wait for him to regain consciousness first? Just a common anterior shoulder dislocation. Also how? I’ve seen too many videos to know the ‘tried and true’ from a best guess. How would you do it?

Jordyn Says:

For this patient, the neurological injury would take precedence. It doesn’t matter much about his shoulder if he never wakes up. So, if he does have an epidural bleed, that would be the surgical priority. When he’s under anesthesia for the surgery and his epidural bleed has been stabilized, they could relocate the shoulder intra-operatively.

The videos you’ve seen are probably accurate— yanking and pulling a certain way to get the shoulder back in. Sometimes, if the patient is just sedated enough, the shoulder will relocate on its own, but it is more common to have to pull it back in to place.

The only thing that might make them rush with the shoulder is if they felt that the patient wasn’t getting blood flow into his hand on that side. Since he’s unconscious, he really couldn’t say if there were any numbness to that hand that would also be an indicator he might be having trouble with blood flow into the hand.

That being said, I’ve not personally seen neurovascular compromise with a “simple” shoulder dislocation (though I’m sure it does happen on occasion) so precedence would be his head injury.

Author Question: The Perfect Skull Fracture

Ethan Asks:

I’m looking for the Goldilocks of skull fractures. My main character is a college age male that got into a fight. I’ve tried doing my own research but I’m second-guessing myself on which part of the skull to hit. I’m looking for a crack (not a shatter), minimal blood loss, he stays conscious for ten minutes or so, and a hospital stay of about five to seven days. I’m guessing there’s no way to avoid a concussion, as long as there’s no permanent brain damage I can work with it. Is such a skull fracture possible? If so, where on the skull?

Jordyn Says:

Yes, there is such a skull fracture that I think would fit your scenario perfectly.

In a small amount of cases, patients who receive an injury to the side of their head causing a fracture of the temporal bone can tear their middle meningeal artery causing an epidural bleed.

An epidural bleed/hematoma is considered a neurological emergency. Most of these patients will require surgery to save their lives. With epidural hematomas, the patient can have an initial loss of consciousness followed by a distinctive lucid period, and then worsening neurological status after that.

This article gives a nice overview of the condition and treatment for epidural hematomas. Also, this is a good article as well.

Hope this helps and best of luck with your story!