Cuts on the inner forearm

Posted on March 11, 2009 by arizela

A question recently hit my in-box from an author who has a character being tortured for information. In the scenario, the author intended to have the protagonist “stabbed on the inside of his forearm and the knife gets dragged through the flesh towards the wrist a couple of inches.” The protagonist needs to be worried, but able to walk a good distance and not pass out or die from shock.

The trouble with using a knife as a torture device is that unless the torturer is very skilled at what he does and knows anatomy very well, he’s as likely to kill as extract information. In this particular case, there are two decent sized arteries running along the inside of the forearm, the radial and ulnar arteries (see photo). Stabbing down into the flesh and dragging the blade toward the wrist is almost sure to hit at least one of them.

Slashed wrists is a common method of attempted suicide which is widely known to not be terribly effective because by the time the artery gets to the wrist, it’s pretty small. It can take hours to bleed to death from a slashed wrist, but cut the artery higher up the arm and you’ve got bigger problems. Shock can set in pretty quickly – my best guess being within ten minutes. And after that, you’ve got some time to stabilize the victim, but he’s not going to be doing much to help you as he will likely be unconscious or too confused to function.

If your victim gets away within minutes of the cut and applies pressure directly to the wound and then gets help, chances are good with surgery and perhaps blood transfusions that the victim will live.

If you want a lot of pain, an alarming amount of blood but not truly immediately dangerous, you could go with any major muscle group that isn’t near a major artery. Muscle bleeds a lot. Some locations that are pretty choice, the calf muscle, the muscles of the outer forearm, the top of the thigh or outer thigh area, the shoulder. Think meaty parts that aren’t near pulse-points. The muscle will likely stop working for a while, but with some stitches will generally heal up pretty well.

Alternately, cuts that bleed an alarming amount, hurt a lot, and are generally unlikely to cause death are cuts to the ears, scalp or forehead. Try not freaking out when someone slashes you across the forehead and there’s blood running into your eyes.

*****This blog is written for fiction writers, for the purpose of writing fiction. Information herein is not intended for use by real people, pets, trees, or imaginary friends. Arizela is not responsible for information used for purposes other than those expressly intended*****

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Rib Injuries

Posted on January 26, 2009 by arizela

Question: What are the differences, symptoms, severity, and complications of rib injuries, and how much do they hurt?

Ah, ribs. Those grand old things that protect all your most vital organs. What lay-people generally think of as a ribcage aren’t just bones though. They are actually composed of twelve bones on either side of the chest, plus thick, tough cartilage (like in your nose, only stronger), and the sternum (breastbone). All 24 long, curved rib bones attach to the spinal column in the back (backbone), but in the front, only some of them are attached at all. The top seven on either side are attached to costal cartilage which attaches directly to the sternum. The next three pair are attached to costal cartilage which attaches to another cartilage rather than the breastbone, and the bottom two pairs, called “floating ribs” don’t attach in the front at all.

In the above computer modeled ribcage photo, the white areas indicate bone and the golden-yellow areas are costal cartilage. The area circled in pink is a small tip of bone called the xyphoid process, which can be broken off pretty easily. In a living body, there would also be muscles called intercostal muscles in between each long rib bone to connect each bone to the one above or below it.

Types of Injuries

There are three basic types of injuries that can happen to the ribs: Fractured or broken bones, bruised bones, and torn cartilage. “Cracked” ribs are broken ribs – there is NO difference between cracked and broken ribs, however breaks can have varying severity – anything from a little “crack” to a complete break across the entire thickness of the bone. The symptoms for all three are going to be pretty much identical.

  • Pain, especially when taking deep breaths, coughing, laughing, bending, twisting, lifting weight, or pressing over the injured area.
  • Possibly bruising over the injured area
  • Crunching or grinding noises or sensations with movement
  • Actual deformities in the shape of the chest over the injured area (a dent, basically)
  • Difficulty breathing (either from the pain or as a complication of a fracture – see below)

How do rib injuries occur?

Anything that causes a trauma to the chest can injure the ribs. Contact sports, fighting, car crashes, and CPR are some of the most common causes of damaged ribs. I once had a doc tell me that if you’re doing CPR chest compressions and you DON’T feel ribs breaking, you aren’t doing it right. While not a really good rule of thumb, it is true that CPR chest compressions often result in broken ribs, especially in the elderly and small children. It is important not to be afraid of breaking ribs though, when doing CPR. Most people would rather be alive to complain about the rib pain later.

How are they treated?

In modern medicine, all three injuries are basically treated the same way:

  • Rest – avoid anything that makes the area hurt, except breathing.
  • Ice, on for 10-20 minute and off for 20-30 minutes. Rinse and repeat.
  • Over the counter pain medications – preferably in the NSAID (non-steroidal anti-inflammatory drug) class such as aspirin or ibuprofen because these drugs treat inflammation/swelling as well as pain, unlike tylenol(acetaminophen)
  • Deep breathing exercises to prevent pneumonia if breathing is troublesome.

In days past, docs used to apply rib splints or compression dressings (think ace wrap) to help “support” the ribs and prevent them from moving around too much. This decreased the amount of pain associated with breathing and coughing and whatnot, but in turn significantly increased the risk of pneumonia and death as complications. Oops.

We don’t do that so much anymore, although applying some firm, consistent pressure with a hand over the injured area only when coughing or sneezing, or doing something else short term that causes increased pain can be effective at decreasing pain. These days compression dressings and splints are only used in cases that are VERY severe.

What nasty little surprises can my characters expect me to spring on them down the road?

Ah, complications. They do make a story interesting. The complications of rib injuries are going to vary by the injury a bit.

  • Pneumonia – All three types of injury can cause significant pain with breathing, encouraging the person to take very shallow breaths. If the person keeps this up for a few days or a couple of weeks, chances are good that the person is going to regret it later, in the form of a solid case of pneumonia. The lungs produce mucous constantly. Kind of ichy, but there’s a good reason for it. Germs, dust, and other nasty things that shouldn’t find a home inside your lungs get trapped in the mucous and coughed up. If you don’t take breaths that fill your whole lungs up with air, over time the mucous can thicken up and “collapse” the air sacs inside the lungs, along with their collected germs. Viola, pneumonia. Symptoms of pneumonia include fever, chills, coughing up stuff from deep in the lungs(usually yellow, tan or green in color), wheezing, and difficulty breathing. If not treated or overcome by the body’s natural immune abilities, pneumonia can quickly lead to blood stream infections (sepsis), shock, and death. Or it can linger around for a long time and cause a gradual worsening or leave permanent damage (short breath, wheezing).
  • Punctured lung – this is usually going to show up pretty quickly and only in severely broken ribs (think massive trauma to the chest, like smashing against a steering wheel while not wearing a seatbelt in a 50mph car crash). The space between the injured lung and the ribs will fill up with blood(hemothorax) or air (pneumothorax), squishing the lungs over in the process and making it harder and harder to breath. If there is air moving from the lung into the space, the lungs and eventually the heart will get smooshed over to one side (away from the injury) until they can’t expand anymore and the person basically suffocates and the heart can’t refill with blood to pump anymore. This is called a tension pneumothorax and MUST be treated immediately.

This illustration depicts the insertion of a chest tub, a flexible tube that is placed into the space that fills up with stuff to allow the blood or air to drain back out. Just sticking a tube into the wound isn’t going to help much though. Chest tubes use basic principles of pressure differentials to “seal” the tube so air and blood can leak OUT but air and germs can’t get back IN.

All this scientific stuff is neat, but how does it FEEL?

Speaking from experience, broken ribs HURT. And by hurt, I mean it sort of feels like someone is sticking a high-heeled shoe straight into your lungs and giving it a little twist. That said, it is certainly possible to battle through the pain, especially when the injury is fresh and all those endorphins (brain chemicals that tell your brain to ignore pain) and adrenaline are sloshing around inside you. I personally took three good swings with a baseball bat at the jackass who broke two of my ribs before the pain hit. (He was much bigger and stronger than me. The bat evened things out nicely) After the pain hit, I did a lot of walking humped over, holding my side, and generally being miserable for a couple of months. Life went on.

How long does it take to recover?

Bruised ribs and torn cartilage usually take 3-4 weeks to recover. Fractured bones, 6-8 weeks. However, this rate is GREATLY impacted by numerous factors and the healing can take MUCH longer. This is great news for our intrepid writer, as you can really play with the time factor here. My personal rib injury still gives me significant trouble off and on 15 years later.

Factors that increase time to heal:

  • Old age
  • Osteoporosis or generally weak bones
  • Reinjuring the area (like the folks who continue to play football with cracked or broken ribs)
  • Not resting enough (like that character who’s going to be dodging bullets or swinging swords)
  • Other injuries – the body has limited resources and not all things are equal
  • Nutrition – bones and cartilage require certain components to heal, like calcium and especially protein. Healing will still happen for folks with very poor diets, because the body will rob from other areas eventually, but proper nutrition will help speed healing and prevent infection
  • Infection – infected tissue doesn’t heal. Basically, the body has other things on its mind if it’s trying to put out fires
  • Severity of the injury – a complete break along the full thickness of the bone is going to take longer to heal than a partial fracture. Likewise, multiple rib fractures or multiple torn cartilages will not provide adequate support for each other to heal and may slow the process down a bit

Rib injuries can be a nice way to give your characters unpleasant lives for a while and make things just that much harder on them, but by themselves they aren’t going to keep a determined hero or villain out of action most of the time. They’ll hurt enough to discourage athletics, but those endorphins and adrenaline can work magic even here in the real world.

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Official Cause of Death

Posted on January 19, 2009 by arizela

A question recently hit my inbox about what the official cause of death would be listed as on a death certificate of a person who died of cancer. As I don’t deal much with that end (pun not intended) of the health care spectrum, I did a bit of digging and found out that writing the “cause of death” statement is surprisingly complex and yet also a thing of simple beauty. Ok, so I’m a bit morbid.

A typical cause of death statement might read:

Acute Myocardial Infarct

Now, if you aren’t an MD or a nurse, that might look like a load of gibberish, but really it just says “heart attack”. Simple, right? er… not quite as simple as that. Actual cause of death statements are written in two parts. The purpose of these statements is to allow tracking bodies to develop statistics on diseases and processes that kill people, and the things that put us at greater risk for these conditions. So if a coroner or MD writing a death certificate has more information (ie from medical history or an autopsy), they are going to fill this section in with as much data as possible.

Part I

The purpose of part 1 is to determine the series of medical events that lead up to the death, in reverse order, starting from the most recent condition and working backwards to the oldest relevant condition that lead directly to the death. So that very basic heart attack up there would become something more like heart attack due to hardening of the arteries that feed the heart, or in medical jargon:

Acute myocardial infarct
due to or as a consequence of Athrosclerotic coronary artery disease

As another example, if you had someone die of a pneumonia because they had AIDS, their cause of death statement would look like:

Klebsiella Pneumonia
due to or as a consequence of Acquired Immune Difficiency Syndrome
due to or as a consequence of Human Immunodeficiency Virus infection

If there isn’t a lot of data on what lead up to the death, or if the person was terminally ill from a known disease but there isn’t a way to determine what complication of that terminal disease exactly killed the patient, you can sort of guess or just leave it off. As below:

Acute myocardial Infarct
Due to or as a consequence of Probable Atherosclerotic coronary artery disease

Or simply:

Adenocarcinoma of the prostate

Part II

Part II is to list risk factors that lead to the sequence of events that lead to the death. These can include other diagnoses, like high blood pressure (hypertension) or diabetes (diabetes mellitus type I or type II), or behaviors, like alcohol abuse, IV drug abuse, etc..

Do’s and Don’ts

Don’t report signs or symptoms as the cause of death

So a person cannot be said to have died of a cough, fever, or elevated blood alcohol level. They can die of pneumonia (that caused the cough), or a specific infection (that caused the fever), or alcohol toxicity (with the high blood alcohol level would diagnose, but the blood alcohol level itself is a test, not a diagnosis).

Don’t report mechanistic causes of death

Mechanistic causes of death are the physical process that stopped or failed due to disease or trauma, rather than the disease or trauma itself. As in cardiac arrest caused by a heart attack, or respiratory arrest caused by pneumonia. Other examples of things that shouldn’t be reported in this class include heart arrhythmias like asystole (flat line), or ventricular tachycardia (V-tach, a fatal change to the electrical impulses in the heart. See photo).

Do be specific and exact

Don’t oversimplify or under-report. For instance, a doctor wouldn’t write that high blood pressure killed anybody. High blood pressure may have lead to stroke that killed someone, or it could have lead to hardening of the arteries and a heart attack. It’s better to include too much information rather than too little.

Relevant for fiction?

Depends on your fiction. If you have a doctor or coroner talking about a cause of death, then this statement is going to be very important. Doctors are trained to analyze cause of death in this pattern, and so it’s going to be this pattern that they are most comfortable with when reporting cause of death at trials, to reporters, to family members who want more specifics, etc.. They will also use this basic pattern of understanding to ask for permission to do an autopsy on cases where they don’t understand exactly what progression led to the death. ie “We believe your aunt died of an overwhelming urinary tract infection, but we would like to be sure/we need to understand what caused this infection to be so severe.”

Why is cause of death important?

In my particular line of work, (in a NICU with newborn, premature, and young babies) the official cause of death can be very important. Information like genetic or infectious reasons for the death can help us council families who wish to have more children. Information also needs to be gathered to prove that everything was done as it should have been, that the death was not do to medical error (either ours or the birth hospital’s), or some other process that can be prevented or mitigated in future pregnancies.

Cause of death statements also allow us to track which diseases and problems are killing us, and thereby allow us to work harder on cures, treatments, and solutions to those same diseases and problems. Keeping mortality and morbidity statistics is one of the best ways to start tracking the impact of disease and death. Of course, the cost of disease and death can’t just be measured in death. Quality of life, healthcare costs, the costs to survivors, and other factors must be weighed as well.

Autopsies and how they help us understand death

Autopsies are frequently requested when children or young people die and the exact cause of death was not well understood. Autopsies can be requested by the hospital, the coroner, or the family, though the latter option can be prohibitively expensive for the family. Autopsies can be done even if the deceased was an organ donor.

There are also legal reasons why an autopsy would be required. If there is suspicion of abuse, murder, or death by unnatural causes, the family might not have a say as to whether or not an autopsy takes place. In these cases, cause of death statements must be exact and as complete as possible because they might effect future prosecution. Cause of death statements can be amended if new evidence later comes to light in these situations.

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Hollywood Flub-Ups: The dying breath

Posted on January 18, 2009 by arizela

The dying breath

How many times have you seen that pivotal death sequence, where the character lives just long enough to gasp out his last words of wisdom to the protagonist. Often either giving the answer to the plot all along or one word short of it and frustrating the protag even more? I’ve seen it a few too many to count.

Our Flubber: Serenity (which still manages to be my favorite movie of all time)

Shepard Book has been shot. He’s covered chin to belly button in fake blood. He has time to give Mal (Captain Malcolm Reynolds) all the benefits of his sage advice and swing the plot drastically sideways. Then he keels over and dies mid-sentence following some witty banter and a tear-jerking moment.

The trouble here? Book has a mouth full of blood and is wheezing and coughing. Which means… you guessed it. Lung shot. When the lung is punctured, the space between the lung and the chest wall starts to quickly fill up with air and blood, as the lung itself starts to fill up with blood. The person in question is going to feel like a fish out of water. He won’t die instantly, but he sure won’t be giving any sermons.

On another related note, Book also had one side of his mouth drooping. And since he didn’t have any damage on that side of his face, I’m guessing they were going for a stroke. And I think you can figure out for yourself why that might make the sermon a bit hard to deliver.

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Hollywood Flub-Ups: watering the unconscious

Posted on November 28, 2008 by arizela

In this repeating column, I will explain how Hollywood (and various TV mini-series and shows) get it all too wrong.

Our first culprit: Legend of the Seeker (and yes, I know it sucks. Bare with me here)

The great wizard, Zedd (left), has been struck by an underworld creature and is unconscious. His trusty companions Kahlan and Richard (right) are sitting around worrying about him. Kahlan tilts a canteen of some liquid, presumably water, into Zedd’s mouth while complaining that “his breathing is getting worse.”

OK, OK. I know you don’t have to be a rocket scientist to figure out where they went wrong on this one. People tend to breathe worse when you are drowning them.

For the love of Pete and all his Pete-like friends, please folks, do not have your characters pouring liquids into unconscious companions (unless they are secretly trying to kill said companions). Aspiration pneumonia or drowning is the much more likely outcome of that than oh, keeping the person well hydrated.

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