Body Trauma

A Writer's Guide to Wounds and Injuries

David W. Page

• Publisher: Behler Publications
• Year: 2006
• Print ISBN: 9781933016412
• eBook ISBN: 9781933016689
• Topic: Personal Development
• Subtopic: Writing & Presentation Skills

Body Trauma explains what happens to body organs and bones maimed by accident or intent and the small window of opportunity for emergency treatment. Research what happens in a hospital operating room and the personnel who initiate treatment. Use these facts to bring added realism to your stories and novels.

PART I

An Overview of
Trauma

ONE

CONCEPTS AND TERMINOLOGY IN TRAUMA CARE

Injuries occur for a reason.

Before entering the world of trauma, you need to know a few basic terms. If you understand simple mechanisms of injury causation, this part of modern medicine and its funny-sounding verbiage will be easier to grasp. For your story to sound authentic, you need to know what you're talking about.

Trauma refers to the physical wounds and innumerable body insults that result from direct or indirect contact with something in the environment. In the chaotic history of medicine, surgeons became the specialists who assumed the task of managing traumatic wounds, treating terrible numbers of war casualties from the numerous conflicts that seeded every century. With time, weaponry became more sophisticated, more destructive. Nonetheless, even the rock hatchets, spears, darts and arrows of primitive humans were deadly, and the injuries horrible.

Warriors wear scars with pride, and one wonders if physical conflict is our species’ norm. In humankind's history, it seems quite possible that intentional wounding has been more frequent than the occurrence of unanticipated trauma. A cursory examination of man's warring history reveals repeated, massive conflicts in which large numbers of warriors became wounded. Many died. But many survived their injuries to fight again. Scientists refer to an animal's (including man's) response to confrontation as the “fight or flight” reaction, the choice presumably determined by recognition of the odds. Man has a poor track record of avoiding the odds of sustaining traumatic injuries.

Traumatic events can thus be accidental or intentional. Some injuries are more repugnant precisely because the assault is premeditated, an attack designed to hurt another person. But even so-called accidents may be more a matter of inattention and risk taking than of pure chance.

For the writer, the introduction of any form of body damage into a sordid tale increases suspense and introduces an element of uncertainty. Plot possibilities emerge from the doubt born of disaster and from the character's back-story—for example, the compulsion to practice risky behavior. On the other hand, some folks are so preoccupied with problems of daily living they become distracted and are therefore accident-prone. In this book, we look at accidents as well as injuries that result from being in a hostile environment.

Why Do Accidents Occur?

For a moment, let's consider real accidents. This term implies a traumatic episode occurred that could not have been anticipated and therefore is not the consequence of an expected series of events. The accident produced an unexpected outcome because it occurred suddenly, created alarm, and resulted in injury.

A true accident can't be avoided. Why do accidents occur? Two reasons why accidental events occur are sudden, unexpected changes in:

1. A person

2. The environment

Consider the elements of a typical automobile accident. Available data indicates that most accidents occur on the weekend and at night. Young people who consume alcohol are involved in the majority of car crashes. The person components that result in so-called “accidental” automobile mishaps include:

• Inebriation or drug abuse

• Distraction by others in the car

• Excessive speed

• Risky maneuvers, such as passing or bumper hugging

• Falling asleep at the wheel

• Anger, rage, depression, anxiety that cause preoccupation and failure to pay attention to driving chores

• Inadequate driver training

• Visual or motor skill impairment, as in some elderly drivers

Environmental factors also contribute to car crashes and may include one or a combination of the following:

• Poor road construction

• Poor road conditions, e.g., rain, snow, ice or fog

• Excessive traffic

• Lack of familiarity with road

• Abusive drivers, e.g., risky passing behavior or startling another driver with high beams

Defective car parts, such as brakes, windshield wipers, or engine components, may compound these factors. Also, an impact may involve a poorly designed car. Failure to wear a seat belt and failure or absence of an air bag makes the impact all the more dangerous.

Therefore, an accident may be viewed in general terms as an unexpected event that occurs because of the linkage of a series of related factors:

• Distraction (inattention to the task at hand)

• Lack of training with specific equipment

• Lack of motor skills (inferior innate talent)

• Cavalier attitude toward dangerous equipment

• Ignorance about potential dangers with specific equipment

• Poorly maintained equipment

• Effect of aging or disease on person's mobility, reasoning ability and perception

The terms described next are used in the assessment and care of the trauma patient.

Assault includes both physical and verbal attacks on another person. A character's interpersonal relationships and background will contribute to which element is most often employed in relationships. Verbal abuse may be more subtle, frightening and chronic than outright fisticuffs.

Domestic violence, including elder abuse, child abuse, spouse abuse, and rape, involves the most violent of crimes and produces many of the most despicable injuries. These will be covered in detail in Part III.

Self-mutilation is a fascinating topic that implies a purposeful alteration in self-image. We'll merely nudge this topic in our discussion. What happens to self-image? Why tattoos? Scars?

Mortality refers to death. The mortality rate in a given circumstance means how many people died. It's the death rate for a specific medical procedure or life event.

Morbidity, on the other hand, refers to injury. It's the meat of this book. The accidental event itself has a morbidity rate, as does the surgery performed to fix the broken body. Each event has a potentially poor outcome—things that can go wrong because of uncontrolled trauma or despite controlled surgery.

Some things just happen.

Emergency Management

The events that surround the management of major accidents are divided into the sequential events that are part of trauma care.

Extrication: This is the removal of the victim from the scene. It may involve using the “jaws of life” to get someone out of a car wreck, removing a victim from a mountaintop or a deep ravine or bringing a child up from a well shaft.

Transportation of the patient: Three methods of transportation are available for trauma victims and are dependent upon the distance from site of injury to the nearest available appropriate acute care facility.

1. Ambulance—up to about 50 miles

2. Helicopter—about 50 to 100 miles

3. Fixed wing aircraft—about 100 to 300+ miles

Helicopters and fixed wing aircraft provide rapid transport for victims who are only marginally stable and who must reach expert trauma care for specialty surgical care.

Resuscitation equipment is available in all transport vehicles. The most important principle in patient transport is to deliver the victim quickly and safely to the nearest appropriate hospital. A contingency plan for foul weather is needed.

Dead victims don't enter the Emergency Medical System (EMS) but must be taken to the proper facility as directed by the coroner or medical examiner.

Transfer of Patients: This refers to the transfer of a patient from one trauma center to another of a more sophisticated level (see “Levels of Trauma Care” on page 14). Criteria for considering early transport of the injured victim are summarized in Figure 1. An example of a transfer sheet is included in Figure 2.

The trauma victim's illness severity is calculated from vital signs, specific lab tests and other variables. Each patient is assigned what is called the revised trauma score. It gives an estimate of survival potential and consists of:

• Respiratory status

• Cardiac status (blood pressure, pulse, etc.)

• Glasgow Coma Score (see Chapter Five)

Not only does this derived number permit the trauma surgeon to predict outcome, it also gives an estimate of the patient's potential for developing major complications.

A paramedic, doctor, or layperson caring for a trauma victim must recognize where in the following sequence they have entered the continuum of trauma management:

• Assess the extent and type of injuries

• Stabilize the victim/patient

• Prepare for definitive treatment or transfer to another hospital

In the paramedic's case, the initial transportation is to the closest local hospital or to a regional trauma center, depending on the circumstances. If a smaller hospital doesn't have surgeons who are able to care for these patients either through close monitoring in the intensive care unit or by operating on them, then the patient must be transferred.

Figure 1 – High-Risk Criteria for
Consideration of Early Transfer

(These guidelines are not intended to be hospital-specific.)

Central Nervous System

• Head injury

—Penetrating injury or open fracture (with or without cerebrospinal fluid leak)

—Depressed skull facture

—Glasgow Coma Scale (GCS) 14 or GCS deterioration

—Lateralizing signs

• Spinal cord injury

—Spinal column injury or major vertebral injury

Chest

• Major chest wall injury

• Wide mediastinum or other signs suggesting great vessel injury

• Cardiac injury

• Patients who may require prolonged ventilation

Pelvis

• Unstable pelvic ring disruption

• Unstable pelvic fracture with shock or other evidence of continuing hemorrhage

• Open pelvic injury

Major Extremity Injuries

• Fracture/dislocation with loss of distal pulses

• Open long-bone fractures

• Extremity ischemia

Multiple-System Injury

• Head injury combined with face, chest, abdominal or pelvic injury

• Burns with associated injuries

• Multiple long-bone fractures

• Injury to more than two body regions

Comorbid Factors

• Age >55 years

• Children

• Cardiac or respiratory disease

• Insulin-dependent diabetes, morbid obesity

• Pregnancy

• Immunosuppression

Secondary Deterioration (late Sequelae)

• Mechanical ventilation required

• Sepsis

• Single or multiple organ system failure (deterioration in central nervous, cardiac, pulmonary, hepatic, renal or coagulation systems)

• Major tissue necrosis

Making a decision to transfer a patient occurs as the doctor quickly assesses the patient in the ER trauma room. It's not just a matter of the surgeon's time. It's also a question of the local capabilities and limitations. Will the care of one complicated patient consume most of a limited ICU staff's time?

If the d...

Table of contents

• Cover Page
• Title Page
• Copyright
• Dedication
• Preface to the Second Edition
• Foreword
• Acknowledgments
• Table of Contents
• Introduction
• Part I: An Overview of Trauma
• Part II: Specific Traumatic Injuries By Organ System
• Part III: Unique Traumatic Injuries
• Appendix I
• Appendix II
• Bibliography
• Glossary
• Index