by David Page
You have your hero feel the upper notch of the larynx (Adam's apple) and slide the finger down the cartilage until the second notch, a depression actually, is felt. That's where your character cuts horizontally across the neck skin and muscles, right through a tough membrane into the windpipe. The procedure is called a cricothyrotomy. A blast of air spews bloody froth all over your character when the trachea is entered, unless of course your wimpy character reaches the deep membrane with a Swiss Army knife and hesitates, fearful of slicing a jugular, unable to complete the job.
A Breath of Life
If the victim's chest isn't moving when the airway is cleared, or if he's unconscious, you've got to breathe for him. B is for breathing. What's needed is a portable respirator with a good tidal volume (the amount of air exchanged in the lungs with each breath), a ventilator that's immediately available, reliable and with an extended energy source. It means your character must perform mouth-to-mouth or mouth-to-tube respiration. A lot of issues arise in this era of infectious diseases, especially hepatitis and AIDS. Of course, we've still got the old favorites such as tuberculosis. The argument about a person's duty to risk self-harm in the emergent setting becomes distressingly philosophical if the victim is seriously injured and you're the only life-preserving agent in sight.
Conflict? You bet.
Most hotels, recreational facilities and other public places have first aid kits, and some have more advanced equipment including an Ambu bag and face mask. If available, this setup can be used to ventilate the victim. One person can hold the mask over the face and pump the bag, but it's quite difficult. Two helpers can share the task with more efficiency. Oxygen, if available, may be attached to the bag system.
Maintain Circulation
Circulation is best preserved by stopping blood loss as well as by giving the victim fluids by mouth. Most folks don't carry IV equipment with them. Force-feeding liquids may not be as dramatic as IV resuscitation, but in the field, it's all you've got. You may also elevate the victim's legs.
This serves to autotransfuse the person's own blood from the periphery of the body to the central heart-lung core where it's needed. This works for mild to moderate bleeding.
The best way to stop bleeding is by applying direct pressure to the hemorrhaging point. With an understanding of the distribution of arteries and veins in the body, you can apply pressure effectively in a number of settings. Bleeding can occur in the following ways:
• From the head—face and scalp
• From the neck—anterior wounds (where the jugulars and carotids live) are more dangerous than posterior
• From the chest wall or into the chest (hidden cause of shock)
• From the abdominal wall or hidden in the belly—again, shock?
• From the flank or back
• Deep inside the pelvis
• From the arms and legs
Hemorrhage from flat surfaces such as the chest wall, flank, belly, back or scalp responds to direct pressure held for several minutes. If small arteries or veins are responsible, the bleeding will stop with pressure alone. Of course, the wounds will eventually require further treatment. Big arteries can be controlled with direct pressure in an emergency, but definitive surgical care is needed to identify and ligate (tie with a suture) the offending "pumpers" or active arterial bleeders. At times, the really big arteries must be reconstructed.
Bleeding from the extremities, scalp, and some neck wounds can be controlled with pressure dressings—a lump of gauze pads placed over the bleeding point and wrapped tightly with gauze strips. If there's a cavity with tissue loss and bleeding from the defect, sterile gauzes can be stuffed into the hole and wrapped up or pressure may be applied manually.
Tourniquets are seldom used. But, if needed, a tourniquet is placed just above the bleeding point. Anything such as a rope, length of cloth, belt, etc., may be used to apply enough circumferential squeeze pressure to stop the hemorrhage. The problem with a tourniquet is the risk of leaving it on for an excessively long time. How long? The question begs how long tissue below the tourniquet can tolerate having virtually no blood supply. If it's a matter of stopping a life-threatening hemorrhage or creating potential damage, the person in the field must decide what to do. A tourniquet can be released periodically. But usually direct pressure is the best policy.
In the next chapter, we'll discuss hemorrhage in more detail, but for the moment, anyone looking at a pool of blood out there in no-man's-land must have a sense of what volume of blood has been lost. A quick assessment of the victim will give you a general idea about the seriousness of the bleed. A useful guideline goes like this:
• If there's no change in the level of consciousness, breathing or pulse, and if the victim is just a little thirsty, the hemorrhage volume is about a unit of blood or less. Have the victim drink liquids and go on with life.
• If the victim is lethargic or comatose, cold or clammy, with a racing or difficult-to-find pulse and gasping for breath, the victim has probably bled over 40 percent of her total blood volume. This is a life-threatening picture, and IV fluid replacement and transfusions are essential. In this scenario, two to three quarts of blood have been lost; it doesn't matter how or where. Field treatment alone isn't going to do it for this poor soul. Transport to medical care ASAP.
• Between these two extremes are lesser degrees of hemorrhage— losses of two to four pints of blood. These victims present with a rapid pulse, rapid breathing and a look of anxiety. Although serious, they do well after transfer to a hospital where transfusions are administered.
Control of bleeding is relatively easy because the source is usually obvious, and pressure suffices for emergency treatment. Follow-up depends on how much blood is lost. Major hemorrhage requires hospitalization, intravenous fluid administration and, often, transfusion.
Disability: Can the Victim Talk and Move?
The basis for a quick evaluation of the victim's brain and spinal cord function is observation of the best verbal and eye movement responses to questions and the presence of limb movement. Detailed in chapter five as the Glasgow Coma Scale, this assessment involves determining whether the victim can answer questions or is in a coma, whether the victim can open his eyes and look at the examiner, and whether the victim can move his arms and legs.
Not only is this information important as the first assessment, it must be recorded in case the examination data change. For example, if an alert trauma victim slips into a coma, the change in level of consciousness may signal a major intracranial bleed (subdural or epidural hematoma). Similarly, a person with a neck or back injury who is able to move the arms and legs may, with time, become paralyzed. In both scenarios, if your character is out in the wilderness, there's trouble in the wind. Brain and spinal cord injuries can progress. Prognosis may depend on whether the victim is stuck in the field or is immediately transported to medical care.
Make certain your description of the victim's initial condition is clear and that the course of any deterioration is vivid and concise. Tension mounts because of the uncertainty that characterizes the interplay between improvement and deterioration in neurological trauma.
Expose the Victim
Imagine multiple victims of a drive-by attack lying on the pavement in shock, several with obvious gunshot wounds from an assault weapon. One woman lies in shock with no visible injuries—unless you take off her glove and examine her hand.
Why?
Figure 4 (page 34) demonstrates the random nature of some impacts. Other serious trauma such as impalement may be quirky and occult. Such trauma may only become evident after thorough examination of the victim. More than once, a gaggle of young doctors have stared at a trauma victim lying on a stretcher with no obvious reason to be near death. Only when they flip the victim over do they discover the tiny stiletto wound between the patient's ribs.
ABCDE. It's the beginning of acute care in the field. If done improperly, the victim may die or suffer unnecessary disability.
Once life-threatening problems are cared for, the next step is to address specific impacts and evaluate them with respect transport to a hospital.
Special Problems in the Field
Extraction With Head and Neck Trauma
In-line traction on the head and neck is mandatory during any movement of the victim from the accident scene, onto a backboard or stretcher or out of a building, vehicle or wilderness cranny. But get the victim away from a dangerous situation as quickly as possible while controlling the neck and the airway. Scalp wounds bleed profusely and look worse
than they are. Compress head and neck bleeding with sterile bandages, and transport the victim to a trauma center. Always remember a skull fracture or brain damage may be associated with a scalp laceration.
Chest and Abdomen Trauma
Care of abdominal wounds in the field is easy: Cover any wound, even if there are exposed intestines, with a wet, sterile gauze (if possible), bandage and transport. Chest wounds must also be covered in a similar fashion, and if there is a hole in the thoracic wall, a so-called "sucking chest wound," cover it with something to seal it off. Choices include cellophane or plastic with a rim of any ointment you may be carrying on your person. Wrap the chest and transport. Oxygen should be provided to any seriously injured trauma victim, especially one with chest trauma, when respiration is compromised.
Arm and Leg Trauma
Bleeding is easily controlled with direct pressure, and wounds may be cleaned gently and bandaged with sterile gauze. Dislocations of the hip need little intervention before transport to the hospital, while a knee dislocation should be aligned if possible by gentle traction to remove any compression of the artery to the lower leg. Fractures should be splinted, and the pulses below the fracture or dislocation site evaluated and documented, if possible. At least determine if the foot is warm or cool.
Bites
Cover and seek medical care. But before you do, obtain as much information about the biting agent as possible. If it's a dog attack, is it a known dog? Have it quarantined for possible rabies. Rabies is also possible with raccoon, fox, bat and other small mammal bites. Snake bites must be treated according to the degree of envenomation and the poisonous status of the disgruntled reptile. Speed is vital in seeking medical care as swelling, tissue death and infection at the fang penetration site may swiftly ensue.
Impalement
If the object impaled in the body is small, it should be left untouched as the victim is transported to a trauma center. If fixed, as with a picket or wrought iron fence, the fencing material must be cut within a foot or so of the body and transported without movement to the hospital. If some part of the body is impaled on a small sharp fixture, e.g., a bolt protruding from a concrete slab, the body must be lifted from the impaling object. In all of these scenarios, two potential problems exist: Will the removal or movement of the impaled object cause massive hemorrhage or further internal organ damage?
Traumatic Amputation
The stress of dealing with a traumatic amputation is similar to discovering someone impaled, in pain and in danger. The first responder has several specific duties:
• Stop bleeding from amputation stump. Apply wet, sterile (if possible) gauze. Wrap.
• Find the amputated part.
• Clean amputated part gently if dirty. Wrap in wet gauze or cloth, and place in a bag of ice—but not in contact with the ice.
• Transport victim and part to trauma center immediately. Minimal passage of time before an attempt at replantation is crucial.
Burns and Frostbite
Local care is adequate for small areas of skin involvement. This includes topical over-the-counter antibiotic ointment and frequent dressing changes. Larger burns or severe frostbite require hospital care. For affected areas covering more than 10 percent of the body, frostbite or burns that involve the hands, feet, face or genitalia or local deep injury with obvious full thickness tissue death, care must be provided by the appropriate surgical specialist. Other issues such as body fluid loss, infection and surgical cleaning of ongoing tissue loss justify hospitalization.
Diving Accidents and Altitude Sickness
Anticipation and prevention are the hallmarks of the style of serious climbers and divers. Where is the closest decompression chamber? Are there helicopter facilities to get an injured or sick climber off the mountain? Do you have oxygen? What special medications do you need to take at high altitudes? Do you have rope and extra tanks to execute a decompression dive? Do you have waterproof U.S. Navy Decompression Tables with you? Do you know the waters you're diving in? Do you need a guide for your proposed climb? Is everyone in the party in good physical condition?
Certain questions must be answered before any short or prolonged expedition is attempted. It's a matter of planning a fallback position if something goes wrong.
Assaulted Elders, Battered Women and Injured Kids
Underestimated over the years, domestic violence may be subtle or flagrant, occasional or agonizingly repetitive. No age group is spared. The resultant injuries may be trivial or quite serious. At times, battered elders and children are misdiagnosed by their doctors, especially if their caregivers or parents purposely scheme to keep the trauma concealed.
Clues to hidden injuries as well as to constant abuse from domestic violence abound, and the wise writer sprinkles them about her story like a delicate spice. One very productive source of conflict for writers in the arena of battered people is the dilemma of distinguishing accidental injury from malicious violence. Also, a history of battering—for the abuser and for the recipient—serves as a powerful ingredient of your character's back story.
Sexual Assault
The victim of sexual assault usually brings herself to the hospital, although not all sexual assaults are reported. Many women feel embarrassed, frightened and, at times, responsible for the assault. If a victim is found injured, helpless and possibly in shock, the first responder's task is to provide first aid, comfort and transportation to a hospital. But it is also the helper's duty to contact local law enforcement personnel. The first responder is in a crime scene, and certain procedures must be followed in order to preserve sensitive information for subsequent prosecution of the criminal.
You'll learn more about these individual problems in part three if you wish to incorporate any of them into the world of your story.
More physicians than you might imagine dread the responsibility of caring for trauma patients. Even seasoned doctors hesitate before the broken body, held back by a twinge of doubt and a passing uncertainty about how they will behave in the presence of the torn-up body.
Like you, doctors dislike injury-associated gore. And that, in itself, may serve as a source of story conflict. The hospital course of a trauma victim is uncertain, and the length of follow-up isn't well-defined— nothing as predictable as elective surgery. The day after laparoscopic gallbladder surgery, you pack up your toothbrush and go home. A single follow-up office visit completes your care. Sadly, for the victim of uncontrolled injury, rehabilitation may go on for months, possibly years.
A heavy artillery of interventional diagnostics and treatment booms loudly in the modern high-tech hospital. A lot happens quickly. Within most specialties, controversy rages about which tests are most reliable, so you need to grasp a few key points in order to negotiate the trauma center when you write your hospital scene. This includes an appreciation of the interactions of the different players on the trauma team.
The Dynamics of Trauma Care
Despite the media's splashy, intermittent interest in acute hospital care, this part of the physician's world has not been delved into much by writers. It's an expansive vista of opportunity. And every day, it changes.
Lots of conflict can arise when you mix stressed doctors with sick patients. Mounting survival stakes flush adrenaline through your physician character's circulation and sweat drenches his clothes as he stands in the trauma room with a fresh broken body. What to d
o first? What's really wrong with this one? Are there others? Should he be operating on this patient?
In addition to learning how a trauma center functions, you'll become aware of a load of medical dirty laundry. Not an attempt to smear the profession, this information provides you with more ideas about how to create conflict when you write your hospital scene. Ugly turf battles, fear and indifference all insinuate their unwashed hands into trauma care at all levels.
Why? Because doctors are human.
And while fifty million people are injured in the U.S. each year and are managed by trauma specialists as well as other doctors, there exists in this complex care system an underlying current of greed, ego and recrimination. Why does a young vascular surgeon in a small community hospital treat a child's severely compromised arm herself rather than refer the case to the nearby level I trauma center? For the fee? For glory?
Why not?
You can take advantage of your own discomfort as you think about these issues, as well as the bothersome subjects of traumatic amputation, impalement and mutilation, and create a realistic tone in your injury scenes.
Of course, not all injury victims go to a level I trauma center. Most are transported from the field to the local community hospital where they are treated effectively by a variety of physicians. The national trauma care system certainly isn't a seamless whole, and many parts of the country still aren't set up to provide adequate care to everyone. It's constantly improving, and overall the system works well.
Still, there are flaws in the organization and provision of care to the injured. These areas of concern that have arisen over the years include:
• Appropriate levels of physician training
• Which victims to transport to level I trauma centers
• How to prepare victims for transfer
• Who is responsible for the transfer
Which story elements from these issues might you write about? Where is the conflict? Here are a few suggestions:
• The surgeon on call is not immediately available when called by the hospital with a trauma patient. Does the ER doctor transfer the patient himself? Does he call the administrator on call? Does he report the delinquent surgeon for disciplinary measures?