I have a specific situation I'm writing about that I think you can help with.
Have a guy and a girl in a war zone being pursued by the enemy . The girl has broken her tibia, at first a small fracture, but as things go along it becomes a compound fracture, protruding from the skin. It also starts raining and is a cold night.
So, the question is, since the guy would have basic field medicine training and would know what to do... what would he do? What are the priorities? (Besides evading the bad guys, which is a must).
Does he stop the bleeding? (Would it be that bad?) Is hypothermia an issue, especially with the blood loss? Enough that he'd not tear pieces of her clothes off to stem the bleeding?
And would he bother to set that bone at all while they're on the move? I figure no since he's going to have to carry her anyway.
What do you think?
This is a softball. I expect better from you, Thuggish.
A) If actively pursued, they will be caught if they have to deal with a fractured tib/fib. It's just the reality of the situation. Unless they have some outside help to hide them, two people will not outrun bad guys who are healthy. Just not going to happen. Always, first and foremost, ensure the scene is safe. Do not try and save a life which will in turn get you killed. You're no good to anyone if you get yourself killed. Or captured.
B) The wound needs to assessed. There will be blood with an open compound fracture. The question is if the blood is bright red and coming in spurts, or if it is dark red and oozing. Bright red and spurting is an arterial bleed. If that is not managed within minutes, she dies. She will go into hypovolemic shock and her body will start to shut down piece by piece. If it is dark red, it is a venous bleed, you have a bit more time, but not much. Once again hypovolemic shock is a factor.
C) After assessing the wound and determining what is going on, the bleeding must be stopped first and foremost. Bleeding is stopped in a variety of ways. 1) Direct pressure, 2) elevation (moving the injured area above the heart, so lay her down and lift her leg,) 3) using pressure points (basically slowing the flow of blood to the area by putting pressure on an artery. There are 22 viable pressure points on the body, 11 on each side. If he is a dumb grunt, which it sounds like, he may not know this,) 4) and then using a tourniquet on the closest flat bone area, which in this case will be her femur. So, direct pressure, elevate the wound, use a pressure point in conjunction with direct pressure, and then if all else fails, apply a tourniquet. If pressed for time, just go to a tourniquet and get the hell out of dodge. Just as a note as to why an arterial bleed is so bad, a person with a .5mm femoral laceration will go hypovolemic in about 15 minutes. A full arterial laceration can bleed a person out in under 90 seconds. So, tick tock, tick tock.
Note: Typically, an open compound fracture, of the tibia and fibula, will not be a serious issue where the person will bleed to death unless, as stated above, a major artery or vein was lacerated by the sharp edges of the bone. The major arteries run between the tib/fib so they aren't likely culprits. Just direct pressure, elevated the wound and good secure bandage should work. Anything absorbent and dry should do.
C.2) Constantly make sure she has an open airway and is breathing. It's vital, not over the bleeding, but it's vital. If she's screaming of making lots of ooh and aaahh sounds, she has an open airway and is breathing, move on.
D) Dealing with the fracture. Simple, immobilize as is using anything you can get your hands on that is straight or semi-straight. Sticks, metal rods, a gun, anything. Place two sticks on the sides of the fracture, tie them in place above and below the wound. DO NOT SET THE BONE. That is an idiot mistake. If you try shoving jagged bone back into a wound, you have a high probability of causing more harm. You could lacerate an artery at worst, you just lacerate a vein, you just mangle the wound. It's not good.
E) Now that the bleeding has been stopped, the wound has been immobilized, you need to treat for shock. Lift the legs, keep them elevated, check her airway, ensure she's breathing, find a way to keep her dry and warm, keep her out of the elements as much as possible. Cold and rain are killers to the injured. They can become hypothermic quickly.
F) Check the pulse rate, check the breathing rate, and constantly recheck the work you did on the wounds. Usually about every 5 - 15 minutes at first, then you can move it out to 30 minutes, an hour, as time goes on and she's stable. Keep the pulse rate under 100, above 60. Keep the breathing at around 12-20 breaths per minute. Keep the patient calm, apply any pain medications if they are on hand. If this is basic medicine dude, he doesn't have anything. She'll just have to suck up the pain. And it will be painful.
G) And when you get moving again, lift her up slowly, she'll go tits-up (pass out) if lifted too quickly because of the rush of blood from her head. Call for help, get to a safe place, manage the wound as necessary, and good luck.
This should all take a person, decently trained, to get through steps A - E about 10 - 15 minutes if done properly. If they are a dedicated corpsman, medic, then about 5 - 10 minutes. If they're just an idiot, who knows.
Let me know if you have more questions.
Next time, come at me with something more pressing. Give me a double leg amputation, sucking chest wound, open head wound, with a possible occlusion to the upper airway. You can throw in some burns for added effect, maybe even an eviscerated abdomen. Give me a full med-kit, one other person I can direct to help, and I'd have a 50/50 shot at saving their life. Which depends on how quickly I can get to the person.
@Jose. FANTASTIC! I knew you were cool.
Yeah, well, it's my first one.
Dude, talk about super helpful... Awesome.
Alright, so he's not super trained in medicine, but she actually is. (Seems I should have mentioned that). So, what pressure point would she know about? And how does that work? Can he aply a tourniquet-like device to said pressure point?
Also, when they get to a place with some basic medical shit, (they're still alone), would he want to set the bone then?
This is all rapid response emergency medicine. This isn't a hospital or clinic or anything of the sort. You bandage her up and then you're done with the exception of ensuring the dressings are good and she is stable. In the field he doesn't set the bone. You never set the bone. Unless emergency medicine has changed in the last four years, you don't set the bone in the field.
You keep the patient comfortable, attempt to minimize sepsis (infection), and monitor, that's it.
As for the pressure points, just google it so you can see pictures. It's far more helpful than using medical jargon.
A tourniquet is basically using pressure points. It compresses tissue to occlude blood flow. Tourniquets should be a last resort. If a tourniquet is used, it's because it is believed that the loss of the limb is preferable to the loss of life. A tourniquet is usually a one-way ticket to an amputation, exception is applying one for brief periods, under thirty minutes or so. It's not a thing to be used lightly and shouldn't be incorporated into a story if you want any realistic expectation of keeping the limb. If you use one, and they run around for ours, and then are saved and the next day she's just hanging out in the hospital, anyone in the medical field will call bullshit. An orderly who knows little would call bullshit.
So, use it at your own peril.
@ smithreynolds: Thank you. You're not so bad yourself.
This conversation has just proven that if I am injured and stranded on a dessert island, my one item is gonna be a direct phone line to @Jose. He knows his stuff. But if my dog gets injured, I got that covered (provided I'm not a sobbing mess over my poor dog).
Yeah, you would fair much better with an animal. I only received minimal traning with dogs, or at least working service dogs. Basic stuff like how to start IVs and run in the bite suit.
Ha, run in the bite suit... sounds fantastic.
Okay, so once out of the immediate danger (i.e. hooray, we got away), and it's time to do a little more fixing... Set the bone then? At this point, let's say they have a brace or a cast or whatever, how mobile can you expect her person to be? (And how quickly?)
THE PERSON IS NOT GOING TO SET THE BONE. DO NOT SET THE BONE.
For fucks sake, man.
And the person has limited mobility. Think of it this way. Bend your leg at the knee. Now, take two straight sticks and put one of each side of your leg. Tie the sticks to your leg above and below. That means you tie the sticks to your leg at the shin, and you tie the sticks to your leg at the thigh. Now, how much mobility do you have? Simply move that image down to where this lady has her leg broken. Think of the bend at your knee as the bend in at her tib/fib. You'll need crutches or buddy assistance to move. That or you hop on one leg.
She will move as quickly as anyone with a broken leg in which she can't put any weight. How fast can you move holding on to another person for leverage as you hop on one leg? How fast can you move on crutches? How long and far can you hop on one leg before you're exhausted?
If you want a wound that's just as horrible, just break her arm in much the same manner as you did her leg. She can still run and jump, the treatment of the wound is basically the same, you don't lose much. And she'll still have one free hand to shoot with.
Okay, okay... so under what circumstances would it be okay to set the damn bone? I'm really not clear on that. (Obviously).
When you get to a hospital and it's done surgically. Under sterile conditions. By a trained surgeon.
I was afraid you'd say that.
So... since you wanted a challenge and not a softball... What's an injury that would leave someone barely mobile, in a good deal of pain, and could be somewhat "operated on" (or whatever) when they find some basic medical equipment and aren't in immediate danger?
And, you know, not kill her because that's not in the plot.
How long do they have to be operational? Time is a factor because of sepsis. Are we talking hours, days, or weeks?
You could shoot her in the stomach, it's hobbling, and stupidly painful, and sepsis would take effect within 1 to 2 days.
Maybe she can twist an ankle. Stub her toe on the piano that no one uses anymore but it's too heavy to move and no one wants to buy it because one of the black keys is missing. Perhaps she step on some legos that her kid left out even though she told them to put them away before they went to bed and she thinks they didn't brush their teeth but said they did but they've lied to her before but now that she's stepped on the lego she doesn't feel like dealing with it.
She could dislocate her knee by rolling down a hill getting it caught between two rocks and her momentum wrenches it the wrong way. That would need to be set, and you can do it in the field, and she is still hobbled, but can move after it's set despite the pain. Lots of people dislocate shoulders or fingers, but no one uses dislocated knees. It's a simple procedure of pulling on the leg until it kind of slips back into place.
Or maybe just dislocate the patella. I've seen that twice.
So, basically, if you want to maintain realism, open wounds are pretty much out of the picture. Dislocations are your safe bet. You can make them stupidly dislocated and still be able to reset them in the field. And joint can be dislocated. We had one girl dislocate her hip. I think that was the most painful.
Whoa, what's dislocating a hip like? (Never actually knew that was possible.)
So let's say a bullet, shrapnel, or whatever hits her in the stomach. I think I like that one. There's blood loss but not necessarily a ton, what else are the concerns, consequences, etc?
They're going to reach a hospital within 24 hrs, she's going to see action between the injury and then, and she's going to get some medical type help between the injury and then.
Basically, her huge concern, considering it will be a peripheral shrapnel hit, maybe to the posterior region of her lower back, is sepsis. Your intestines carry what through your body? Waste. aka, shit. So, imagine you open a wound and through shit into it. That's would be the biggest concern. It could just be an abdominal wound that didn't hit any major vessels and didn't ruptures the intestines. In which case it would be painful, slightly bloody, but the person would be back in business in a few weeks. Maybe 3 months before 100%, depending on the severity of tissue affected.
If I were on the gun line and came across someone with this kind of wound, I would ensure nothing serious was hit, make sure no huge chunks of debris are in the wound, slap some packing (lots of gauze stuffed into the wound) in and slap a cover bandage on. Slap them in the face for getting hit in the first place, and move about my business.
But, always always check for secondary wounds that you might have missed. We learn how to do this by doing penny drills. We "glue" 100 pennies on the skin of a person, we clothe them back up with their full battle gear, and lay them down in a room. We bring in the corpsman, or medic, blindfolded to simulate night, and have them examine the patient. They need to remove every penny from the person before the exam is done. Mind you, we stick pennies everywhere. Anus, on balls, inside of thigh for girls, on boobs, it doesn't matter because shrapnel doesn't give a fuck on who or where it lands. You just need to do the job and save the patient. Get over your insecurities and do the fucking job. No one has time for people to respect modesty in combat. You expose, find wounds, bandage, and transport.
If this is going to be a combat story. Your characters can be scared shitless, but they need to be trained to fight through it no matter what and get the fucking job done and not be little fucking bitches about every fucking thing.
And remember, fire superiority is the best medicine.
Black Hawk Down did a good job with this. Saving Private Ryan was great. We Were Soldiers is spot on. Pay attention to the medics/corpsman and how they run through patients. It'll give you a better understanding of what I'm talking about.
Oh, and I don't know personally. I just know people scream like new born babies when it happens. Full grown ass bearded Recon Marines scream like little girls and cry big sopping tears. And it isn't technically life threatening. And setting it is even more painful because you have to find out how and where it slipped out of the socket, and then try and slip it back in. You find out by digging your fingers into the flesh and feeling around the bone. And when you set it, you hope and pray you don't snap the head of the femur off which would just triple the pain, and then you're really fucked because theirs no way they are getting up and hobbling anywhere. They would rather stay and die than get moved.
So, enjoy that.
Truthfully, if you haven't been near combat or are in the medical field and understand trauma, I would just stick to some Hollywood bullshit and say she gets shot or hit with shrapnel, somewhere, and the dude puts a bandage on and she's fine. I wouldn't worry about the details.
I was in the medical field for over 13 years. Nine of those years were focused on combat trauma when I was with Marine Infantry units. I studied it, worked it, and taught it.
Awesome info, again. (The 100 pennies thing is something I'm going to remember.)
So, my philosophy is to know more than I actually put into the story. I'm not writing hard military scifi where every little detail about each gun they use really, really matters... but I also don't want some hollywood bullshit where the hero gets shot in the shoulder but still uses that shoulder freely, you know? Hate that.
So, is the hip being dislocated super painful? Could one be expected to ride on another person's back with a dislocated hip? Or is it just the setting that puts badasses in tears?
The only way they can be transported is by stretcher, and each bouncing step of the stretcher bearers is going to exacerbate the pain. So no, no piggy back rides.
All of it is painful.
Actually here's a question for you:
When people relocate (what's the word?) a dislocated shoulder on TV, it's always portrayed to hurt incredibly when happening, but then they're more or less fine. Is this accurate?
Aaannnnd what about someone going into shock? What do you do when you can't lay them down and cover them in a blanket with their legs elevated and blah-blah?
Okay, so I was conversing with one of my fellow corpsman about the hip dislocation. And I was incorrect. A hip dislocation is an absolute medical emergency. If the patient doesn't get help as soon as possible there is concern that severe nerve damage could occur. (I always forget about the nervous system.) (End my friends input.) Also, along with every dislocation there is a significant concern that a fracture has occurred on top of the dislocation. But regardless, still stupidly painful. Full on 10/10 pain scale.
You reduce a dislocation. Or, it's called the reduction of a dislocated joint. The reduction of a dislocation is extremely painful. In a hospital they usually administer an anesthetic or decent sedative before the procedure.
And, sometimes a dislocated joint will simply slip out and then slip back in. So, you get the trauma, but no further steps besides pain management is necessary. HOWEVER, it takes extreme force to dislocate the femoral head from the acetabulum. We're talking severe car wreck or major fall.
In reality, you can get all this information from the web. Just find the sites that are .org for the various institutions, orthopedic society of whatever, cardiovascular society of the who whos. Do research. I leave some shit out because it doesn't really come to mind. Like you always need to check distal pulses when dealing with any orthopedic problem because you can't tell what's going on under the skin. If there is an abdominal bleed, a person can lose 1 to 2 pints of blood into their abdominal cavity before it shows, and then you're way behind the game. The thigh you can lose about a pint, but then you have to start worrying about compartment syndrome, which is when the tissue swells more than the skin is elastic, then it starts putting pressure inward and it can occlude the arteries and veins. More common in sever burn patients.
On a fun fact, one of the major killers of burn patients besides infection and shock ...... hypothermia. Ironic.
What happens if you can't treat for shock .... the person dies. You can't will yourself to not go into shock. It's an automatic response by the body. The body is literally shutting down all non-essential services. It starts distally, otherwise stated as it starts from the tips of the toes and fingers and works its way in towards the heart and brain. People start talking all funny because higher brain function isn't necessary, or they just pass out cold, motor function goes out the window so no more walking or holding stuff with any true dexterity, the ability to control your bowels goes bye bye, and so on.
Body temperature regulation is a fun one to watch. So if a person is heating up, the skin gets cool and clammy because the body is trying to keep the blood close to the necessary bodily organs, thus away from the skin. Then, if the person doesn't cool down, the body starts the shock process, motor function is gone, higher brain function, the body suddenly vaso-dialates flushing blood out toward the skin in order to try and cool the blood down on the surface. The person looks really red and their skin is super hot and really dry.
Heat exhaustion is around 100-102 degrees. Heat stroke is around 102-106. If they get over 106 the brain literally starts to cook. Permanent damage can and will occur.
So your characters need to keep that in mind as their running and gunning for however many hours, especially if they don't get any water or food.
You kind of understanding why there are dedicated medics on the field of battle. A regular first aid helper can do stuff to keep people up and running for about 10 to 15 minutes. They just make sure the person doesn't die in that time. After that you need trained people to work through all the possible scenarios through which the body can start unraveling. And they need to know how to predict how it will occur. It's an actual science.
Or you can pray. It's the same as letting a person die, but you feel better about it because you're delusional.
Okay, I'm done. I drank coffee like two hours ago. I'm pumped! But I'm still rusty in my field medicine. I'd have to crack my books if we want to start running through each and every tiny detail. I'm just giving you broad strokes.
No, broad strokes are good. And it's not that I don't google this stuff, but take the 10/10 pain for hip dislocation. Take the fact that the baddest badasses are reduced to blubbering over it. That's something .org sites leave out. That's good shit right there, that'll help me make it seem real if I ever dislocate a character's hip. (Sounds like I won't for what I want to have happen, though. Because she's not supposed to die...)
Or things like prioritizing in a practical manner- i.e. staying alive while running away.
You could always have the hip dislocate and then reduce on its own. Like you hear a huge pop when she falls, she screams fucking bloody murder, and then it reduces so, she gets the pain, the horror, and the pseudo crippling effect, but she can keep on keeping on. Bodies aren't written in stone. Lots of things can happen.
Now there's an idea! Would it reduce immediately if it did it by itself? And would she be at least somewhat mobile after? My understanding is the femur would still be fractured at least.
You know what? I'm pretty sure I momentarily dislocated my elbow back in May. Back squatting of all things. It didn't really start hurting until the next day when I woke up, so off to the doc I went...
I'm also looking for something that can be somewhat, and very painfully, fixed kind of like they (unsuccessfully) did in Black Hawk Down. I hardly remember, it's been a longass time since I saw it, but that was an intense scene.
... I should rewatch that...
In the scene you're talking about, the Army guy had a femoral bleed and the medic was trying to clamp it shut. He had to literally dig his hand into the guys thigh, whole hand inside his thigh, feel around for the artery, grab it, which is like grabbing a small wet rubber tube with the tips of two fingers, pull it out far enough so he could use forceps, and then clamp it. He almost got it, but ultimately the artery slipped through his bloody fingers and he wasn't able to do anything else but watch his friend bleed to death.
And mind you, what makes all of those scenes truely sad is that none of those people in the streets is older than 35, the vast majoriy being approximately 22-26 y/o, and they are all friends who have been living and working together for at least one to two years. Some as young as 19. Maybe one or two in the Command Post are older than 40.
To me that's just one thing on a list that makes it truly sad...
Here's one I suspect I know the answer to, but let's verify...
Having rewatched Blackhawk Down, the part where the guy's legs and very bottom of torso, it looks like, were blown off. He's lying there still alive, says a few words to that raspy-voiced-guy from Saving Private Ryan. How feasible is that?
It's feasible. Mind you the person will be in near instantaneous shock from the injuries.
So, a full amputation of a major limb, leg, will allow blood to escape at a very rapid pace. If left untreated, a person will bleed to death in under two minutes. So, think BOOM, start timer...
But, they get there quickly and put on a tourniquet. Great. It stops the blood flow, helping to prolong his departure from the mortal coil. The issue in the film is that the injury is relatively high on the leg, that means the femoral artery was slipping past the tourniquet where it could free flow once again. So, the medic was attempting to catch it with his fingers, pull it out far enough, so he could apply forceps to clamp it off, and thus keep it from slipping away. He makes the grab, but it still slips away. Thus, the guy dies because he's bleeding out into his pelvic region, or even his abdomen. Both can hold significant amounts of blood. Therefore, in a relatively short amount of time after it slips away, the man succumbs to hypovolemic shock or hypovolemia.
So, during that time, the man could in theory, and does happen, maintain consciousness long enough to have a pseudo-cohenrent conversation. But one he loses around 1.5 to 2 pints of blood, (the body holds 4.5 to 5 pints) the low blood volume would cause his blood pressure to dip down real low. When the body doesn't have as much blood to pump, it doesn't transfer oxygen (because that's how oxygen gets throughout the body), and he would become a bit delerious as his blood pressure dropped.
It's like the guys who climb Mount Everest, the low oxygen can make them go all loopy. Same type of thing is going on in trauma patients with significant blood loss.
So, if you're writing this, the guy can be in shock from the trauma, maintain some coherence, but as the time goes on, and blood is lost, the coherence goes away. He will need to start reverting back to his base instincts for survival. Death is iminent. The stages of death begin. Bargaining, denial, anger, and so on. In the end, most just look for any hope of survival no matter how absurd. They call for their moms and dads and god and so on. Anyone to help.
Nooo no, not that part of the movie, earlier on, the violence was just erupting, the dude (kind of middleish aged looking) is literally blown right about half off. He says tell (my girls? I think he said?) it'll be okay... few more seconds... gone.
Oh. Not really. That'd hit the inferior vena cava, or both of the femoral arteries at once. Unless someone got to him within a minute, he'd be long gone. I mean, the brain can stay active for up to two minutes on low oxygen, but yeah, no.
Think about in reality: Boom! How long for anyone near him to come to if they're that close to the blast, gather their wits as the reality of what just happened dawns on them, locate him through the dust and debris, make an accurate assessment of how bad off he is, trot over to him, and kneel next to him in time for him to say his last words?
I mean, we here the stories, but in reality, no. I've never seen it, never heard a real life example of it, it's only a story that's told to widows and their children to make them feel better.
If it did happen, it wouldn't be this clear, direct statement. It would be something more like a stunned stutter through failing and burnt lungs to someone who is on pure adrenalin. The blood. The subconscious acting. The brain's inability to grasp reality. Yeah, if it is uttered, it is not this meaningful, "Tell my wife and kids I loved them." It would come out as a mumble from a brain incoherent. "Tell, hurts, stop the blood, tell kid wife, tell my blood, hurts, stop, listen, tell my wife, kid, love, love, love. hurt." Then the person who hears him would "understand" and relay this clear direct message to the family or friends or command.
Oh, really? It wasn't more than ten seconds in the movie that someone talked to him, I think, and the guy died in maybe twenty, thirty seconds? I thought he'd be gone before that though. But he was a little more lucid than you describe.
did anyone else just develop a crush on jose
@Max. We all have a crush on Jose.
Hey Jose! I got another one for you, new angle...
Let's say you, I dunno, spoke perfect Russian, and joined the CIA, and infiltrated a Russian army whatever unit. You're reporting back to us the condition of their medical facilities.
Now, a guy like me, I wouldn't really know how to evaluate stuff. I'd be like, um, there's some beds, and IVs and stuff...
But what would a guy like you, with your knowledge of medic stuff, know to look for?