Trauma Unit Broken Ribs Life-threatening CHEST injuries Tension pneumothorax Open pneumothorax -- the sucking chest wound

Hemothorax Cardiac tamponade Flail chest Intubation and Extubation What does it feel like to be intubated? Evaluation and management of a gun shot wound to the chest Gun shot wound to the middle chest, near the heart (Injury to the great vessels) What would happen if a person were shot in the back with the bullet exiting out the front? HEAD trauma Epidural hematoma Concussion Treatment of a Concussion Cerebral contusion Hospital course following surgery for an epidural or subdural hematoma Injury to the UPPER AIRWAY/THROAT (trachea, larynx) Injury to the ABDOMEN Liver injury Duodenal hematoma Traumatic pancreatitis Splenic rupture Appendicitis Kidney injury Complications of Gun Shot Wounds to the Abdomen Infection (Peritonitits) -- Large and small intestines Bleeding -- Spleen and liver Motor vehicle accidents Suturing a wound Wound Care Instructions Transporting someone with severe back and internal injuries Would paramedics give a patient a painkiller? Sharp object impaled in a shoulder Please read the Sentinel and Medical Disclaimers. Broken Ribs How you get them: usually by blunt trauma (getting beaten up by someone's fists or other object) or being in a car crash or falling down and smacking your chest. Symptoms: pain, pain, lots of pain over the area of the broken rib - very tender to touch. It also hurts to breathe, which is the main problem doctors worry about. If a patient doesn't breathe deeply, they don't expand their lungs all the way and the lungs can partially collapse ("atelectasis"). Then the patient is at risk of developing a nasty pneumonia. The other problem with broken ribs relates to if the person's lung was punctured or damaged during the injury (doesn't always happen, but is common with severe chest trauma). See pneumothorax, flail chest, below. Treatment: the patient should be taken to the ER and examined for other injuries. Contrary to what we saw in the TS episode The Iceman, the accepted treatment for broken ribs is no longer taping or splinting of the ribs (sorry, Jim). If the patient can breathe OK, doctors prescribe ample pain medication (Tylenol with codeine is good) and encourage the patient to breathe deeply and cough as much as possible to prevent lung collapse and a possible pneumonia. The ribs usually heal fine by themselves. And no, you don't usually die from broken ribs. Life-threatening Chest Injuries Tension pneumothorax How you get it: a tension pneumo happens when you develop a large air leak into the chest wall that acts as a one-way valve -- air rushes into the chest but can't get out. Air keeps building up and ends up squashing the lung (collapsing it). Obviously you can't breathe well with a collapsed lung, but what kills you is that the increasing pressure cuts off blood flow to the heart, so it's as if your heart has stopped

pumping. A tension pneumo can happen with penetrating or blunt injury to the lungs, or if the patient has been on a ventilator. If not recognized quickly (within minutes), the patient will go into cardiac arrest and die. Symptoms: the patient is having difficulty breathing and looks distressed (if they're conscious) and their blood pressure drops. You cannot hear any breath sounds when you listen with a stethoscope to the lung which is collapsed. They may turn blue and their neck veins may stick out. If they aren't treated, they can die in a matter of minutes. Treatment: stick a big needle (or other sharp object) between the ribs into the chest wall ASAP. This allows the air that was building up to escape, and you are rewarded with the sound of air rushing out. Blood can now get to the heart and the lung can re-expand. The patient looks much better. Eventually the patient will need a chest tube (a plastic tube inserted into the chest wall and hooked up to suction.) It decompresses the chest wall of any air and allows the lung to fully expand. A patient typically has to have the chest tube in for several days to a week to allow the chest wall to heal. Often when a person's lung collapses, it is only a partial collapse, and they do not necessarily have to be put on a respirator. Also, a person can still survive (get enough oxygen) with only one lung if that lung is still working well. The goal is to re-expand the lung as soon as possible with a chest tube that sucks out the air surrounding the lung and allows it to re-inflate inside the chest. This usually solves the problem and the person doesn't need to be put on a respirator unless they are still having difficulty breathing (usually due to other injuries or because they weren't very healthy in the first place). Open pneumothorax -- the "sucking chest wound" How you get it: Basically an open hole in your chest wall, which makes you lose the negative pressure inside your chest cavity that enables you to breathe normally. More common than a tension pneumo with blunt trauma or penetrating trauma. Symptoms: patient has difficulty breathing, may have broken ribs. Often an obvious wound. Treatment: cover the hole with a piece of special occlusive gauze taped on three sides. Stick in a chest tube (see Tension Pneumothorax treatment above) if necessary. Surgery (sew the hole closed) if necessary. Hemothorax -- blood filling the space around the lungs How you get it: usually from a car accident or getting beat up really bad. Person often has obvious external injuries, like broken ribs. Can happen when one or more of the major blood vessels in the chest cavity are broken (see car accident section below). Symptoms: patient has difficulty breathing, doctor cannot hear breath sounds (or they're very muffled) with a stethoscope because of the blood muffling the sounds. On a chest x-ray, the side that is full of blood is totally white (not normal; the lungs are usually dark to black). The person can die from massive loss of blood into their chest. Treatment: Stick a chest tube in the person's chest (see Tension Pneumothorax treatment above) to let the blood drain out. The person also often needs surgery to repair the damaged, leaky blood vessels. Cardiac Tamponade -- blood filling the sac around the heart How you get it: usually from a stab wound to the heart. The knife (or whatever the weapon) pierces the chest wall, then the sac around the heart, and then the heart itself. The blood in the heart leaks out into the sac (the heart lives in a sac called the pericardial sac, which prevents the blood from escaping into the rest of the chest, i.e. where the lungs are), but may not come out of the external hole made by the weapon. The blood collects there, finally building up so much pressure the heart that the heart can't pump against all that pressure (doesn't have room to work, bascially). If not recognized quickly (within minutes), the patient will go into cardiac arrest and die. Symptoms: person looks very distressed (if conscious) and their blood pressure drops because their heart is having such a hard time. They really look like they might have a tension pneumothorax, but when you listen to their lungs everything sounds fine (you can hear breath sounds). They may turn blue and their neck veins may stick out. Treatment: Stick a needle into the heart sac ASAP and suck out some of the blood, thereby relieving the pressure around the heart and allowing it to pump more normally. The person will probably need surgery to fix any holes in the heart wall itself. Flail Chest -- a particularly bad kind of multiple broken ribs How you get it: car accident or getting beat up really bad (heard that before?). Flail chest is where you have several ribs in a row broken in two places (like one break in the front and one break in the back), allowing a piece of the chest wall (a "separated" section thanks to the broken ribs) to move by itself apart from the rest of the chest wall. What happens is that this separated piece of chest wall moves inward (instead of outward) when the patient takes a breath in, due to negative pressure. If the chest wall moves inward, the patient's lungs can't expand, thus they can't get enough oxygen. Plus having lots of broken ribs this hurts like the dickens, and the patient doesn't want to take deep breaths anyway. Also, the lungs underneath the broken ribs may be bruised or lacerated, which doesn't help the patient breathe either. Symptoms: patient has hard time breathing and this hurts BIG TIME. You can see a part of their chest moving inward when they take a breath in.

Treatment: Get them some oxygen fast and load them up with pain medicine. If they really can't breathe at all, then you have to intubate them and let them breathe on a machine for awhile. Again, most trauma and ER doctors do not believe in taping or splinting the ribs together because it can interfere with breathing. Intubation and Extubation The decision to put someone on a respirator (intubate them) is largely based on how the person "looks" -- mainly, if they are able to breathe well enough to get enough oxygen. If they look like they are getting tired and their oxygen saturation is low, or if their mental status is impaired (i.e. comatose), then the person may be intubated. As for how long a person must stay on a respirator, that really depends on the individual case and how well they do. Someone on a respirator most likely has severe injuries, and may stay on the respirator for a long time before the doctors feel they are strong enough to get off it and breathe on their own. It could be hours, days or weeks, depending on how badly they were injured. Doctors may try weaning the person off the respirator and see how they do; if they don't do well, they go back on the machine until later when they try again. The process of intubating a person must happen as quickly, smoothly, and with as little discomfort to the patient as possible. First, if they are conscious, the person should be told that they are going to have a breathing tube put in them to help them breathe (if it is an emergency and the person is hypoxic, informed consent is not required because a person is often not mentally aware enough to give an informed consent). If they are awake, the person is often scared and may feel like they can't breathe, and it is important to keep them as calm as possible. Then a sedating drug like Versed is given IV to put the person to sleep so they don't feel the intubation happening. As soon as the person is asleep (seconds), a paralyzing agent such as pancuronium is given IV to make the intubation easier (another reason giving Versed is very important, because most people panic when they become totally paralyzed and unable to breathe). At this point the person's breathing muscles no longer work, so they must be "bagged" every 10 seconds or so until the tube is placed and connected to a respirator. The device for intubating someone looks like a metal blade with a handle attached and a light on the end. The blade is placed in the person's mouth and throat and used to lift the epiglottis away so the plastic tube can be inserted past the vocal cords into the trachea. The light lets you see where you're going. Usually this maneuver takes only seconds, especially if the person doing the intubation is experienced. As soon as the tube is in the trachea, the bag is attached and oxygen is delivered through the tube. The doctor listens to the person's lungs to make sure they can hear air entering and exiting, which means the tube is in the correct spot. Then the tube is connected to a respirator and taped to the person's face with some tape so it won't move (something they forgot to do with Blair when he was intubated in Blind Man's Bluff). A chest x-ray is obtained to make sure the tube is not in too deeply or too shallowly. A person who is intubated cannot speak at all because the tube passes through their vocal cords. This means no deathless prose <g> or whimpering or vocal noises of any kind! Initially they are also usually asleep (and usually remain sedated so they don't feel too uncomfortable) because of the sedative and paralytic medication. Eventually, however, the medication can be allowed to wear off and the person can be allowed to wake up. They still won't be able to talk, but they can be alert and communicate by moving and blinking. While a person is intubated, they often have difficulty getting rid of their secretions and may require suctioning of the mouth from time to time. If a person thrashes too much while they are intubated and must continue to be on the ventilator for other reasons, the doctor will not hesitate to prescribe more sedation and/or paralyzing drugs in order to make the person more comfortable. It's the humane thing to do, and the patient will appreciate it! Removing an intubation tube is called extubation. Doctors wait to remove it until after the person wakes up. They would also do some tests like an ABG (arterial blood gas) to make sure that the patient was getting oxygen into his blood and carbon dioxide out of his blood okay. If everything looks okay, then they "wean" the patient off the respirator. For a younger person, this would probably happen rapidly versus an old person with emphysema or other problems breathing. Weaning consists of decreasing the amount of oxygen supplied through the ventilator until the person is on something close to regular room air. They also wait until any pain or sedating medications have worn off that would make the patient sleepy or not want to breathe (narcotics such as morphine or demerol, or Versed). Then if the ABG values still look good, the patient would be extubated (tube removed) and start a trial with something called CPAP (a mask that supplies oxygen at a certain base pressure, but the patient breathes by himself, whereas with a ventilator it provides intermittent breathing pressures so the patient doesn't have to exert much effort to breathe). If the CPAP thing works okay, then they would remove that and give oxygen by mask or by nasal cannula. Sometimes they don't even do the CPAP thing if the person hasn't been intubated for very long -- they just pull the tube out and give them a mask with oxygen. If the patient looks okay and can breathe on his own, then voila! they have been weaned. What does it feel like to be intubated?

When a patient is getting ready to come off a ventilator, the doctors will allow the sedation and paralyzing medicines to wear off so the patient can wake up before the tube is removed. At this time, they can "feel" the breathing tube. From what I understand, the breathing tube is definitely *not* comfortable, and some patients try to pull it out, especially if they aren't totally with it. It can even hurt, and sometimes you can give a patient a throat spray that numbs the throat somewhat to make it a little easier to handle -something like Chloraseptic. After the tube is removed, the patient will have a very sore throat and often have a hoarse voice -- hard to talk. You can make a swallowing motion a little with the tube inside you, but it isn't very effective, and you certainly can't drink or eat anything, nor talk. One of the worst parts of having the tube is that the person must be "suctioned" from time to time because they can't cough to get rid of their secretions. The long tubing is disconnected from the mouth portion, and a suction tube is put down the tube and inside the person's mouth to suck out the secretions. This causes a gagging sensation and is very unpleasant, and the person also can't breathe during this time. Pulling on the tube will also make the person gag. In fact, it is important that the patient *can* gag, because this means they can protect their own airway (meaning they will be able to cough out secretions) when the tube is removed. The question about how an intubated person can breathe when they regain consciousness but are still on the ventilator is a more complicated question and very astute. There are several different "modes" of mechanical ventilation that a modern machine can do. The machine can be set at different modes depending on the patient's own abillity to breathe and their level of consciousness. I'll describe three of the modes. The most basic mode is called "Assist Control" (AC) and initiates a breath every so many seconds (whatever the doctor sets it as). With AC, the person can breathe *only* when the machine lets them. If they try to breathe more often, nothing will happen -- as you can imagine, this would be okay if the person was comatose and not trying to breathe on their own, but it would be a very uncomfortable feeling if you were conscious. When a person starts to get better and stronger, the doctor will usually switch the ventilator to SIMV mode, in which the machine makes sure that the person breathes a certain number of times per minute. If the person tries to breathe on their own, the machine will let them and will synchronize the next breath according to how fast the patient can initiate their own breaths. If the patient doesn't try to breathe on their own, the machine will continue to initiate mechanical breaths so the person does get enough oxygen. Another mode is called CPAP, and CPAP is usually the last mode the patient is switched to right before they are extubated (taken off the ventilator). In this mode, the patient initiates all breaths on their own, but the machine provides a little extra support to keep the patient's lungs inflated more easily. Weaning someone off a ventilator can be a rather complex process, as you can see. Basically, the goal is to decrease the number of breaths and amount of oxygen provided by the machine until the patient can re-assume all breathing on their own. So in answer to your question, if the patient is on SIMV or CPAP mode, they can breathe in addition to the machine. This is much more comfortable for the patient than AC mode, where the patient isn't allowed to breathe independent of the machine. Another note: weaning someone off a ventilator also depends on how long they've been on a ventilator and how sick they have been. If they only had to be on a ventilator for a brief surgery and are otherwise relatively stable, then often they will be taken off the ventilator very quickly after surgery (sometimes they won't remember being on a ventilator). On the other hand, if they have been very sick and needed to be on a ventilator for a very long time (days or weeks), the weaning process will be more gradual and involve letting the patient wake up while intubated and gradually decreasing the machine's support until the person can take over all breathing on their own. Evaluation and Management of a gun shot wound to the chest Assuming the person is healthy... The initial assessment and treatment would follow the steps on the ER page, including assessment of airway, breathing, and circulation. A careful examination of the lungs (listen with a stethoscope, percuss/tap over the lungs) would be very important, because you can detect signs of pneumothorax or hemothorax (see above), which if massive, can be fatal. If the bullet nicks the lung, that means that it would have penetrated the pleural cavity (the space surrounding the lung and separating it from the chest wall). Any obvious holes would be covered by a square of occlusive gauze, taped on 3 sides only to allow air to escape but not to enter. The patient would almost surely need a chest tube placed to make sure the bleeding hadn't continued and to treat any pneumothorax (air leak) that would have resulted from the hole made by the bullet. The chest tube would most likely be placed by the trauma team in the ER upon arrival in the hospital. It can be a pretty gory procedure and very painful, since you have to cut a hole in the person's chest wall and dissect through the muscle with surgical instruments in order to thread the large plastic tube into the pleural space. Give lots of pain medicine beforehand (a hefty shot of Demerol would work), and oxygen levels would have to be closely monitored with a pulse oximeter (band-aid type thing stuck on the index finger). After placing the plastic tube, the tube is connected to a special plastic container partially filled with water (tinted blue with a dye capsule) and wall suction to suck out any air or fluid in the pleural space. They would give oxygen by face mask and watch to see whether they needed to be intubated (breathing gets too fast (above 40

breaths/minute would be pretty bad), oxygen level goes too low, she turns blue, she stops breathing). The person's breathing and oxygenation are extremely important in a trauma situation. They would definitely get a portable x-ray while the patient was lying on the gurney to check for the presence of hemothorax (blood surrounding the lung) or pneumothorax (air leaking into the space around the lung). If the patient looks stable after all this, then he/she would go to the ward for monitoring (continued pulse oximetry and oxygen as needed) and care of the chest tube (you usually don't get to go home with a chest tube in you). What determines when you can get the chest tube out is 1) whether there is fluid -- blood, pus, etc. -- draining out of it; 2) whether there is an air leak (you do this by clamping a section of the tubing and having the person cough. You watch the plastic box the tube is hooked to for any bubbles, which are a sign of an air leak; 3) whether there is a pneumothorax (get chest x-ray to assess for presence). What you want is NO fluid coming out of the tube, NO air leak, and NO pneumothorax. Most people I've seen have to have their chest tubes in for about a week, sometimes several weeks, before they meet all criteria for removal. Once there is no fluid coming out, the wall suction is turned off and the chest tube is considered "put to water seal" because the water in the box is the only thing keeping air from going in. After being put to water seal for a day or so, and making sure there is no air leak, the person can have the tube removed. How would a person with a nicked lung feel? Well, it would hurt to breathe deeply. They may need pain medicine to help them breathe more easily, and breathing deeply is very important to prevent a condition called "atelectasis" (fancy word for collapse of the alveoli in the lung) which can lead to pneumonia. They would be given a contraption called an "incentive spirometer" which is a plastic toy with a hose on one end and a scale showing how hard you can breathe out. We usually tell patients they have to blow in this thing 10 times every hour (they hate it because it hurts, but it's really good at preventing atelectasis and pneumonia). They would also be encouraged to get out of bed as soon as possible (in the next day or so - at least up in a chair) which also increases expansion of the lungs. After they are put to water seal, they can walk around while carrying the box. It would also probably hurt to raise the arms on the side(s) where they were shot, and sitting up wouldn't be too fun either, but they should be able to do both with some effort and discomfort. Removing the chest tube is a lot of fun to do (for the medical student, anyway). Usually the person has tons of extremely sticky tape securing the tube to their chest. The tape has to be loosened (guys with hairy chests just love that part.) The person removing the tube has a piece of occlusive gauze ready. The patient is told to breathe in as deeply as possible, and at the end of the breath when the lungs are fully expanded, the tube is literally yanked out of the person as quickly as possible and the gauze slapped over the hole and taped shut. The speed is necessary to prevent air from entering the hole. Then the patient must get a chest x-ray *again* to check for pneumothorax. If everything's okay, then they can probably go home! The patient has to come back 1 week after the chest tube's been removed to get the occlusive gauze bandage taken off. By then the body should have clotted off the hole pretty well and no leak should occur. Consequences of a gun shot wound to the middle chest, near the heart (Injury to the great vessels) Two things that could happen, depending on how close the bullet was to the heart: a lung could be punctured, and/or one of the great vessels surrounding the heart (the vena cavas, the aorta, the pulmonary arteries and veins) could be nicked or lacerated. See above for a description of a a punctured lung (pneumothorax). Injury to one of the great vessels is very serious and can cause death in minutes to hours (the person bleeds to death internally), depending on the severity of the tear and whether surgery can be done emergently to repair the tear. Blood collects in the pleural cavity surrounding the lungs causing a "hemothorax". Symptoms of this include difficulty breathing and shock (weak pulse, dropping blood pressure, pale, cool skin, confusion progressing to unconsciousness) if the person is bleeding to death. There isn't much that can be done for such a person in the field, and they need to be transported to a hospital immediately. Vital signs (blood pressure, pulse, and oxygen saturation) should be constantly monitored. A quick physical exam should be done to listen to the person's lungs and heart as well as quickly assess for other injuries. The person should get an IV immediately and be given normal saline. (The paramedics can begin monitoring vital signs and start the IV in the field.) A chest x-ray should be done to assess how large and where the hemothorax is located (though a the doctor should already have a good idea of this from the physical exam). The chest x-ray may either show a "white-out" of one side of the chest where the lung should be, OR another common presentation is a "widened mediastinum" in which the white area where the heart is located becomes wider than normal. If necessary, a chest tube may be place to try to drain out some of the blood to make breathing easier, but the definitive treatment is emergency surgery (open the person's chest up) where the vessel tear is repaired. What would happen if a person was shot in the back, under the shoulder blade, and the bullet exits out the front, just below the collar bone (clavicle)?

In this case, the victim's lung would almost *surely* be perforated. The lung basically fills the rib cage and actually extends *above* the clavicle, especially during inspiration. You'd be dealing with a tension or open pneumothorax, maybe a hemothorax, needing lots of oxygen and pain killers, needing a chest tube and possibly a respirator depending on whether a person could maintain their oxygen saturation well enough -I think there'd be a big chance they would be intubated at some point, if for no other reason than to give the patient a break because of difficulty and pain with breathing. They would also be very vulnerable to getting a whopping pneumonia on top of that as well. Head Trauma Skull fractures: luckily, all of us have a skull which is designed to take a lot of beating (witness Jim's concrete head). Surprisingly, just because you have a skull fracture does not mean you have brain injury (the skull takes the blow), and people can have serious brain injury without having a skull fracture. Therefore, the more important thing is not whether the skull is cracked, but whether the injury resulted in a major blood vessel being broken and causing bleeding (hematoma or hemorrhage) or whether the brain itself was bruised (a contusion) or cut. Epidural hematoma: I picked this type of bleeding to talk about because it has a very classic and unique presentation and can be treated in the ER. If it is not recognized and treated right away (within 24 to 48 hours), it is fatal. How you get it: an epidural hematoma happens when a person is hit on the temporal bone of the skull (approximately the area above the ear), and usually (but not always) goes unconscious. An important blood vessel (the middle meningeal artery) runs just under the skull in this area and gets busted and starts bleeding. The person stays unconscious for a few minutes, but then wakes up and seems to be fine. However, the artery keeps bleeding and creates a collection of blood between the inside of the skull and the brain. In 4 to 8 hours, this collection of blood is so big that the person's brain starts getting squashed. The person develops signs of increased intracranial pressure (headache, nausea and vomiting) which can progess slowly at first but then progresses rapidly to confusion and coma. If the condition is not recognized and treated in 24 to 48 hours, the person's brain gets so squashed (it "herniates") that they die. You can see a crescent-shaped collection of blood on a CT scan of the patient's head. Treatment: the doctor must make a small hole in the skull over the temporal bone and evacuate (suck out) the blood collecting there, thus relieving the pressure on the brain. The patient usually recovers all right. Another fact: epidural hematomas tend to happen more often in younger people (yes, like Jim & Blair). Concussion: when a person temporarily goes unconscious as a result of trauma (being hit on the head). The classic example is a knock-out in the boxing ring. Treatment: Make sure the person had a concussion and no other brain injury . Check to make sure there are no neurological defects on physical exam and then do x-rays of the skull and neck [c-spine]). ER doctors often do a CT scan just to make sure there was no bleeding in the brain. That's the machine that looks like a big donut hole. They slide you inside and it takes a couple minutes to complete the scan. If that checks out okay, you can pretty safely send the person home with instructions on how to care for someone with head trauma (below). The treatment is close observation of the patient by a reliable adult for 24 hours to make sure the person doesn't deteriorate (go unconscious/into a coma/have other problems). The adult will do frequent mental status checks and knows to come back to the ER if need be. The patient does not have to necessarily stay awake, but the person watching them should wake them up/check on them probably every hour or so, especially at the beginning. They can take Tylenol for pain, but no narcotics or stronger pain medicines because that might make them more sleepy than normal and it'd be hard to tell if the person was getting sleepy from the drug or because their head injury was getting worse. People sometimes get what is called "post-concussion syndrome", in which they get a headache and nauseated, and sometimes throw up. This is not alarming unless things get really bad and they lose consciousness again. It's fine to give the person some medicine for nausea to help them feel better (Compazine pills or suppositories are a good one) and Tylenol is best for headache. These people usually don't need an IV (although in many ER's most patients get them automatically as a precaution -- I wouldn't put in an IV unless the person looked bad or was vomiting). They also don't need to be admitted to the hospital for observation unless they don't look good or the scan looks bad. A real hospital's instructions for head injury: Awaken patient every 2 hours even during the night to check for any of the following signs: Pupils unequal in size, double vision Persistent or increasingly severe headache (minor headache should be expected) Dizziness or weakness and/or paralysis of arms or legs Confusion, irritability, or personality change Drainage of blood or clear fluid from ears and nose

Convulsions or repeated/persistent vomiting Difficulty in arousing the patient, excessive sleepiness IF ANY OF THE ABOVE SIGNS ABOVE ARE PRESENT, CALL YOUR PHYSICIAN OR RETURN TO THE EMERGENCY DEPARTMENT IMMEDIATELY. Avoid sedatives and alcohol. Tylenol may be given for headache. Cerebral contusion: a bruise on the surface of the brain as a result of trauma. These are permanent but aren't usually of major significance unless you have a lot of them or they are very large. Basically, these are common in head trauma but the patient usually has bigger problems to worry about (like bleeding). Man, Jim must have several of these! Hospital course after having surgery to treat an epidural or subdural hematoma An epidural hematoma or a subdural hematoma (see above for details) are treatable by draining the accumulation of blood to relieve the elevated intracranial pressure -- in fact, these surgeries are lifesaving. The patient's head is shaved for the surgery. A piece of skull is removed to access the brain during surgery, and sometimes they don't put the piece back. So the person just continues to have a soft spot where the bone is missing. This isn't usually a problem. After about a week in the ICU, the patient would be transferred to the regular ward for several more days. It really depends on whether there are any complications (infection, reaccumulation of the bleed, etc.). If a person *doesn't* do well, it could be weeks. It's very variable. Long-term recovery: if the person gets surgery in time, they could feasibly do well and go home without needing further treatment if the surgery stopped the bleed. If the person's surgery was delayed, there could be brain damage, and then there would be the issue of long-term rehabilitation similar to a stroke patient. Injury to the upper airway/throat (trachea, larynx) The trachea (a.k.a. windpipe) is the tube made out of cartilage rings, that connects your throat (pharnyx) with your bronchi and lungs. The larynx is another name for the voice box and is located just above the trachea. Air passes through the larynx, vibrating the vocal cords and allowing you to speak. If these structures are injured so that air cannot pass through them, the patient will suffocate and die if another airway is not made for them immediately. The patient may need an emergency cricothyrotomy or tracheostomy (a hole is cut in the trachea just below the Adam's apple with a knife or other sharp object and a tube inserted so the patient can breathe). The patient can then breathe through this new hole that was created below the point of obstruction (hopefully with some extra oxygen if it's available.) Lesser injuries to the trachea and larynx can also occur. These injuries can often happen in a fight when someone gets punched or struck on the neck and their windpipe gets crushed. They might not be totally obstructed (they can still breathe somewhat), but it's pretty difficult to breathe because their airway might be partially blocked, plus it really hurts. If a person gets hit in the throat and then becomes hoarse, and you can feel air underneath the skin of their throat (called subcutaneous emphysema or palpable crepitus -- it feels like crackling air pockets when you touch their skin), that is highly suggestive of a fractured voice box (larynx). The patient needs surgery right away. Motor Vehicle Accidents Pedestrian hit by car: the most common sites of injury are 1) the legs (height and shape of fracture can help tell what direction the car was moving and the height of the bumper and whether or not the brakes were on). 2) head (site of most fatal injuries) 3) chest and abdomen (common site of injury when the person is run over). Car accidents: facts ER doctors like to know -- how did the cars impact each other (head-on?), speed of cars, wearing seat belt, had air bag, was the person ejected (thrown) from the car (much, much worse!), how smashed was the inside of the car, was the windshield "starred," did they have to use the "jaws of life" to get the person out, etc. Common injuries: Head -- major site of fatal injury if impacted with steering wheel, windshield, or dashboard Chest -- rib fractures, lung injuries with steering wheel impact (leaves classic round imprint on chest). Also rapid deceleration can cause breaking or shearing off of the great blood vessels near the heart (aorta, vena cava, pulmonary artery); the person either dies immediately or shortly after from bleeding to death (Princess Diana). Knees -- commonly hit the dashboard and fracture the patella or leg bones. The knee may also be dislocated posteriorly (backwards) from striking the dashboard. Person may have longterm disability. Injury to the Abdomen

I've categorized the following abdominal injuries by the area of the abdomen where the person was shot or hit. The abdomen can be divided into four quadrants, using the belly button as the center. Imagine the abdomen with a cross drawn on it and the belly button where the lines intersect. Helps to know some anatomy, too, but I'll tell you what's in each quadrant. Right upper quadrant This is the section underneath and below the edge of the rib cage on a person's right side. The liver, gallbladder, and large and small intestines are located here. The liver is one of the most commonly injured organs in blunt trauma (getting beat up really bad). It can be bad because the liver has lots of blood vessels in it and when it bleeds (as in when you get beat up) it can be very difficult to stop. The patient often needs surgery immediately to stop the bleeding. Epigastric area This area is the top middle section of the abdomen above the belly button and below the breastbone (sternum). The stomach, pancreas, and part of the small intestine (the duodenum) are located here. This is where you feel "heartburn" from eating too much Mr. Tube Steak or Cuban food (Jim must have an ironcast stomach!). If a person was hit here, they could develop a duodenal hematoma (bleeding in the wall of the duodenum that can eventually block off that part of the intestine and give the person a small bowel obstruction -basically the food can't get past the blockage and the person starts having a lot of pain, constipation, and nausea/vomiting). This could take hours or days to develop. The treatment is surgery to remove the obstruction. Getting hit here could also give you traumatic pancreatitis. This is a very nasty problem because the pancreas is the organ that makes most of your digestive enzymes, but it keeps all of them inactive so it doesn't digest itself. When the pancreas gets angry or inflamed, the enzymes it's been making can spill out and get activated, giving you pancreatitis. Basically all these enzymes start digesting your insides! Yuk! Pain, pain, pain. The classic pain is epigastric pain that radiates to the back, so the patient has a horrible "stomach ache" plus a horrible back ache. Not fun. The treatment is IV fluids, pain medicine, and not letting the patient eat anything, and waiting for it to get better on its own. Left upper quadrant This is the area underneath and below the left rib cage. The stomach and spleen are located here, as well as some large and small intestine. The spleen is an important organ because it is the most commonly injured organ in blunt trauma (getting beat up, car accident, etc.). The spleen is a very vascular organ located just underneath the left rib cage (its main purpose is to clean out old blood cells and bacteria from the circulation) and bleeds like crazy when injured. These people often have signs of bruising on the skin above the spleen, and may have left shoulder pain (Kehr's sign). A person can easily bleed to death if their spleen ruptures. The person needs to go to surgery ASAP where the bleeding is stopped, sometimes by totally removing the spleen (a "splenectomy"), because you can live without your spleen. Sometimes surgeons can save the spleen by tying off bleeding blood vessels or other nifty techniques. Right lower quadrant This is the area of the abdomen to the right and below the belly button. Important things here are the appendix and large and small intestines. It's the classic place to get pain when you get appendicitis. Appendicitis isn't usually caused by trauma, but I'll say something about it because it's so common. Appendicitis classically starts with pain centered right around the belly button. After a few hours, the pain migrates to the right lower quadrant to a place called McBurney's point where most people's appendices are located. The person's having pretty bad pain by now and doesn't want to eat anything, and feels nauseated and might be vomiting. (There's something called the "hamburger sign" -- if you ask a person if they want their favorite food -- like a hamburger -- and they say yes, then they don't have appendicitis.) If you wait longer, the person's appendix might burst, spilling out all its nasty contents into the abdominal cavity. Hopefully by now they're getting some medical help 'cause they look pretty sick. When you examine a person with appendicitis (or any other kind of busted internal organ), they often have signs of peritoneal irritation (the junk spilled out inside their abdomen is irritating the lining of their abdomen). This means they're really tender when you try to touch them, and their abdomen might feel like a board (really hard). People with appendicitis may also have a fever, and a blood test may show an elevated white blood cell count. These people need surgery to get that appendix out. In about 20% of appendectomy surgeries, the surgeon goes in and doesn't find anything wrong with the appendix. They take it out anyway because you don't really need your appendix, and so future doctors aren't confused when they see an appendectomy scar. This 20% rate is considered acceptable, though, because considered it's better to err on the side of taking too many appendices out rather than missing one that's sick. A person can die if their appendix bursts and they don't get it removed; they'll get a terrible infection that will spread to the blood. Left lower quadrant There ain't much special here except the large and small intestines. Oh yeah, if the patient is a woman, a whole bunch of things can go wrong with the female organs (located in the right and left lower quadrants). I won't go into those here. The large and small intestines are often injured when someone is shot in the

abdomen, because they take up the most space in the abdomen. See the section below, Complications of a Gun Shot Wound to the Abdomen, for what happens when you get shot in the intestines. Flank This area is the upper back (lower part of the rib cage) on both sides, where the kidneys are located. The kidneys are often injured in blunt trauma ("kidney punches" in fights). Injured kidneys may bleed and the person may have blood (either obvious or microscopic) in the urine. The worst thing that can happen is that the kidney is so badly injured that it "fails", or stops producing urine like it's supposed to. The bad thing about this is that you need your kidneys for getting rid of the waste products the body produces and keeping all the electrolytes at the right levels. If this happens quickly and you can't get rid of the waste products or balance your electrolytes, you get very sick and might need dialysis. If you don't get dialysis, you go into a coma and die. Luckily most people have two kidneys, so if one fails at least you've got the other one as backup. Someone with injured kidneys needs to be watched closely at first to make sure they don't go into kidney failure. Doctors can follow a person's kidney function with a blood test called "BUN and creatinine." When the BUN (blood urea nitrogen) or creatinine get too high, that's a bad sign that the kidneys aren't excreting these waste products like they're supposed to. Doctors often order a test called an "IVP" (Intravenous Pyelogram), where you inject dye into the person's blood and take a series of x-rays, watching to see the kidneys light up on the x-ray as they clean out the dye molecules from the blood. If you do an IVP and a kidney doesn't light up, that's bad and means there's some malfunction with the kidney. Complications of a Gun Shot Wound (GSW) to the Abdomen The main complications of a gunshot wound to the abdomen fall under bleeding or infection. A GSW that punctures the large or small intestines (you call it "perforation" or a "perfed viscus") is mostly a problem with infection, because all the bacteria inside the intestine spill out into the abdominal cavity (peritoneal space) and set up a big nasty infection called peritonitis. It's worse if the large intestine (colon) is hit because there are a lot more bacteria inside the colon. BTW, the most common organ to be hit in a GSW is the small intestine, because it takes up the most space in the abdomen. The problem with getting peritonitis is that the person may be overwhelmed when huge amounts of bacteria enter the bloodstream and they may go into septic shock, with high fever. These patients look sick and may feel warm and sweaty with the fever. Later, they get cool and clammy. All the blood vessels dilate and the person's blood pressure drops, therby killing them. It usually takes many hours (24 hours or maybe more) to die from peritonitis usually (if you're a healthy person). Survival depends on a lot of factors. How much blood the person lost, how healthy they are to begin with, and most importantly how soon they get to a hospital and get help. Getting the person to a hospital and giving them IV fluids and antibiotics can save most people with peritonitis. Bleeding is the other main thing that can kill a person with a GSW to the abdomen. Bleeding is worst if the person gets shot in the liver or spleen. The spleen is actually the worst (it's a little-talked-about organ tucked underneath the bottom of your right rib cage) because it is the most vascular organ -- lotsa blood stored there. The spleen and liver are most vulnerable if the person suffers blunt trauma (gets beat up or pounded with something). Bleeding can also be a problem if you get shot in the intestines because they have blood vessels too, but it's not as big a problem as with the liver or spleen. Blood loss can kill a person much faster than infection. It all depends on how many blood vessels have been punctured and how big the blood vessels are. These people look pale from loss of blood, their skin feels cool and clammy, they breathe fast, their pulse is very fast, and their blood pressure may be low depending on how much blood they've lost. If a person gets a serious wound in the liver or spleen, they could die in a matter of minutes from bleeding to death on the inside (the blood goes into the abdominal cavity -- "massive internal bleeding") unless the bleeding is stopped very quickly. And if you get shot in the aorta (the main artery of the body coming from the heart -- it's in the midline above the belly button), well you're pretty much a dead duck in a few minutes. The person never makes it to the emergency room. It's possible for the bleeding to stop by itself if the person is lucky enough to get shot in a spot where the pressure from the collecting blood stops the bleed by itself. If the person does make it to the hospital within an hour or so (which they do often in liver or spleen wounds), you usually have to do emergency surgery to stop the bleeding. If it's the spleen, they can totally take the spleen out (splenectomy) because you don't need your spleen to live. If it's the liver, that's harder because you need your liver. They may try to cauterize (burn) the bleeding blood vessels to stop the bleeding, sew them up, or whatever. I don't know exact survival rates on GSW to the abdomen. Survival depends on a lot of factors, like I said before -- how healthy the patient is, how badly they're injured, what organs were hit, how quickly they get medical help. People have survived from pretty much all types of GSW, but a good number die as well. Gun shot wounds generally have to be explored with surgery, because sometimes it's hard to tell what organs were exactly injured. Also, the shock wave from the bullet may injured surrounding organs not directly in the line of fire.

Suturing a wound in the ER This is assuming the person's injuries aren't severe enough to need surgery, and they're otherwise okay -obviously you aren't going to try sewing someone up if they've got more pressing problems (like they're dying), or if the wound goes into the chest or abdomen and needs surgery, or if there's a huge broken bone sticking out from it! We're talking classic Jim and Blair "flesh wounds" that are too big and deep to heal well on their own, so they need stitches. First, you should give the person some anesthetic because cleaning and sewing the wound will hurt a lot. You get a small syringe with lidocaine in it and inject generous amounts inside the wound and under the skin where you'll be sewing. It usually burns when it's going in, but in a few minutes the area goes numb. You can use lidocaine with epinephrine in most wounds (examples of places you do not want to use lidocaine with epi are the nose, fingers and toes). Epinephrine is helpful because it helps stop the bleeding. After you've injected lidocaine and given it a few minutes to kick in (you can poke around and see if they can feel it -- the person will still be able to feel pressure, just not pain), then you must explore the wound. That means making sure there aren't any foreign objects (splinters, pieces of glass, rocks, etc.) inside the wound. Then the wound must be irrigated (washed) with a lot of sterile saline. You usually stick the body part in a basin and pour tons of saline over it. If it's really dirty, you can use a sterile brush to get the junk out. Now you're ready to sew. Most wounds close well with a series of "interrupted" stitches, which are separate stitches (not connected) individually knotted. You use a curved needle and often nylon suture. The important thing is to bring the two edges together but not too tightly. Once you've placed the stitches, you can cover the wound with some topical antibiotic like polysporin or neosporin gel, then put a bandaid or sterile gauze on top of it. The number of days suture should stay in depends on where the wound is. Stitches on the face stay in the shortest amount of time -- about 5 days. Stitches on areas with a lot of tension (joints like knees and elbows) must stay in a lot longer -- 2 or 3 weeks. Other places like arms, legs, hands, feet, stay in about 1 to 2 weeks. The patient should be given instructions on when to return to get the stitches out, and wound care instructions below. Wound Care Instructions from a real hospital Keep wound clean and dry. Watch for signs of infection: 1) swelling, 2) excessive tenderness, 3) redness or streaks, 4) heat, 5) drainage (pus) Change outer bandage if soiled or wet. How would the paramedics transporting someone with severe back and internal injuries? The default position for transporting an injured person is lying on their back because it is the easiest position for paramedics and other medical personnel to get access to the person's mouth and to control their breathing (the most important thing). So even if a person had back lacerations, if they were unconscious or in any way unstable or had serious internal injuries, they would still be transported on their back because the paramedics would need to be able to have easy access for delivering oxygen to their nose/mouth (probably via a bag). Theoretically they could deliver oxygen if the person were lying on their side, but it's a lot harder to keep an unstable person in that position during a transport (they would roll too easily). On the other hand, if the person was conscious and didn't have anything else wrong with them besides the back lacerations, the paramedics would probably have mercy on the person and let them lay whichever way was most comfortable for them (probably on their side or stomach). Would the paramedics give a patient painkillers? Depending on the county, paramedics can give certain drugs including painkillers for certain pre-defined conditions including injuries and chest pain, per the protocol determined for them by doctors. Their main job is to stabilize the person and keep them alive until they can get them to the hospital. A person gets impaled by a sharp object through the shoulder, with the object exiting out the front. How should they be treated before they can get to a hospital? OUCH!!! Ow, ow, ow. Ow. Did I say OW? <g>. When people get impaled by something in a non-vital spot (like the shoulder), the best thing to do is leave the foreign object where it is (don't try to remove it) and get the person to the nearest hospital where surgery can be performed to remove it. I have seen pictures of *much* more disgusting things impaled in much worse places (a pitchfork and a stop sign post impaled into a person's abdomen comes to mind), and they just get the person to the hospital as soon as possible. These people actually usually survive after the object is removed. Try to make them as comfortable as possible. You'd just have to use common sense, but fashioning a sling for the arm (probably held bent at the elbow like a broken arm would be) in the most comfortable position for the person, would probably

take some of the tension off the injured shoulder and make it easier on them. The biggest thing you'd have to worry about would be bleeding, but if you leave the object in place, that usually isn't too much of a problem. Infection could be a problem, but only if the person couldn't get medical help for many hours.