Author Question: Motor Vehicle Collision 2/2

Today, we’re focusing on Susan’s questions surround two victims of a car accident. You can find the first post here.

Let’s turn our attention to the second patient.

Patient #2: The passenger (the above's twenty-six- year-old sister) flies from the convertible.
 

1. If she was found unconscious about 20 feet from the vehicle without any injuries, how would EMT's treat her?

2. Would she still be in her own clothing while unconscious at the hospital?

3.What sort of treatments would they give her, if any, at the ER? IV's, examinations, etc?

We find out later that the passenger actually was near death and healed by a supernatural character. She actually hit her head (skull fracture?) and is close to death when he finds her

4. Is this scenario even possible or would she have immediately died from the injury?
5. If her survival was impossible, what can I make her injuries so she can be healed by the other character?
6. How would she appear? Eyes open, eyes closed, or would it matter? Vomit? Skin coloring?

Jordyn Says:
1.  One, they’ll assume she could be gravely injured considering her mechanism of injury. They’ll first check to see if she’s breathing and has a heartbeat. At the same time, they’ll be stabilizing her spine by putting on a C-collar and placing her on a backboard. If she’s breathing on her own at an adequate rate, they’ll give her some oxygen via a mask. If she’s not breathing or doesn’t have a pulse then they’ll begin resuscitation by giving her breaths and doing CPR. After those major things are taken care of, they’ll start an IV to give her some fluid. Then begin to look for secondary injuries. An unconscious patient thrown from a vehicle will have presumed traumatic brain injury or TBI.
2. If the EMS team can provide her adequate care without cutting off her clothes, then they’ll leave her that way until she gets to the hospital.

3. In the ER, we start where the EMS team left off. We’ll start our assessment much in the same way the EMS team does. We continue any care they’ve provided. If they were unable to get IV access—we’ll start to work on “getting a line”. We’ll do a detailed secondary survey looking for other injuries which means entirely undressing the patient, log-rolling them to their side and checking for injuries to their back as well. A catheter would be inserted into her bladder and the urine tested for blood and she’d also likely get a pregnancy test.

Additional tests in the ER for this unconscious patient would be: x-rays of her spine, CT of her brain and likely chest and abdomen. Some baseline labs: blood counts, electrolytes, labs that look to see if organs have been injured and bleeding time studies. They’d likely “type and cross” her for blood products. Any other injuries would be x-rayed as well—for instance if her arm were misshapen or significantly bruised.

The unconscious patient is challenging because they can’t tell you what hurts.

 4. Skull fractures can run the gamut and there are several different types of skull fractures. A patient could have a traumatic brain injury that eventually causes death but just have a simple linear skull fracture. Or, a patient can have a depressed skull fracture and be awake and talking to you. As an author, you have a lot of leeway here.

5. I guess it depends on what you mean my “healing”. Do you want her to have evidence of injury but be fine?

6. I’ll go with the assumption that she presents to the ER unconscious. An unconscious patient can look relatively well to nearly dead—again, you have a lot of leeway here. They can “appear to be sleeping” except they’re completely dead weight. There are specific vital signs a patient will demonstrate when their brain is swelling but I’m not sure you want to go that route.

Hope this helps and good luck with your novel!

Author Question: Motor Vehicle Collision 1/2

Susan Asks:

I found your site while I was researching some things for a story I'm writing. I'm not sure I will ever try to get this story published or anything, but I wanted to get all my details as accurate as possible.  

In the story two people are involved in a car accident.

Patient #1: The driver, twenty-three- year-old male. Hits the steering wheel and ruptures his aorta. This character dies.

My questions are: 

1.  Could he be conscious immediately following this?
2. Would he make it to a hospital about 4 miles away in an ambulance or likely die at the scene?
3. How would he look in the hospital after death (coloring, would they leave his clothing on if he just died)?
4. Would they let his sister see his body?

Jordyn Says:
1. Would he be conscious? Yes, it’s possible but for a very short amount of time following his injury. Your aorta is a very large vessel that comes right off the heart. If it is entirely ruptured—you’ll bleed out in one to two minutes. The quicker the blood loss the sooner unconscious sets it because blood supplies oxygen to the brain and the brain is a very oxygen sensitive organ.
2. This character would likely die at the scene.
3. What you might want to look into is reasons an EMS provider is allowed to call death at the scene. Patients who are obviously dead may not even go to the hospital. Let’s say they do “work” him and bring him to the hospital where he is declared dead shortly after. Likely, his clothes are on with the exception of the care EMS provided. It’s atypical for them to cut off all their clothes like a trauma center will. He’ll be extremely pale with areas of blueness. Livor Mortis begins fairly quickly where the blood will be begin to settle in dependent areas of the body. This looks like bruising. If he lying on this back—it would settle all along his backside.
4. Yes, the sister would be allowed to see his body. Nurses are pretty sensitive to this so they’ll try to make the body as presentable as they can and explain what the sister will see before she views the body.

We’ll tackle Susan’s second patient in the next post.

Author Question: Delivering Bad News

John Asks:

I'm killing off the husband of a wife. He's had a car accident and will die in the ER. His jeep was T-boned, rolled, and he was thrown out of the vehicle into oncoming traffic. The first vehicle rolled over his legs. She's been called to the ER. Can you point me to a good write-up of what would go on in the ER for both him and his wife as she arrives? 

Jordyn Says:

I don't know of one specific source so I'm including some links to my blog that talk about care of the car accident victim.

http://jordynredwood.blogspot.com/2012/10/author-question-car-accident-injuries-12.html

http://jordynredwood.blogspot.com/2012/10/author-question-car-accident-injuries-22.html

http://jordynredwood.blogspot.com/2013/04/author-question-treatment-of-car.html

As far as the wife-- typically news of a patient's death is not given over the phone. We usually say something like, "My name is Jordyn and I'm the nurse taking care of Johnny. He was involved in a car accident and is critically ill and we need you to come to the hospital. Please take your time and drive safely and we'll talk more when you get here."

When the spouse arrives they are usually taken to a small family room where the attending physician and likely the nurse (or some other person who can care for the spouse so the physician can leave) delivers the bad news. We don't use phrases like passed on, gone home, or lost the battle. It usually goes something like-- "Johnny was involved in a serious car accident. Despite our best efforts your husband died from his injuries."

The first part should be short and to the point because families don't hear much after you tell them that their loved one has died. Then we'll usually take the family's lead and let them ask whatever questions they need to.

Usually there is some prepping of the body so it's as presentable as possible. However, if the patient is going to be a coroner's case then all lines and tubes must be left in place. This is explained to the family as well as to what they'll see when they get into the room.

"I'm going to take you to see Johnny now. Just so you're aware he has a tube still left in his mouth and nose and several IV's in place. His face is very bruised from the car accident and his left arm is deformed from a broken bone."

Something along those lines. Even if the patient hasn't died-- we do try and prep the family for what they will see.

Families are given as much time as they want to be with the patient. If the ED is CRAZY busy and we absolutely need the room, arrangements might be made for the patient to go to a med/surg room to give the family more time with the body. It would mean needing to move the patient out of the ER for this and would be very rare. 

Author Question: Car Accidents, Head Injuries and Strokes Oh My!

Holly asks:

Got a question. Ok....let me try to make this simple. Charlie sees a doctor for some dizzy spells about a month prior to his accident, but doesn't go for further tests. He needs orthopedic surgery for broken bones after the accident. Would they do the surgery?

Jordyn: I don’t see this as a big reason NOT to do the surgery. Dizzy spells are pretty non-specific meaning LOTS of things benign (like I have extra fluid in one ear) to major (I have a brain tumor) can cause this. Most often times it is something very benign and transitory.  

Holly: And if he hit his head when his truck rolled over, would he HAVE to have a head injury?

Jordyn: No, he wouldn’t have to have a head injury in the sense that he wouldn’t have to have concussion. He likely would have some bruising and pain at the site of impact but head injury is denoted more by global headache (my whole head hurts and not just the bump), loss of consciousness, nausea/vomiting, confusion, and perhaps amnesia progressing to more serious things if you choose.  

Holly: I'm setting up a scenario where the insurance wants to deny coverage because of a pre-existing condition. (the dizzy spells maybe caused a stroke, or so they determine.)

Jordyn: I don’t think a complaint of dizzy spells would be enough for this. It’s not really a pre-existing condition. A pre-existing condition has to be an actual medical diagnosis and dizziness is a symptom—something only the patient can tell us they experience. A symptom is not something we can measure. So, if he had a diagnosis of TIAs or Transient Ischemic Attacks and one of his symptoms was dizziness then this might be more believable.

Holly: Which gives me a new question. Can you prove a stroke has happened? Or a mini stroke.

Jordyn: Yes, strokes (new and old) can appear on certain imaging tests. MRI is more specific for old and new brain injuries caused by stroke.

Motor Vehicle Collision: Dianna Benson, EMT

I love this post by Dianna Benson, EMT written in first person about the treatment of a patient involved in a MVC. A lot of information presented in such an interesting way.

Dianna's debut novel, The Hidden Son, released in March.

Welcome back, Dianna!

EMS #16 and #22 MVC at Park Avenue and Green Street.

I toss the rest of my sandwich into a trashcan, and rush out of the fast food joint toward my ambulance, my partner behind me.

Less than five minutes later, we roll up on scene behind an arriving ladder fire truck. I slip mybright orange reflector EMS vest over my head and lurch toward two cars mangled together in a huge intersection, their hoods now one. The EMS #22 crew heads to the one patient in one car, so my partner and I bolt for the two patients in the other.

A civilian is leaning inside the driver’s door.

“Sir?” I say, approaching.

He looks at us, eyes wide, face pale. “Glad you’re here. I’m a doctor, an urologist, but I see patients in my office. I don’t deal with emergency—”

“It’s okay. We got it.”

Blowing out a sigh, he backs away.    

Unconscious, the driver’s face is buried in the deployed air bag, arms dangled around it in a laxhug.

“Sir?” I feel his pulse. It’s thready and rapid. Blueness surrounds his mouth and colors his lips, his chest not rising and falling. “Respiratory arrest,” I say to my partner who’s assessing the unconscious passenger, the lifeless patient’s head caught in the shattered door window.

Frowning, my partner shakes his head. “Cardiac arrest over here. Facial skin ripped away. Neck twisted 180 degrees and split open. Bled out.”

Code for: We can’t do a thing for her.

My partner rushes our equipment-loaded stretcher around the trunk to the driver door, as I wave a firefighter over to climb into the backseat. With both hands, the firefighter stabilizes the patient’s head straight against the headrest as I assess the minor facial wounds caused by flying glass. Another firefighter grabs the airbag, punctures it and rips it out of my way.  

I insert an oropharyngeal down my patient’s throat to protect his airway. I cover his mouth and nose with a BVM—bag valve mask—connected to oxygen tubing and a D-tank running at 15 liters per minute. As I squeeze the football-size bulb every five seconds to oxygenate his system,I assess his legs. Right femur appears fractured, left is covered with bleeding abrasions and lacerations, but no hemorrhage threat.

I strap a C-collar around his neck. Keeping his spine in-line, my partner and two firefighters place his body on a backboard on top of the stretcher, as I continue to bag him. I check his pulse again. Still present. I check for spontaneous breathing. Still nothing, although cyanosis no longer blankets his lips. I brace his entire right leg in a traction split to assist with hemorrhage control.

Inside the ambulance, my partner hooks our patient up to the cardiac monitor via a 12-lead, a firefighter bags the patient, and I perform a rapid trauma assessment, head to toe. After I find no other significant trauma or issues, I spike a bag. Less than a minute later we have an IV bolus in place, running high fluids.      

Spiked and dipped lines display on the monitor screen. “Normal sinus rhythm,” I speak out loud. “But hypotension and tachycardic.” Meaning low BP and high pulse rate. I’m thinking it’s possible this patient is headed to hypoperfusion (shock) due to internal blood loss.

   

“Ready?” another firefighter asks from the ambulance’s driver’s seat.

“Yep, take off.” I listen to our patient’s chest. Heart beating rapidly but strong. Lungs sounds absent on the left side. Diminished on the right.

I eye my partner. “I’m thinking left pneumothroax. Right may be heading in that direction.” I read the monitor screen. “Severe hypotensive now. How about administering Dopamine?”

“Already on it,” my partner says, filling the IV catheter with the med. “He needs chest decompression. Let’s—”

“I’m having trouble bagging,” the firefighter says. “You wanna intubate him?”

   

“Do you have full resistance or only some?” I ask.

“Full.”

Blood quirts out of the patient’s mouth.

I gain my partner’s eye contact. “Cricoid intubation?”

“Yep. Chest decompression can wait.”

I locate the cricothyroid membrane, and prep the area with betadine. My partner punctures the skin with a needle while aspirating for air with a syringe, then slides a cannula along needle and syringe. I secure the cannula with a neck strap, and osculate for breathing with my stethoscope.

I hear solid breath sounds. “We’re good,” I say then eye the firefighter. “Continue bagging.”

I snag the radio and switch the channel to the number one trauma hospital.

“Wake Med? This is EMS #16. We’re en route with an MVC patient. Unconscious. Absent left lung sounds. Diminished in right. Surgical trach in place. O2 saturation 90% with BVM at 15lpm. Bolus IV in place. Dopamine dose administered. BP 90/50, pulse 162.  ETA 15 minutes.”

“Chest decompression,” my partner says as he arranges equipment.

To prep the site, I rub iodine to the patient’s second intercostals in the mid-clavicular line. My partner inserts a 14-guage catheter into the skin over the third rib. He advances the catheter through the parietal pleura.

“Pop,” he says indicating he felt a pop, which is the goal. He advances the catheter to the chest wall, then removes the needle, leaving the catheter in place.

I secure the catheter to chest wall with dressings and tape.

Six days later, I see the patient exiting the hospital in a wheelchair, his right leg casted. Two hospital employees assist him into an awaiting car. I smile huge and thank God.

***********************************************************************

Dianna T. Benson is a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne de Maurier Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. Her first book, The Hidden Son, released in print world-wide March 1, 2013. 

After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMS degree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need. Her suspense novels about adventurous characters thrown into tremendous circumstances provide readers with a similar kind of rush. Dianna lives in North Carolina with her husband and their three athletic children. Learn more about Dianna at www.diannatbenson.com.

   

Author Question: Treatment of Car Accident Victims

Taylor asks the following regarding treatment of multiple victims of a car accident. 

SCENARIO: Serious MVC involving two cars and multiple victims. All passengers were wearing seatbelts, and airbags deployed, but the crash was serious enough that victims are still severely injured.

Jordyn: When writing about the car crash—I’d have it be pretty visual that the car is near ruin. Particularly if someone has died on scene. Having the car rollover several times would accomplish this.

Taylor: Three girls (friends) were in one car together, on the way to a Christian concert. Drunk driver character had an argument with his wife about his drinking, denying that he has a drinking problem, then got angry, left the house and went out for drinks (doing the very thing they just argued about, partly to spite her and partly "to calm down"). He causes a crash with the girls.

CAR ONE: This vehicle contains only the driver.

DRIVER: The driver is a male in his early thirties. He is slumped forward in his seat, initially unresponsive, but rouses when medics address him. There is a strong smell of alcohol on his breath, and although he is responsive, he is displaying obvious signs that he is intoxicated. Upon seeing the crash scene in front of him, he becomes upset, crying and saying things like, “I didn’t mean to”, “My wife is going to kill me”, and “What have I done?” He has a bleeding laceration on his forehead and minor scrapes and bruises on his face (from the impact of the crash and airbags), and bruising from his seatbelt. Aside from these, he is uninjured. Vital signs are elevated, but within normal limits.

Jordyn: This patient would be placed in C-spine precautions. An IV/fluids started. Usually, when EMS starts an IV—they’ll grab several tubes of blood that the hospital can send to the lab. They’ll dress the laceration on his forehead and not likely worry about the minor cuts and scrapes. Whenever there is seatbelt bruising, we always worry about what would be injured underneath.

In the ER: Since he’s intoxicated, he’s not a reliable informant about his pain. So, he’ll get automatic C-spine films to rule out neck/back fracture. They might even consider a CT of his chest and abdomen (they’ll take vital signs into consideration). Law enforcement will be involved and they’ll want blood alcohol levels and if your book is in a specific/real location—I would figure out what the procedure is in that town/city. After major stuff is ruled out—his cuts will be cleaned. The laceration to his forehead would be irrigated and stitched. Tetanus shot if none in the last five years. Once he’s medically cleared, I’m guessing he would be off to jail.

CAR TWO: This vehicle contains a driver and two passengers.

DRIVER: The driver is a female, age 18. She has no detectable pulse or respirations. Apparent DOA, killed on impact in the crash.

Jordyn: She may be declared dead at the scene. That would probably be the easiest way to manage this patient.

PASSENGER ONE: Female, age 17. Managed to free herself from the car after the crash, and is sitting in the grass a short distance away. She is displaying signs of shock. Respirations are slightly shallow and rapid, skin is pale and clammy, and pulse and heart rate are elevated but still within normal limits. She is mostly responsive, but groggy/drowsy and complaining of severe headache, nausea, and dizziness. Chest and neck are bruised from her seatbelt, and she has several other bruises and superficial bleeding cuts on her body. Her right arm is bruised, swollen, and oddly angled, and she is cradling it against her chest and complaining of pain.

Jordyn: Since she is shocky, she’ll get an IV/fluids and tubes drawn for labs at the ER. Considering the mechanism of injury (the fact that one of the occupants of the crash has died) she’ll be placed in C-spine precautions as well. All surviving patients (including the drunk) will also be give oxygen (as it is treatment for shock as well). Her arm will be splinted in a position of comfort. It’s hard to know if they would give her pain medication or not—her c/o of headache, nausea and dizziness could signify head injury and giving a narcotic could complicate that assessment. So, she may just have to tough it out until she’s in the ED.

ER: Vital signs. X-rays of neck, back and deformed arm. Possible CT of the head, chest and abdomen. Often times, deformed extremities need to be reduced either in the OR or can be done under conscious sedation while in the ED. Depends on how you want to go. This patient may be able to go home if her arm can be set in the ED and no other significant injuries are noted.

PASSENGER TWO: Female, age 17. Pinned in her seat inside the car, unable to free herself. Conscious and responsive, but clearly very frightened, and displaying signs of shock. She is complaining of some pain in her neck, numbness and lack of sensation below the waist, and inability to feel or move her legs. Chest and neck are bruised from her seatbelt, and she also has several bruises and cuts on her face, arms, and legs. There is a large, deep bleeding laceration on her right lower leg.

Jordyn: Same: C-spine/back board. IV, fluids, oxygen. Get blood for labs. Laceration of right lower leg will be bandaged to control bleeding. 

ED: Largest concern for this patient is her sign of C-spine injury. So, not only would she get C-spine films. She’ll likely get CT of her neck, spine, chest and abdomen. Probably would x-ray the leg with the laceration to look for foreign bodies before closing it up. Stuff like the leg laceration can wait until a medical game plan is decided upon after they figure out what her neck injury is.