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by Murder

  What Happens When Someone's Nose Is Broken?

  Q: What does a guy look like after a broken nose? Does it have to be operated on? Is it possible to suffer a severe blow to the nose and just have a nosebleed and no fracture?

  A: The victim's nose could simply bleed; or it could swell up, turn purple, and bleed; or it could be shattered and deformed, even flat-

  tened, and bleed. Regardless, it would bleed. Since the inside lining of the nose (called the "nasal mucosa") is very vascular, bleeding is common even in minor injuries.

  The nose is mostly cartilage; only its base is bone. Since the cartilage is flexible and springy, sometimes a heavy blow only damages the soft tissues and no fracture occurs. Sometimes the cartilage or the bone, or both, will fracture. Anything is possible.

  A fractured nose is often maneuvered back to its original position, bandaged, and allowed to heal. Though it usually isn't, surgery may be required. Often a short metal splint is taped along the nose to support it during the healing phase.

  The injured nose would remain black and blue—as would the area beneath the eyes, since the blood tends to collect there—for at least two weeks.

  How Long Will a Black Eye Persist?

  Q: My character gets punched in the face, near her eye.

  How long will her black eye last?

  A: Bruises (contusions) are caused by the leakage of blood from the small capillary blood vessels that have been injured due to some trauma. A fist in the eye, a thigh banged against a table corner, and a twist of an ankle are traumas that can lead to bruising. The extent of the resulting blue-black discoloration depends on how much blood seeps from the damaged vessels, and it varies in different areas of the body. The tissues around the eyes (the periorbital area) are very vascular (loaded with blood vessels) and soft. As a result, they bruise easily and severely. The discoloration that appears in this area is much more pronounced and more prolonged than a contusion of the thigh or the arm. In periorbital contusions the effect of gravity often pulls the blood, and thus the bruise, downward into the upper cheek.

  The seepage of blood from the capillaries continues over two to three days, so the bruise expands and darkens during this phase. That is why you should apply ice to contusions for the first seventy-two hours. It helps the blood clot by slowing its flow, which reduces the leak and thus lessens the bruising.

  From day three to about day ten the blood that has leaked into the tissues is broken down and removed by the body's enzymes and scavenger cells (macrophages). The initial deep blue-black color progressively fades.

  From day ten through about day twenty the purplish remnant of the bruise becomes brownish green and/or brownish yellow. This is due to the body's enzymatic destruction of hemoglobin (the iron-containing oxygen-carrying molecule in the red blood cells), which produces breakdown products that possess these characteristic colors. These, in turn, are consumed and carried away by the macrophages. The discoloration should resolve by day twenty, and the skin color in the contused area should return to normal.

  In summary, the blue-black bruise deepens and expands over three days, lightens and begins to fade over the next seven days, changes to a brownish, yellowish, then greenish color, continues to fade over the next ten days, and finally resolves.

  Your character should be able to cover the damage with makeup after day seven to ten or so.

  Where Would the Spinal Cord Have to Be Injured to Cause Quadriplegia?

  Q: A character in my story is paralyzed when he walks away from a confrontation and is shot in the back. He becomes a quadriplegic with some use of his right arm and hand, and he can breathe without help from a respirator. Where would the bullet enter the spinal cord to cause this? What caliber bullet would be required?

  A: The spinal cord extends from the brain stem, which protrudes from the base of the brain, down the back. It is protected by the bones of the spinal column. Along its path the cord sends nerves out to the lungs, heart, arms, legs, and so forth. Think of the spinal cord as the main electrical cable into your house. As it extends from one room to the next, it splits off branches to the living room, bedroom, kitchen, garage, and so forth. If the main cable is severed, the branches that come off after the area of damage will fail, while those that split off earlier will continue to function. In the above sequence, if the cable is cut between the bedroom and the kitchen, the kitchen appliances will no longer work and the garage door opener will be dead. The lights in the living room and bedroom would not be affected. Similarly, if the spinal cord is damaged, all the body parts distal (downstream) of the area of damage will cease to function properly.

  Functionally, the spinal cord is divided into "levels," though if you viewed it anatomically, it would show no such divisions. The spinal cord levels are named to correspond with the spinal vertebra at any given level. The major levels are the cervical (neck), thoracic (chest), lumbar (lower back), and sacral (tail or buttocks). There are eight cervical vertebra and cord levels designated CI through C8; twelve thoracic (T1 through T12); five lumbar (LI through L5); and five sacral (SI through S5).

  Each level sends its nerves out to different parts of the body. These areas of enervation are called "dermatomes," and charts exist that show what level of the cord sends nerves to what parts of the body (Figure 4). When a physician examines a patient with a spinal injury, he can determine the level of the injury by determining what parts of the body have defective motor (movement) or sensory (sensation) functions. For example, C2 enervates the scalp and jaw, T10 the body at the level of the umbilicus (belly button), and LI through L3 the upper legs. If the physician finds that no cord function exists below the level of the umbilicus, he may con-

  clude that the cord was injured at about T10. In this case the victim would be deemed paraplegic, since he would have lost use of his lower extremities while everything above T10 would function normally.

  In your scenario the important levels would be C3 though C5, which control the diaphragm and respiration, and C6 through C8, which enervate the upper extremities. Your character's injury must be below C5 for respiration to be intact but above C8 if most of his upper extremity function is lost. This means that an injury at the C6 or C7 level would work. This corresponds to a bullet entry wound near where the neck joins the shoulders in back. An injury at this level would allow the victim to retain the ability to breathe while losing function of one or both arms.

  It is important to note that the defect doesn't have to be symmetric; that is, the left side can be affected more than the right, and vice versa. So your character could have some or even complete use of his right arm and hand, and complete paralysis of the left. Such is the nature of these types of injuries.

  Any gun could cause this injury. Small calibers, such as .22 and .32, could sever the cord with a direct hit. Larger calibers, such as .357 and .44, can do a lot more damage and injure the cord with a less-than-direct hit.

  Could My Pregnant Character and Her Unborn Child Survive a Severe Concussion and Near Drowning?

  Q: One of my characters is a woman who is six months pregnant. During an explosion she bashes her head on an indoor swimming pool ladder and falls unconscious into the pool. She is without oxygen for an undetermined amount of time, but not long. Mouth-to-mouth is performed almost immediately, and she begins to breathe but doesn't regain consciousness. At the hospital the doctor determines that she is in a light coma. The baby, based on ultrasound, seems to be okay. She remains in the coma for two or three days, each day becoming more responsive. Does this make sense? Would there be long-term side effects? Are there any other tests or treatments they might perform?

  A: Your scenario is not only possible but also likely.

  What happens long term depends on the severity of the original trauma, the effectiveness of her treatment, and luck. She could have nothing more than a concussion, or she could have an intracranial bleed (bleeding within or around the brain) such as a subdural hematoma (the collection of blood between the brain and t
he skull), which requires surgery. She could suffer severe and irreversible brain damage from lack of oxygen during the period that she wasn't breathing, or she could recover with no long-term impairment. From your description a simple concussion fits best. People with concussions may wake up almost immediately or remain in a coma for days, as in your situation.

  Most likely she would recover well with only residual problems such as headaches, some loss of cognitive function (thinking and problem solving), and some difficulties with memory. These would probably be minor and improve in a month or so. She likely would not have any motor or sensory problems; that is, her legs, arms, and other parts would work okay. She could develop a seizure disorder from a brain scar left by the force of the trauma, but this would be unlikely.

  In the hospital an X ray of the skull and an MRI or CT brain scan (with shielding of the abdomen by a lead apron to protect the fetus from X-ray injury) would be done, and possibly a spinal tap and an EEG (electroencephalogram—a test of brain wave activity).

  She would be treated with IV medications such as steroids (Solu-Medrol and Decadron are good ones) and possibly diuretics (Lasix or Mannitol, most likely) to reduce any brain swelling, and she would be watched for complications. That is about the only treatment available or necessary.

  The baby would be watched closely, and if any problems or signs of fetal distress appeared, a cesarean section would be done. The monitoring is accomplished by placing electrode patches, which record the fetal heart rhythm and rate, on the mother's abdomen. Also, a fetoscope would be fixed to the lower abdomen. Thi| is an ultrasound probe that images the fetus in real time using sound waves and displays a picture of the baby on a small TV screen. Signs of fetal distress would include an abnormal increase or decrease or irregularity in the heart rate or rhythm and any abnormal movements by the fetus.

  After recovery from the event, she may have some emotional

  difficulties such as crying, irritability, anxiety attacks, and so forth. She may have insomnia, depression, and fits of anger. After all, she's still pregnant and worried about the health of the baby. She might blame herself for allowing this to happen or blame her husband for not being there—whatever fits the story.

  Could Death from Bleeding Be Delayed for Several Days?

  Q: My story takes place in a wagon train in the late 1800s. My character is dragged by a horse while crossing a river. He hits rocks and is bounced off the back wheel of a wagon. Of course the horse's hooves do damage as well. Three days later he dies due to massive bleeding from his internal injuries. This three-day delay followed by the sudden and dramatic loss of blood is important to the story's timing, but is it realistic?

  A: The answer to your question is yes.

  This type of accident could result in all types of injuries: broken bones, skull fractures, neck fractures, cracked ribs, punctured lungs, and intraabdominal injuries (injuries inside the abdominal cavity). This last type of injury might serve you well.

  A ruptured spleen or lacerated liver or fractured kidney would bleed into the abdominal cavity. Death could be quick or take days if the bleed was slow. There would be great pain, especially with movement or breathing, and the abdomen would swell. Also a bluish bruiselike discoloration could appear around the umbilicus (belly button) and along the flanks. This usually takes twenty-four to forty-eight hours or more to appear and occurs as the blood seeps between the "fascial planes." The fascia are the tough white tissues that separate muscles from one another. The blood seeps along these divisions and reaches the deeper layers of the skin, causing the discoloration.

  The problem for your scenario is that none of these types of internal injuries would lead to external bleeding. The abdominal cavity is a closed space, so the blood has no exit route.

  However, if the injury was to the bowel, then external bleeding could occur. For blood to pass from the bowel, the bleeding would have to be within the bowel itself and not just in the abdomen somewhere. If the bowel was ruptured or torn so that bleeding occurred within the bowel, the blood would flow out rectally. But blood in the bowel acts like a laxative, so the bleeding would likely occur almost immediately and continue off and on until death, which in this situation would be minutes, hours, or a day, two at the most. It would be less realistic for the bleeding to wait three days before appearing in this case.

  There is one exception, however, that may fit your story needs. The bowel could be bruised and not ruptured or torn, and a hematoma (blood mass or clot) could form in the bowel wall. As the hematoma expanded, it could compromise the blood supply to that section of the bowel. Over a day or two the bowel segment might die. We call this an "ischemic bowel." Ischemia is a term that means interruption of blood flow to an organ. If the bowel segment dies, bleeding would follow. This could allow a three-day delay in the appearance of blood.

  In your scenario the injuries would likely be multiple, and so abdominal swelling, the discolorations I described, great pain, fevers, chills, delirium toward the end, and finally bleeding could all occur. This is not a pleasant way to die, but I imagine this happened not infrequently in frontier days.

  The victim would be placed in the bed of one of the wa|ons and comforted as much as possible. He might be sponged with water to ease his fevers and offered water or soup, which he would likely vomit; prayers might also be said. He might be given tincture of opium (a liquid). This narcotic would also slow the motility (movement) of the bowel and thus lessen the pain and maybe the bleeding.

  Of course, during the time period of your story, your characters wouldn't know any of the internal workings of the injury as I have described. They would only know that he was severely injured and in danger of dying. Some members of the wagon train might have seen similar injuries in the past and would know just how serious the victim's condition was, but they wouldn't understand the physiology behind it. They might even believe that after he survived the first two days he was going to live and then be very shocked when he eventually bled to death. Or they might understand that the bouncing of the wagon over the rough terrain was not only painful but also dangerous for someone in his condition. The train could be halted for the three days he lived, or several wagons could stay behind to tend to him while the rest of the column moved on.

  What Was the Technique for Limb Amputation in the Nineteenth Century?

  Q: My story takes place in the American frontier in the late 1800s. Near the end of the novel my protagonist must perform an amputation of an arm (a close-range gunshot wound at the elbow, with amputation just above the elbow). Can you tell me the typical procedure followed in an amputation? Blood vessels were badly damaged by the bullet, so I thought the protagonist would first apply a tourniquet. Is that okay? I'm letting the patient have a whiff of ether, so the surgeon may not have to rush through the job.

  A: Amputations during the nineteenth century were dangerous and brutal. The ability to repair injured extremities and to control infections in gangrenous limbs did not exist at that time, and amputation was viewed as the only hope to save the victim. However, blood loss followed by shock and death or infection of the

  remaining stump dogged the surgeon's every effort. There was no blood to replace losses and treat shock, and antibiotics did not exist. Even with a successful procedure, the victim could die, and often did, from continued bleeding or infection.

  The surgeon attempted to perform the procedure as rapidly as possible since it was very painful, and in frontier areas or during times of war anesthetic agents weren't readily available. A typical anesthetic was alcohol and sometimes tincture of opium or ether. Dr. Crawford Long first employed ether in surgery in Atlanta, Georgia, in 1842. The first public demonstration of its use took place in Boston in 1846, so it would be realistic for your protagonist to have access to it.

  Even with a whiff of ether, the patient would likely have to be restrained by some of the stronger members of the community. A strip of leather or a piece of wood to bite down on might be employed.

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bsp; As a medical student I scrubbed in on a couple of amputations. I came away with the impression that it remains a fairly brutal procedure with knives and saws and chisels and hammers. Yet even after those experiences, the most vivid image I have of this procedure is still the dramatic scene in Gone with the Wind.

  Yes, a tourniquet would be tied very tightly around the extremity to prevent bleeding from the arteries that the surgeon would have to cut through. In your situation this would be done at the mid-humeral (upper arm) area. A large knife would be used to cut the tissues circumferentially (all the way around) down to the bone, and then a handsaw would complete the process. The stump would then be cauterized with a hot blade or other piece of metal heated over a fire and dressed with the cleanest pieces of cloth available.

  The mortality rate for these procedures in the late 1800s was 50 percent or more. Most deaths occurred fairly quickly due to bleeding and shock; other victims lingered for days or weeks before succumbing to infection.

  What Are the Physical Limitations of Someone with a Shoulder Dislocation?

  Q: A character in a story I'm writing needs to be stuck in a remote hunting camp for two or three days with a dislocated shoulder. These are my questions:

  1. If he doesn't get immediate treatment, will the damage continue to increase, or does the condition stay about the same?

  2. What symptoms would he have? Will the immediate pain of the dislocation subside or get worse over the two to three days it goes untreated?

  3. What kind of dysfunction will he have? Will he be able to use the arm at all? If he can't use or move the shoulder, will he still be able to grip things with the hand or lift very light objects?

  4. When he does finally get treatment, exactly what is done for such an injury? How long will he be out of commission? If he was really tough, could he get back into action within a day or two?