by David Page
Table of Contents
Introduction
Part I: An Overview of Trauma
1 Concepts and Terminology in Trauma Care
Why Do Accidents Occur? Emergency Management Levels of Trauma Care Destructive Impacts Wounds in a Trauma Victim
2 Care of the Trauma Victim in the Field
Managing the Airway in the Field A Breath of Life Maintain Circulation
Disability: Can the Victim Talk and Move? Expose the Victim
Special Problems in the Field
3 The Trauma Center
The Dynamics of Trauma Care
The Level I Trauma Center
The Trauma Room
The Four First Steps in Trauma Care
4 Care of the Trauma Patient in the Operating Room
The Operating Room The OR Personnel
How Cases are Listed: The "Bumping" Scenario
When Things Go Wrong in the OR
OR Atmosphere
PACU: The Recovery Area
The Intensive Care Unit
The Surgical Floor
Rehabilitation and Going Home
Part II: Specific Traumatic Injuries By Organ System
5 Head Trauma: From Concussion to the Persistent Vegetative State
Diffuse Brain Injury Focal Brain Injury Scalp Injury Facial Injuries Lower Jaw Injuries
6 Neck and Spinal Cord Injuries: Snapped, Stabbed and Strangled
Direct Trauma to the Neck Indirect Trauma to the Neck The Treatment of Neck Fractures
7 Chest Trauma: The Dirty Dozen Maiming Injuries
The Dirty Dozen
Injuries That May Kill Within Minutes Injuries That May Kill Within Hours
8 Abdominal Trauma: Beware of Hidden Damage
Patterns of Intra-Abdominal Injury Blunt Trauma to the Abdomen Penetrating Trauma to the Abdomen Diagnosing a Major Abdominal Injury The Outcome of Abdominal Injury
9 Extremity Trauma: Crunched Arms and Legs
The Upper Extremity The Lower Extremity
Part III: Unique Traumatic Injuries
10 Bites: Animal Assaults
Dog Bites Human Bites Snake Bites Shark Bites Horse Bites Stings
Sea Life "Bites" Animal Defenses
11 Impalement Injuries and Mutilation: From Fencing to Fences
Features of an Impalement Injury Mutilation and Torture
12 Traumatic Amputations and Replantation: Don't Lose the Missing Part!
How a Finger Is Replanted Are Kids' Injuries Different? A Warning!
13 Burns and Frostbite: The Scars of Temperature Extremes
Burns
House Fire Smoke Inhalation Electrical Burns Lightning
Environmental Temperature Damage
Heat Stroke (Sun Stroke)
Heat Prostration (Heat Exhaustion)
Frostbite
Hypothermia
Other Cold Injuries
14 Diving Accidents and Altitude Illness
Diving Accidents and Their Consequences Decompression Sickness ("The Bends") Barotrauma
Nitrogen Narcosis ("Rapture of the Deep")
Altitude Sickness
Acute Mountain Sickness (AMS)
High Altitude Pulmonary Edema (HAPE)
High Altitude Cerebral Edema (HACE)
15 Assaulted Eiders, Battered Women and Injured Kids: The Defenseless
Battered, Bruised and Abused Kids Battered Women Abused Elders
16 Sexual Assault: Unspeakable Trauma
What Is Rape?
Why Do Men Rape Women?
Myths About Rape
The Initial Examination of the Victim
Sexual Assault Against Children
The Sexually Abused Adolescent
17 Organ Donation: Who Makes the Ultimate Gift?
Who Becomes an Organ Donor?
The Process of Obtaining Organs for Donation
The Process of Performing an Organ Transplant
Bibliography Glossary
Introduction
In literature, as in life, sooner or later everyone becomes injured—accidentally or as a consequence of malice—somewhere in the story. The writer must force characters to face conflict. And that includes creating injuries. Every writer needs to understand how to create authentic traumatic injuries as well as how to deal with their consequences.
The focus of this book is on violent injuries that do not result in death.
Every writer confronted with the dilemma of how severely to hurt a character must understand the consequences of the physical havoc created. Injuries should be realistic, reflect the character of the person inflicting the insult and be tailored to the needs of the plot. More sophisticated than in the past, today's readers have become avid, critical consumers of media violence. Hence, your story's accidents and injuries and the convalescence they cause must ring true.
As you write what is referred to in this book as an "injury scenario," you must hold the tuning fork of authenticity to your ear. You'll learn to review pertinent anatomy, assess the world of your story—what's there to serve as a weapon and who's present in the scene to use it—and decide what mayhem your tale needs. These are the elements of a trauma prescription.
Whether the genre is mystery-murder, horror, romance or any of the varieties of mainstream thrillers, the writer's art hinges on accurately depicting human suffering. Ernest Hemingway insisted it is what the writer leaves out that counts most. The late Gary Provost in a similar vein taught his writing students: Less is more. Richard Cohen, in Writer's Mind, instructs: Fiction writing should imply there is a great deal more than what has been written.
If using less material is the goal of good writing, why learn so much about inflicting injuries?
In "The Snows of Kilimanjaro," Hemingway never describes the gangrenous leg that plays a central role in the story. He alludes to the offensive smell and the progression of gangrene and even reflects on how it began with an element of neglect on Harry's part. At no point is there an explicit description of the rotting leg.
In Ian Hamilton's biography entitled In Search of J.D. Salinger, he describes the author of The Catcher in the Rye as he becomes progressively urbane, increasingly accomplished at his craft. Following the
publication of Salinger's "A Perfect Day for Bananafish," Hamilton states, "Thanks to The New Yorker he was beginning to learn the pleasures of reader manipulation, of having a sophisticated readership that had been trained in the enjoyment of inconsequential sorrow. He was learning how to leave things out, to flatter and deceive."
Herein lies the paradox of fiction writing: You must understand what to include and what to leave out. In order to leave something out of a scene, you need to understand all of the elements that could (but shouldn't) be included.
Authenticity emerges from personal experience, struggle and then understanding. Certainly, Hemingway had seen his share of war wounds. But most writers have little experience with traumatic injuries. This book describes in detail what you must learn about body impact and the spectrum of potential injuries in order to select what details to include in your scene. Once you understand what's there and how it gets maimed, you'll feel the pain and know what aspects of the injury to describe. The reader's visual imagery is enhanced by the inclusion of the right details. By learning a lot about a particular injury, you may select the most visual elements and write a sparse, fast-paced action scene.
Rather than being anecdotal, this book describes the process of how to create a dramatic injury scene. Included are suggestions on how to incorporate the more complicated material into your story.
No writer can describe, allude to or choose to ignore something that she doesn't understand. And you can bet the treasury that before the chubby cherub chortles, someone in your story is going t
o get hurt. If it's your traumatic scene, you'd better know exactly how it happens.
Body Trauma provides an organized menu of injuries and a suggested method of approach to guide you through the process of creating authentic misery. Using the various examples presented in conjunction with master injury lists (a menu of specific injuries) for each body system, you may construct innovative insults and terrible wounds to fit the specific demands of your plot. Not just a mere laundry list of clinical mutilations, this book describes how to create novel impacts, bodily disruptions and agonizing tissue trauma. By identifying where the impact occurs and what it does to the body, you can properly weave the length of the disability into the drama. This is called the time line of the injury.
If imaginable, any injury is possible. By using the ideas presented in this book, you'll learn how to finesse the details.
Body Trauma is divided into three distinct parts in order to organize and highlight for easy use what is at times complex material.
Part one provides an overview of trauma as well as some basic concepts about the body. Principles are explained regarding tissue impacts, mechanisms of injury and how the trauma victim is handled in different locations both in and out of the hospital.
Part two is an intense discussion of major trauma, organized by body area. It includes detailed information about head and neck, chest, abdominal and limb trauma. This section represents virtually all types of major injury seen in a busy emergency room by trauma surgeons.
Part three includes unique injuries according to their cause rather than by body region. Some of these forms of damage are quite horrible. Examples from classic and contemporary literature are included in parts two and three to demonstrate how accomplished authors handled body insults.
At the end of the book, there is a discussion of what occurs when an injured person dies and the issue of organ donation arises. Sitting on the cutting edge of high-tech medical care, organ transplantation programs struggle with a national shortage of organs suitable for donation. All seriously injured victims should be considered as potential organ donors. And although not our primary concern in this book, a discussion of the process of making this cherished gift closes our discussion about broken bodies. It's an important topic for fiction writers.
So often in contemporary fiction, as in the movies, our suspension of disbelief is stretched to near rapture by violent body insults sequenced with an implausibly swift recovery. On the other hand, it seems many writers have an intuitive sense of what is biologically correct, and this book is intended to augment that instinct. Not only will you learn how to write your injury scenarios by using this book, but by the end of the book, you should have become a sophisticated first responder to the injured.
Just as fiction is part of real life, trauma is a glaring real-life epidemic awaiting its place in your fiction. The dilemma for the writer lies in what injury to fit into the world of the story.
Most of medicine is common sense. Have fun with the material, and don't panic at the medspeak.
Writing your trauma scene may be the only time you can be the doctor. Early in my surgical career, I performed my share of trauma surgery, and many of my personal experiences have insinuated themselves into these pages. My professional life includes a busy surgical practice as well as teaching surgical residents and medical students. I trust some of that background will make this material interesting and understandable.
Injuries occur for a reason.
Before entering the world of trauma, you need to know a few basic terms. If you understand simple mechanisms of injury causation, this part of modern medicine and its funny-sounding verbiage will be easier to grasp. For your story to sound authentic, you need to know what you're talking about.
Trauma refers to the physical wounds and innumerable body insults that result from direct or indirect contact with something in the environment. In the chaotic history of medicine, surgeons became the specialists who assumed the task of managing traumatic wounds, treating terrible numbers of war casualties from the numerous conflicts that seeded every century. With time, weaponry became more sophisticated, more destructive. Nonetheless, even the rock hatchets, spears, darts and arrows of primitive humans were deadly, and the injuries horrible.
Warriors wear scars with pride, and one wonders if physical conflict is our species' norm. In humankind's history, it seems quite possible that intentional wounding has been more frequent than the occurrence of unanticipated trauma. A cursory examination of man's warring history reveals repeated, massive conflicts in which large numbers of warriors became wounded. Many died. But many survived their injuries to fight again. Scientists refer to an animal's (including man's) response to confrontation as the "fight or flight" reaction, the choice presumably determined by a recognition of the odds. Man has a poor track record of avoiding the odds of sustaining traumatic injuries.
Traumatic events can thus be accidental or intentional. Some injuries are more repugnant precisely because the assault is premeditated, an attack designed to hurt another person. But even so-called accidents may be more a matter of inattention and risk taking than of pure chance.
For the writer, the introduction of any form of body damage into a sordid tale increases suspense and introduces an element of uncertainty. Plot possibilities emerge from the doubt born of disaster and from the character's back story, for example, the compulsion to practice risky behavior. On the other hand, some folks are so preoccupied with problems of daily living they become distracted and are therefore accident-prone. In this book, we look at accidents as well as injuries that result from being in a hostile environment.
Why Do Accidents Occur?
For a moment, let's consider real accidents. This term implies a traumatic episode occurred that could not have been anticipated and therefore is not the consequence of an expected series of events. The accident produced an unexpected outcome because it occurred suddenly, created alarm and resulted in injury.
A true accident can't be avoided. Why do accidents occur? Two reasons why accidental events occur are sudden, unexpected changes in:
1. A person
2. The environment
Consider the elements of a typical automobile accident. Available data indicates that most accidents occur on the weekend and at night. Young people who consume alcohol are involved in the majority of car crashes. The person components that result in so-called "accidental" automobile mishaps include:
• Inebriation or drug abuse
• Distraction by others in the car
• Excessive speed
• Risky maneuvers, such as passing or bumper hugging
• Falling asleep at the wheel
• Anger, rage, depression, anxiety that cause preoccupation and failure to pay attention to driving chores
• Inadequate driver training
• Visual or motor skill impairment, as in some elderly drivers Environmental factors also contribute to car crashes and may include one or a combination of the following:
• Poor road construction
• Poor road conditions, e.g., rain, snow, ice or fog
• Excessive traffic
• Lack of familiarity with road
• Abusive drivers, e.g., risky passing behavior or startling another driver with high beams
These factors may be compounded by defective car parts, such as brakes, windshield wipers or engine components. Also, an impact may involve a poorly designed car. Failure to wear a seat belt and failure or absence of an air bag make the impact all the more dangerous.
Therefore, an accident may be viewed in general terms as an unexpected event that occurs because of the linkage of a series of related factors:
• Distraction (inattention to the task at hand)
• Lack of training with specific equipment
• Lack of motor skills (inferior innate talent)
• Cavalier attitude toward dangerous equipment
• Ignorance about potential dangers with speci
fic equipment
• Poorly maintained equipment
• Effect of aging or disease on person's mobility, reasoning ability and perception
The terms described next are used in the assessment and care of the trauma patient.
Assault includes both physical and verbal attacks on another person. A character's interpersonal relationships and background will contribute to which element is most often employed in relationships. Verbal abuse may be more subtle, frightening and chronic than outright fisticuffs.
Domestic violence, including elder abuse, child abuse, spouse abuse and rape, involves the most violent of crimes and produces many of the most despicable injuries. These will be covered in detail in part three.
Self-mutilation is a fascinating topic that implies a purposeful alteration in self-image. We'll merely nudge this topic in our discussion. What happens to self-image? Why tattoos? Scars?
Mortality refers to death. The mortality rate in a given circumstance means how many people died. It's the death rate for a specific medical procedure or life event.
Morbidity, on the other hand, refers to injury. It's the meat of this book. The accidental event itself has a morbidity rate, as does the surgery performed to fix the broken body. Each event has a potentially poor outcome—things that can go wrong because of uncontrolled trauma or despite controlled surgery.
Some things just happen.
Emergency Management
The events that surround the management of major accidents are divided into the sequential events that are part of trauma care.
Extrication: This is the removal of the victim from the scene. It may involve using the "jaws of life" to get someone out of a car wreck, removing a victim from a mountain top or a deep ravine or bringing a child up from a well shaft.
Transportation of the patient: Three methods of transportation are available for trauma victims and are dependent upon the distance from site of injury to the nearest available appropriate acute care facility.
1. Ambulance—up to about 50 miles
2. Helicopter—about 50 to 100 miles
3. Fixed wing aircraft—about 100 to 300+ miles
Helicopters and fixed wing aircraft provide rapid transport for victims who are only marginally stable and who must reach expert trauma care for specialty surgical care.
