by David Page
Shock waves are transmitted to the surrounding tissues and cause damage far away from the missile track. Also, the bullet path is not initially narrow but rather cavitation occurs. This sudden expansion and then collapse of the tissues may suck clothing and other debris into the wound. The entry wound may appear to be small because the skin's normal elasticity partially closes it. These wounds often require extensive surgical debridement, or cleaning, to clear the track of dirt and dead tissue.
Shotgun wounds are quite different from gunshot impacts. Multiple pellets cause a literal chewing up of a specific area, with less body penetration than a single bullet. Massive damage to skin, soft tissue and vital structures close to the surface occurs. This is particularly true of the heavier duck and goose loads (numbers 2 and 4, BBs).
Wounds in a Trauma Victim
Any tissue in a trauma victim may be injured, and a host of terms are used to describe these injuries. First, we'll describe those injuries that do not involve bone.
Important Facts About a Bullet and the Wound It Causes
■ Weight and diameter (caliber) of projectile
■ Muzzle velocity
■ Design of bullet jacket
■ Point of impact (skull, leg, buttocks, etc.)
■ Pathway through body (specific tissues encountered)
■ Secondary bone fragment missiles
Soft Tissue Wounds
Not only do these include special structures, such as the ears, nose, eye and genitalia, soft tissue wounds may also include any or all of the following structures:
• Skin
• Fat
• Muscle
• Tendons
• Ligaments
• Nerves
• Arteries and veins
These common types of soft tissue injuries vary in degree of severity:
Abrasion: A superficial "scabbing" injury, like skinning a knee, caused by contact with a flat, rough surface. Sometimes called a "strawberry," it results in a partial-thickness loss of skin with some bleeding and "crust" formation, which is old blood and serum.
Contusion: A bruise or deeper injury caused by a direct strike. Skin, subcutaneous fat and muscle, tendons or ligaments are trapped between the surface and the bone and become crushed. Swelling, pain and loss of function are common.
Hematoma: A pocket, or collection, of blood anywhere in the body. Caused by the rupture of small or large arteries or veins, the collection may be within a specific organ or in soft tissue, such as muscle or fat.
Avulsion: The tearing away of tissue from its attachments. This may
be partial or complete and includes muscle tears, fingernail avulsions or the ripping away of skin from underlying tissue, a so-called "degloving" injury—skin torn away like removing a pair of gloves.
Why does one person suffer major tissue avulsion from direct trauma while another individual develops only an irritating abrasion? Why do some tissues lacerate while others resist trauma? A couple of factors determine how seriously a trauma victim may be injured:
• The elasticity of the impacted tissue—can it stretch or deform and resume its original configuration?
• The speed at which the tissue is loaded—is the arm smacked with a baseball bat at sixty miles per hour or a .44 magnum bullet at 900 feet per second? The tissue can't "escape" the bullet, and therefore disrupts, whereas with the bat, it is compressed and then assumes its original shape. Load a joint suddenly and the ligaments and tendons tear (ruptured ligaments or torn cartilage) instead of stretch (strain).
Fractures and Dislocations
The force causing a broken bone or a disrupted joint may be direct or indirect. An example of the latter is a fall on an outstretched hand causing dislocation or fracture of the shoulder. Direct force from a fall causes a variety of fractures and dislocations.
A fracture is a break in a bone. It may be partial or complete. Different patterns are seen and include:
• Compound fracture—bone fragment projects through the skin causing an open wound
• Comminuted fracture—several small fragments of broken bone in wound rather than one "clean" break
• Greenstick fracture—seen in children, a "buckle," or partial break, of the cortex of an immature bone
• Oblique, spiral, transverse fractures—result from different forces exerted on the bone
A special case occurs with skull fractures, which may be depressed when the bony table of the skull is pushed below the plane of the normal surrounding bone. Treatment involves elevating the fragment(s) surgically. An undisplaced skull fracture may be left alone. Similarly, fractures of the long bones of the arms and legs in good alignment may be splinted or pinned without manipulation or realignment.
Pelvic fractures may be innocent or life-threatening. The "rings of bone," or rami, may break in one place, may become disrupted on both sides or may fracture in two or more locations on the same side. The larger bones of the pelvic bowl may also break with enough impact, and often serious visceral (organ) injuries accompany these pelvic fracture(s). These include ruptured bladder, rectum or major blood vessels. The most serious problem associated with pelvic fractures is massive, uncontrolled hemorrhage. Torn pelvic veins traveling through bone are controlled by pushing sterile thumbtacks into the sacral bone to compress the bleeding vessels.
Dislocations are seen most often in joints with the most freedom of motion. These include the shoulder, elbow, fingers, knee and ankle. The hip joint may dislocate, but it requires a major impact. By definition, a dislocation occurs when all or a portion of a joint surface moves out of alignment and is no longer in contact with its "mating" surface. Specific maneuvers are needed to reduce a dislocation. After a period of time, muscle spasm around the joint will prevent easy reduction.
Spinal fractures are discussed in chapter six.
The Control of Hemorrhage
First responders are required to staunch the flow of blood as part of resuscitating an injured trauma victim. Several techniques are useful and may be employed according to the body area that is bleeding. In order of decreasing effectiveness, they are:
• Direct pressure over the bleeding tissue
• A pressure wrapping of an extremity, especially if a large surface
area is involved
• Packing a bleeding cavity
• Applying a tourniquet above the bleeding point on an extremity
If a pressure bandage becomes soaked with blood, it is often advisable to leave it in place as beneath the gauze the body is depositing clotting factors in an attempt to stop the bleeding. People with clotting disorders, such as hemophilia, will hemorrhage from minor abrasions and lacerations as well as from major trauma. Also, patients on blood thinners, or anticoagulants, such as warfarin or Coumadin, will bleed more from minor trauma. These patients would include people with prosthetic heart valves, those who have had a stroke, those with blood clots in the legs and those recovering from certain operations that carry high risk of phlebitis.
Finally, a medical disaster is defined as an unexpected event resulting in multiple simple and complex injuries to a large number of people with destruction of property and disruption of the daily routines of society.
Thus, a traumatic impact is the result of an energy transfer from an object or body to another body. Either a moving object (a missile of some sort) strikes the body or the moving body hits something.
Either way tissue suffers.
In the field, there are no formal white sheets, no forgiving first bandages, no comforting EKG beeps. In the field, there are no IV poles laden with bags of lactated Ringer's, no authoritative antiseptic odor, no crisp uniforms, no barking intercoms. In the field, no knowledgeable people stand with you to confirm the correctness of your decisions. Not a single x-ray box winks approvingly, not one overhead page announces another professional is nearby to help.
In the field, there is only terror.
Take the viewpoint of a first responder. By tha
t I mean the first person to arrive on the accident scene following a traumatic event. The interval between the accident and the arrival of the first responder may be minutes or hours. Blood and body parts may lie strewn about the accident scene while the more insidious effects of the impact on vital functions (e.g., shock) worsen before your eyes. Deterioration of the victim's condition may continue despite your best efforts. Or the situation may become stable. That's the hell of it. You never know.
In 1994 on a flight from Hong Kong, a woman suffered a collapsed lung (pneumothorax) from a motorbike accident that occurred on her way to the airport. Professor Angus Wallace of Nottingham, England, operated in the back of the plane using a urinary catheter mounted on a piece of coat hanger dipped in brandy, a bottle of Evian water and a few first aid odds and ends. He placed a makeshift chest tube, and the lung expanded. Undoubtedly, so did the professor's free air miles with British Airways. The woman survived. She received the ultimate in field treatment. Now you see that the field can be anywhere.
This is an example of what can be done if you understand the principles of the problem. It's a grand example of how a writer may take the elements of the story's world and create novel injuries and treatments. Wasn't Stallone the first actor, as John Rambo, to suture himself on screen?
Sometimes it doesn't matter if the first responder is an EMT—an Emergency Medical Technician with basic or advanced training—or a paramedic, police officer, physician's assistant, nurse or physician. Yes, physician. With medical training so specialty-oriented of late, not all doctors are properly trained in acute care. Most effective in this setting is the skilled person who knows how to assess injury priorities, sort out victims (triage) and start treatment.
The starkness of the accident scene and the immediacy of broken bodies provokes fear in everyone. Experienced doctors often react with trepidation at the accident scene. In that one instant, the first responder must master her emotions and deal with the disaster in front of her.
In chapter one, you learned about the ABCs of resuscitation. The simplicity of this recall system seemed obvious, so casual that perhaps you skimmed over it. You may have assumed that of all the material tossed at you so far, certainly the ABCs of acute care are the easiest to remember.
How could anyone forget the alphabet?
With an incontinent trauma victim lying in a ditch gasping for air, blood dripping from his smashed face, his life ebbing before you, you forget to breathe. Your world spins into a blur of doubt.
Of course, not every medical emergency is a life-and-death deal. But some startling impacts can scare the hell out of you. In this chapter, we'll discuss a unified approach to common injuries. We'll learn what happens to folks with the unique problems discussed in parts two and three before they arrive in the emergency room.
Many trauma victims would not live long enough to be treated in the hospital without competent initial care in the field by expert paramedical personnel. Let's assume a paramedic's viewpoint. The victim is best served in the field by an individual like a paramedic because of her level of acute care experience.
The beginning of the alphabet serves all first responders well by reminding us of lifesaving priorities in urgent care. Saving a life isn't an act of genius. Not much in medicine requires the sort of intellect required to design and direct manned space flight. Clinical care requires the application of basic principles that work—over and over again. That's what emergency care in the field's all about.
Stick to the basics. Or, if you choose, have your character miss the critical diagnosis. Because, while the doctor in your tale may look like a hero when he diagnoses bacteria-laden growths on someone's heart valves by merely examining the patient's fingernails, it's important for your paramedics to go through the proper steps in assisting a victim in the field to make the thing ring true. If it's important to the plot to have an injury missed, go ahead.
You'll recall from chapter one that missed injuries are an unfortunate but real part of trauma care. The likelihood of not documenting every traumatic injury in the wilderness is quite possible. Stuff happens.
Again, you need to know how to get it right before you can accurately toy with making it "wrong" to complement your story. Acute care resuscitation in the field begins with this "alphabet" mnemonic:
• A is for airway.
• B is for breathing.
• C is for circulation.
• D is for disability (interruptions of neurologic function).
• E is for exposure.
Managing the Airway in the Field
In the field, where resources are limited, the problem of asphyxia can quickly become dire. Two dilemmas confront the first responder:
1. Can I establish an adequate airway with the resources on hand?
2. Does this victim have a broken neck?
To begin with, ask yourself: Is this victim breathing adequately? This means (1) Is there an open airway? and (2) Is the victim actually breathing and exchanging air? If the airway is blocked, there are two easy ways to open it:
1. Chin lift—place your fingers under the front of the jaw, and with your thumb behind the lower teeth, lift up gently without moving the neck. This is the best way to open the airway, particularly in someone who may have a broken neck.
2. Jaw thrust—place your fingers under the angle of the jaw and pull forward. Because the tongue is often what's blocking air exchange ("swallowed tongue") and is attached to the jaw, this move and the chin lift work to clear the passage.
What causes upper airway obstruction? Look to the story environment for the answer. Location and activity determine why blockage to the character's breathing may become a real possibility. Usually it's from:
• The tongue "falling back" in the throat in a victim who is drunk, drugged, diabetic, debilitated or otherwise suffering from decreased awareness
• Grass, sticks, stones, shells, frog, etc., from a river, pond, reservoir, lake or ocean in a case of near drowning
• Chunks of food in a restaurant, the so-called "cafe coronary"
• Swelling of tissues around the airway from an allergic, or anaphylactic, reaction to medication, seafood, bee sting, etc.
• Swelling from attempted strangulation
• Swelling from attempted suicide by hanging
What do victims with blocked airways look like? They're not all the same. It depends on the cause. Here are a few visual clues:
• Victim is awake and anxious with noisy breathing (called stridor, it's a "crowing" sound), but the chest is moving. It's partial obstruction.
• Victim is becoming cyanotic—turning blue—with little chest movement and may be "bucking" to breathe but can't exchange air. It's a completely blocked airway.
• Victim is frantic, can't talk, is becoming panicky and flushed, then blue, with complete blockage from foreign matter or broken larynx (voice box).
• Victim is unconscious when you arrive.
• Victim is wheezing ("musical" high-pitched noisy breathing), typically in asthmatics with partial closure of lower airways (called bronchospasm).
Let's assume for the moment your character arrives on the scene and doesn't have a rescue kit; there's no tube available to place in the victim's throat. Later, in the hospital, the victim may be intubated and placed on a ventilator. But not usually in the field. Your character may carry one of those curved plastic airways in his pack. It's called an oropharyngeal airway.
To use it, the tongue is depressed with a spoon, hunting knife or branch and the airway is slipped past the tongue to keep the throat open. Care should be taken to not push the tongue farther back, making the obstruction worse. Another way to insert the plastic airway is to point the tip at the roof of the mouth, inserting it upside down. Then, when it's far enough back in the throat, rotate it 180 degrees. The victim breathes around it.
If the victim's airway seems all right when the initial assessment is performed, it's time to decide if the victim needs help breathing
. Adequate ventilation may be confirmed in the field if the victim is exchanging good tidal volumes of air heard with a stethoscope. If the victim is not experiencing "air hunger," you should see the chest moving with epch breath, and the victim shouldn't be gasping. But if adequate ventilation is in question, a number of helpful maneuvers may be followed next:
• Provide an oxygen source—mask or nasal tongs
• Mouth-to-mouth respiration
• Ambu bag ventilation
Whatever you do, keep in mind the possibility of a fractured neck. Both the chin lift and jaw thrust must be done without yanking the neck back (hyperextension). Both techniques carry the potential risk of converting a victim with a broken neck without spinal cord damage into a cord-disrupted, incontinent quadraplegic. At all times: Do no harm.
It's not always as simple as lifting the jaw. Airway obstruction may result from a major facial smash, and whether it's from a fall off of Mount Sheercliff or from an unrestrained windshield/face impact, the problems are the same. First, if the head is smashed, the neck may be broken. Second, how do you find the throat if the nose is mush and the mouth is missing? Bruises, blood clots and disrupted tissue may conceal the nose and mouth orifices.
No openings in the face? No air bubbles?
The neck!
Sure, your character must cut open the windpipe in the neck. Not a tracheostomy, the procedure is a little easier (but not much!) and still requires a cut into the upper airway. A character with courage, a sharp knife and a tube of some sort can relieve life-threatening airway obstruction when the mouth and nose are compromised.
