by David Page
In any area of the vertebral column from the neck to the sacrum, any two vertebral bodies can slide on each other or dislocate without actually being broken. Held in place by massive ligaments running up and down the spine in front and behind the vertebral bodies, the bones are also anchored by shorter ligaments between bony projections on the vertebrae and by accessory joints. The smaller stabilizer joints are the ones that pop and crack like firewood when a chiropractor manipulates a patient's neck.
Severe flexion-extension motion of the neck causes most of the unstable as well as stable cervical spine injuries. "Whiplash" is a legal term. It's descriptive. A vivid image of forward bending of the neck with sudden force applied from behind followed by backward motion, or hyperextension, of the neck becomes indelible in your mind. Only the deep ligaments of the neck and the strap muscles can arrest this action. The automobile headrest is designed to modify this sort of movement of the head and neck should impact occur. Pain is often in proportion to the other person's insurance policy.
A blow to the top of the head may cause fracture of the first cervical vertebra, the atlas. If there's no nerve damage, the treatment is conservative with immobilization and rehabilitation. The situation becomes a little more complicated at this point with fractures and dislocations as well as combined fracture-dislocations. Any of these neck injuries may be unstable and therefore critical.
You may have heard of a youngster who became paralyzed after diving into a quarry, empty pool or shallow pond. Cervical spine injuries carry the potential to kill, or to maim for life. These injuries may cause one of two basic types of spinal cord injury: (1) contusion (bruise) of the spinal cord or (2) compression of the spinal cord.
Most severe cord injuries don't resolve. They may occur anywhere down the vertebral column, and as the distance from the neck increases, the degree of paralysis decreases. So the victim of a broken low back (lumbar fractures) would suffer from paraplegia if the cord damage was permanent. This involves loss of leg, bowel, bladder and sexual function.
Of course, many people have suffered from neck spasm at one time or another. Although quite painful, there is no neurological deficiency. A diagnosis of neck sprain can only be made after a careful physical examination and negative neck x-rays. Damage to soft tissues, muscles, ligaments and joints causes decreased range of motion and pain. Treatment involves immobilization with a cervical collar, rest and physical therapy.
Uncertainty always surrounds the exact nature of a cervical spine injury, and x-rays are needed to make the diagnosis of a fracture, dislocation or both. The victim may experience any number of symptoms, including numbness, incontinence, paralysis and pain. Neck pain is the most consistent complaint.
The Treatment of Neck Fractures
A broken neck may require a collar to restrict motion and relieve pain. A larger "halo" collar with rigid fixation, which permits limited neck motion, is used for less stable fractures. For very unstable fractures, inline traction in bed with skull tongs and weights is needed. It depends on what bones are broken and which ligaments are disrupted. The more severe the injury, the more rigorous the traction or immobilization.
Other treatments range from IV steroid medication to a more aggressive open surgical approach. The latter involves surgical fixation (wires, pins and rods) of unstable spine fractures to avoid spinal cord compression and paralysis.
Three time frames for death after an accident also apply to neck injuries, and therefore these traumatic insults carry a ton of anguish and conflict for your story. Death may occur:
• Immediately because of sudden loss of respiratory function
• After an hour or so from spinal cord compression (which may or may not be recognized)
• Following months of rehabilitation because of complications such as urinary tract infections or pneumonia
Death by hanging occurs as an act of homicide, suicide or autoerotic asphyxiation. We are interested in the botched hanging that doesn't cause death. A clean jerk at the end of the rope represents the preferred hanging method to fracture or dislocate the cervical vertebrae, compress the spinal cord and/or cause sudden death by asphyxiation.
In his novel Acceptable Risk, Robin Cook describes the hanging of the witches of Salem, one of whom was Elizabeth Stewart, the wife of Ronald, a friend of Reverend Cotton Mather. Unable to prevent Elizabeth's hanging because of the horrible evidence against her, the good reverend, we are led to believe, does the next best thing. Elizabeth is on the ladder leaning against an oak tree:
For a brief second Ronald saw Elizabeth's eyes rise to meet his. Her mouth began to move as if she was about to speak, but before she could, the hangman gave her a decisive shove. In contrast to his technique with the others, the hangman had left slack in the rope around Elizabeth's neck. As she left the ladder, her body fell for several feet before being jerked to a sudden, deathly stop. Unlike the others, she did not struggle nor did her face turn black.
Robin Cook dramatically and accurately depicts the different effects of a slow, painful hanging and a sudden, compassionate death. Because our discussion centers on near death from hanging, it's crucial to understand that suicide often fails because the rope, belt, electrical wire or whatever only partially strangulates the victim. If not sufficiently far above ground or the floor, the would-be suicide gags, passes out and then recovers. Near-death hanging creates swelling and tiny hemorrhages in the eyes, a circular bruise on the neck and an open-ended question: what to do next. Did the person really want to die or merely send a message?
Neck injuries reflect many of the unsavory aspects of violence. Victims of clinical depression who feel the compulsion to attempt self-destruction often attempt hanging. Neck trauma may also be a by-product of uncontrolled rage, attempted homicide, domestic violence or accidental strangulation during autoerotic asphyxiation. Regardless of the cause, nothing challenges a character's character like the loss of all ability to move, breathe and control one's destiny.
The possibility of paralysis, suffocation and major neck hemorrhage raises the stakes in your plot. It is indeed gruesome when someone takes it in the neck.
Whether you end up writing about a potentially lethal injury or about the cause of death—followed by crime scene investigation, how to deal with the body, disposal, etc.—depends on how you handle the window of opportunity for treatment. This moment is brief, variable. But your characters glimpse at it with the desperate intent of being saved.
For the fiction writer, this dread-drenched interval between life and death defines the ultimate ticking clock. Chest injuries, more than any others, possess their own self-limited course. The threat is death or a life-altering mishap. Only correct emergency medical decisions are acceptable to Madame Fate.
Because we're interested in injuries in this book, we'll now examine the kinds of things that can go wrong inside your character's heaving rib cage. With unexpected death, you fire off a cascade of emotional events that create or aggravate conflict and change the direction of your plot. But by not killing your character, you step back in the story's time line to the traumatic event itself and create even more conflict because of the uncertainty of the outcome of the injury.
His instinct and every fighting fiber of his body favored the mad, clawing rush to the surface. His intellect and the craft thereof, favored the slow and cautious meeting with the thing that menaced and which he could not see. And while he debated, a loud crashing noise burst on his ear. At the same instant he received a stunning blow on the left side of the back, and from the point of impact felt a rush of flame through his flesh.
Moments later in All Gold Canyon, Jack London's tense short story about a miner shot in the depths of a seven-foot-deep hole, the wounded man escapes after killing the intruder. The author's brief description of the miner's relief when he realizes the wound was not fatal rings of authenticity for the era as well as for its medical verisimilitude. Relieved to be alive, the miner opens his shirt and examines himself. "Went clean through
, and no harm done!" he cried jubilantly. "I'll bet he aimed alright, alright; but he drew the gun over when he pulled the trigger."
Sometimes not knowing the outcome of an injury is more unnerving, more difficult to deal with than the certainty of a loved one's demise. What will happen next? The big story question is always open-ended with a serious injury and (almost) always shut tight in death—except for whodunit, and we're interested in howdunit.
Chest trauma is unique because so many insults may occur to the cavity that conceals your character's vital structures. Outcome becomes a literal crapshoot. How marvelous for you, the writer.
One quarter of the victims of chest injuries die, often after reaching the hospital. Fewer than 15 percent of these unfortunate souls need an operation, and their lives may be saved by your hero's actions before the ambulance arrives.
The basic organization of this chapter centers on the "dirty dozen" bad chest injuries and a few other common problems about which you are almost certainly already aware. Before we get to the bad stuff, remember that a bump on the chest may only cause rib bruises, which can be extremely painful, or broken ribs with no underlying injuries. These impacts get your character out of action for days as opposed to weeks or months.
Then there are the twelve terrors. This material is a little heavy, but hang in there. Once you get the basics, you can imply the rest.
The Dirty Dozen
Described below are twelve chest injuries that may threaten your character's life immediately or cause delayed death. The ultimate medical ticking clock is a serious but reversible injury that, when survived, may alter the course of your plot or a character's view of life. The only real difference between the first six chest insults and the rest is time.
All of these injuries can be survived. It's the threat of death that makes them so terrible and so remarkable when the patient walks out of the hospital alive.
Basic Treatment Plan
No matter the specific injury, your hero should follow certain steps as he evaluates the chest trauma victim. Familiar by now, they are repeated with each new trauma problem. Remember, if you want to create more conflict, let someone forget to do something.
Steps in evaluating and treating the chest trauma victim:
1. Conduct primary survey—a quick search for major injuries.
2. Have a high index of suspicion for certain injuries based on history and visible marks.
3. Do simple lifesaving things.
4. Do a secondary survey—go back and look again for other injuries.
5. Get the victim to a medical facility.
Injuries That May Kill Within Minutes
Airway Obstruction
Imagine you are a molecule of oxygen attempting to travel from room air through the mouth, down the windpipe into the terminal air sac in someone's lung. (If you can envision this peripatetic oxygen outing, you can write anything.) Airway obstruction is anything that impedes the molecule's progress down the road to the bloodstream; it usually involves what doctors call upper airway blockage. Anything from a smashed face, swollen lips-mouth-throat from an allergic reaction, the tongue "falling back" to block the inlet to the larynx (voice box) or a chunk of foreign material, such as a piece of meat, will clog the airway.
Master Injury List For The Chest: The Dirty Dozen
Chest injuries that may kill within minutes
■ Airway obstruction—blockage of the windpipe
■ Tension pneumothorax—lung collapse with increased pressure inside the chest from broken rib (blunt trauma), knife, bullet
■ Open pneumothorax—the so-called "sucking chest wound," which means a chunk of the wall is missing
■ Massive hemothorax—a large amount of bleeding (a quart or more) inside the chest cavity
■ Flail chest—a floppy section of chest wall caused by ribs becoming broken in two places and leaving a "floating section" in between
■ Cardiac tamponade—the heart sac floods with blood and squeezes the heart, leading to shock
Chest injuries that may kill within hours
■ Lung bruise—from a direct hit (blunt trauma)
■ Heart bruise—from direct blunt trauma
■ Torn aorta—large artery coming off heart gets lacerated
■ Torn diaphragm—the thin muscle layer separating the chest and abdomen is lacerated
■ Torn windpipe (or its branches)—air leak; lung may collapse
■ Torn gullet—esophagus is lacerated, leaks and causes infection from swallowed bacteria; if the tear isn't treated, death may take days or weeks
Be creative. Imagine the special world of your story. What's in the environment that could be accidentally "inhaled"? At a banquet, someone plummets to the ground. Heart attack? No, she's suffered from what is called a cafe coronary. It's sudden upper airway obstruction from a chunk of food and mimics a true heart attack.
As you know, the treatment is the Heimlich maneuver. Swift pressure is exerted on the upper abdomen (by someone behind the victim who encircles her with his arms, pressing the "pit" of her abdomen) to increase the pressure inside the chest to force air in reverse up the windpipe and blast out the food gob.
The most common form of sudden upper airway obstruction occurs when the tongue falls back and blocks the free flow of air into the windpipe. Treatment involves lifting the chin or elevating the angle of the jaw.
Always, your rescuing hero should check inside the mouth for foreign material.
Tension Pneumothorax
It's pronounced new-mo-thor-ax. A pneumothorax is simply a collapsed lung. Young people get them from ruptured blebs, or weak "ballooned" regions on the surface of their lungs that burst after exertion. It presents as shortness of breath with gasping, and is often accompanied by severe chest pain on the side of the collapse. The victim is treated with a chest tube. That's a simple pneumothorax. As the interns say, you "buy" a chest tube for a few days, then go home.
With a tension pneumo (that's doctor talk), a one-way valve effect develops, usually from a stab wound, bullet or the jagged end of a broken rib tearing the lung. Now we have a problem. One-way means out. Air flows down the windpipe, out through the hole in the torn lung tissue and out into the closed chest cavity, the pleural space (Figure 11).
What happens rather quickly is that the lung collapses and the heart and great blood vessels in the chest are pushed to the opposite side. Everything gets kinked. The heart now doesn't pump enough blood, oxygen delivery to vital tissues stops and your character's got a big problem.
Treatment involves putting a plastic hose, a chest tube, between the ribs of the victim's chest wall. To make the diagnosis, the smart paramedic or doctor inserts a big needle between the ribs just below the collarbone as soon as she considers the possibility of a tension pneumothorax. If air under pressure doesn't hiss out immediately, the small puncture doesn't cause any harm.
Open Pneumothorax
This is referred to as the sucking chest wound, and is also shown in Figure 11. Instead of a buildup of pressure inside the chest, as in the tension pneumothorax, the open chest wound is characterized by a hole in the chest wall through which air flows with every inspiratory effort. It's truly a case of lack of inspiration. The victim exchanges air through the chest wall hole instead of being able to create enough negative pressure to draw air into his airways for a deep breath.
Treatment in the field is a bandage to cover the hole. More on this
later. In the hospital, the trauma doctor will place a chest tube and repair the defect in the chest wall.
Massive Hemothorax
Heme, as in hemoglobin, refers to blood—in this case, blood loss into the chest cavity. Does it require blood replacement? Well, a hemothorax is a condition in which blood from torn blood vessels fills the chest cavity. The chest can hold a lot of blood, and transfusions are often part of resuscitation for these injuries.
The blood can come from several sources in the lung or chest wall and occurs with both blun
t and penetrating trauma. The source is not important. But the chest is a pretty good bucket, and it can overflow with a lot of your victim's precious heme. The victim has difficulty breathing and shock from blood loss.
Have you figured out the treatment?
Two things, right? Place a chest tube (or two) and resuscitate, eventually administrating blood to reverse the shock state. And if the bleeding doesn't stop and the red stuff continues to pour out of the plastic hose, you might hear the intern cry, "Damn it, Luke, we gonna crack this chest or what?" (Ten years of higher education.) Cracking a chest means a chest operation: an emergency thoracotomy—cut between the ribs, pry open the bony struts and peek inside. The trauma surgeon sees what's bleeding and stops it.
Flail Chest
A flail chest means the same rib is broken in two places with a floating piece of chest wall in between. Usually more than one rib gets the double whammy during blunt chest trauma.
Figure 11 (page 91) shows the chest wall with a floating segment with several broken ribs all next to each other. The pressure changes inside the chest make this segment move paradoxically, i.e., balloon out with inspiration and collapse with expiration. It moves in the opposite direction of the normal chest. The injured segment "flails." Oxygenation is hampered because the victim's breathing efforts aren't economical. But the real problem is the huge bruise to the underlying lung tissue from the blunt impact, which interferes with oxygen delivery.
Cardiac Tamponade
Picture the throbbing heart inside its fibrous sac, a tomato inside a small balloon. Imagine the balloon filling with water as the tomato resists the increased pressure, water that compresses the tomato and then expands the balloon. Here's the rub.
While the heart sac fills with serum or blood, the heart constantly works at its task; it contracts and expands, filling up with blood and propelling it forward. The heart squeezes and swells from before birth to death. Ceaselessly, the fabled heart expands with blood, contracts with ejection. Diastole, then systole. Ebb, flow. Driven by emotions, pummeled by disease. Expands, demands. Ejection, rejection. Cycles.
