by David Page
3. Suture arteries.
4. Reattach veins (previously collapsed, but now more easily found because they are flooded with blood).
5. Delicately reapproximate nerves.
6. Close skin.
7. Apply a bulky loose dressing.
If blood vessels are sewn together with any degree of tension, they will clot and fail to supply blood to the finger. Consider the loss of tissue required to trim ragged skin edges, and you can appreciate the need to shorten the finger bones ever so slightly.
It's all done under an operating microscope. If the amputation site is at or beyond the last finger joint, some surgeons feel it's not feasible to repair it. You don't get as good a bang for the buck. Of course, it depends on what the victim does for a living.
Replantation of a thumb is usually indicated, and the results have been good. The younger the patient and the cleaner the amputation, the better the surgical outcome.
Replantation at the wrist, hand or forearm level has produced superb results in some reported studies of patients. However, when you get above the elbow, the results are poor, and fewer of the attempts at elbow or higher replantation are successful. More complications are seen with upper arm replantations.
Ring injuries are caused by traction on a ring that pulls off all or part of the finger. That is, the injury results in the finger being degloved (skin torn back), amputated or merely lacerated. Varying degrees of successful replantation have been observed, and some surgeons recommend amputation for serious avulsion ("ripped off") trauma.
Are Kids' Injuries Different?
Unlike with adults, replantation of the arm is quite successful in the pediatric age group. The indications for attempting replantation in kids are the same as in adults—if anything, the indications are more liberal. Overall, success rate in all children operated on with various traumatic amputations is 85 percent. It's less in avulsion injuries where the tissue ends are ragged and more surgery is needed. In these cases, success rates only reach about 75 percent. If the amputation is clean-cut, success of replantation approaches 95 percent.
Peripheral nerves regenerate better in youngsters than in adults. Presumably, they are less mature and possess residual "growth ability," for lack of a better term. The sensation kids experience in the reattached part tends to be better than that attained by adults. Of interest is the fact that the replanted part may actually grow with the child as he ages.
A Warning!
Not all replanted body parts function well. The microsurgeon must take into consideration many factors before embarking on the arduous task of sewing a body piece back into position. Worse by far than living with trauma of an amputation is the constant reminder of the horrible event by the presence of a useless limb or digit. Failure can result in some cases with the replanted limb literally hanging off the body.
While replacing two or more amputated fingers seems to provide a superior functional result over multiple amputations, replanting a single digit isn't always clearly an improvement over amputation. The surgeon makes the call using all available information.
Conflict arises when an injury threatens a character's goals. The tension in the story may be escalated at several points along the path to replantation. Some of the following questions may help your creative juices:
• Can the severed part be found?
• Can it be preserved properly for transportation?
• How far away is the appropriate hospital?
• Does someone in an intermediary hospital decide it's not worth the effort to send the victim on to the big-city trauma center?
• What are the other injuries your character suffered?
• Does the HMO think it's economical to save the part?
Your task is to think of what's in your story's unique world that might cause a traumatic amputation. Once again, people in conflict with each other make difficult medical decisions all the more complicated. Cut off the body part—not the conflict.
Self-inflicted scrapes, cuts and bruises are daily events for most of us. Nicks and abrasions go through cycles of healing and reinjury for many hardworking souls who labor throughout their lives with their hands. With time, these minor traumas of daily living heal and leave minimal scarring.
Skin consists of layers. The outermost coating is a mesh of dead cells, and the deeper germinal layer produces the layers and is protected by the cells above it. As skin is shed, new cells are born in the active germinal layer and the old mantle is replaced. This process goes on with monotonous certainty all the days of our lives.
Unlike amphibians and reptiles, lizards and snakes, we have neither a tough outer protection nor the ability to shed our integument en masse and replace it with a new coat. Minor sunburns, scratches, scrapes and gouges leave us with scabs and enough pain to be reminded we actually wear our feelings on the outside. Scars are the body's way of keeping the protective skin together; in a sense, it's nature's self-suturing. Excessive scarring, as we shall see in a moment, may overwhelm the skin landscape and create both cosmetic and emotional turmoil.
Two of the most devastating injuries known to man occur as a result of extremes of temperature; the worst by far are big bums. Local heat, if intense enough, damages all layers of the skin, not just the outer layer as with a sunburn. All sorts of agents of intense heat may damage the skin. And if a burn occurs in a closed space, the airways and lungs may also suffer with a reaction similar to pneumonia.
Cold injury almost always occurs out-of-doors in the harsh winter environment. And just as boiling water, oil and flame injure in distinct ways, so do the primary agents of cold injury: air, ice and water. Putting your characters in a polar setting is one way to expose them to the cold. Canadian researcher, explorer and author Dr. Joe MacInnis described to me the conditions he encountered when he performed the first dives attempted in the Arctic environment. Standing in the dive tent erected over a square opening cut into the deep Arctic ice, air temperature at head level reached almost 80° Fahrenheit while the diver's ankles endured temperatures hovering at ten degrees below zero! But don't think for a moment that cold injuries happen only to Arctic explorers. The potential for cold injury and hypothermia lurks even in temperate regions—not just in the high Arctic.
Common Ground
You might imagine burns and frostbite as distinctly different types of skin damage. In fact, they mimic each other. For both problems, it's an issue of degree of injury. Figure 18 shows the skin layers affected as a burn or frostbite progresses. Regardless of the type of thermal or cold insult, the skin may die partially, in which case it will regenerate itself, or it may succumb completely.
Keep in mind that skin damage is either partial thickness or full thickness. Thus, burns and frostbite injuries are classified according to depth of damage. The outcome of the injury and extent of treatment necessary to clean up the wounds (debridement) depends on whether the deep germinal cells are destroyed or preserved.
In a sense, your skin is a skating rink and life is a frenzied hoard of midget hockey players running over you, etching you with nicks and cuts. Your body has its own built-in Zamboni machine: Surface cells shed like snowflakes; deep cells resurface you daily.
But this surface rejuvenation can't fill in deep gouges. Deep injury means tissue loss with scarring. And scar tissue leaves irregular pits and
depressions, an ugly engraving that serves as a reminder of the impact.
Deep injury means trouble.
Burns
While a flame burn of the hand may require extensive reconstructive surgery, it doesn't affect the body's immune system or fluid balance. If small burns are first- or second-degree depth, they may be bandaged with antibiotic ointment and kept protected while new skin resurfaces the area. Small, full-thickness burns on nonessential surfaces, e.g., the back, leg or belly, may also be managed at home, although the pain can be impressive. Thus, the first factor in determining the severity of a burn is the depth.
Minor burns ch
aracterize people as smokers, sloppy amateur cooks or hardworking blue-collar types whose hands reflect a lifetime of toil. Old minor burn scars are white, flat and irregular—something else to read on a character's outward appearance.
Big burns result from home or industrial fires (often caused by careless smokers), forest fires (careless campers), kids playing with matches (careless parents)—you set it up any way you want in the world of your story. The second feature of a burn that determines how sick the patient will become is the percentage of the body burned. Figure 19
(page 161) gives you a rough idea of what percent of the total body surface is represented by the head, arms, legs and trunk.
The emergency treatment of a big burn begins with replacing the large amounts of body fluid that rapidly leak through the burned skin into the hospital sheets. The victim's "internal sea" is no longer protected by the skin envelope, and body temperature drops swiftly if other treatments such as raising the ambient room temperature aren't started immediately. Antibiotics are given intravenously, and the wounds are smeared with antibiotic ointment. At some point in the future, full-thickness dead skin must be removed surgically and replaced by partial thickness grafts from the victim's remaining patches of intact skin.
One of the first things the doctor will do in the ER is to calculate the burn victim's fluid needs for the first twenty-four hours of care. Interested in howl (This is to show you the incredible amount of IV fluid big burns require just to stay even with losses).
Take the percent of surface area burned and multiply it by the victim's body weight in kilograms. If the average person weighs 70 kilograms and suffers a 50 percent burn, you've got 70X50 = 3500. Multiply that by 4cc of IV fluid to get the amount to be given over the first day. That's 4cc X 3500 = 14,000cc, or fourteen liters or IV bags, in twenty-four hours.
Your burn victim is going to receive half of this amount in the first eight hours! No, you won't drown her. Her skin's leaking like a fifty-year-old roof, and she needs this much fluid just to survive. The terrible insult to the victim's body occurs because patches of skin are missing in places, and the more gaps present, the greater the changes in body
physiology. Keep the following facts in mind if you decide to inflict a big burn on one of your characters:
• Body fluid, or the internal sea, leaks out through the burned skin rapidly.
• Body temperature drops quickly if the room temperature isn't kept artificially elevated (making caring for the burn victim miserable work).
• Protein leaks out with the salt water marking the beginning of potential malnutrition.
• The body's metabolic rate—the speed at which the body burns fuel—soars upward.
• Bacteria find their way into the sterile tissue beneath the burned skin and can establish major infections quite quickly.
House Fire Smoke Inhalation
More than half of all deaths from house fires occur because the victim inhales smoke, which causes respiratory failure. Various noxious chemicals are found in house fire smoke. These include carbon dioxide, carbon monoxide, nitrogen dioxide, hydrogen cyanide and others. Burning wood, plastics, fabrics, cotton, wallboard and paper create dense smoke that irritates the lining of the windpipe and bronchi, causing the lungs to flood with fluid. Decreased oxygenation occurs, resulting in dizziness and lethargy. It's not the heat, it's the composition of the smoke itself that causes the damage.
The result of smoke inhalation is disorientation, confusion and, at times, coma. Combine a lung scorch with a big-league body burn and your character becomes critically ill. That means an ICU bed, a ventilator and a dedicated team of doctors and nurses. In other words, treatment includes intubation, oxygen, mechanical ventilation, pulmonary toilet (suctioning, chest physical therapy) and antibiotics. A slow wean from the ventilator—gradually letting the patient breathe for himself as the number of machine breaths are reduced—permits independent lung function in weeks or, sometimes, months. Prolonged respiratory support (over three weeks) necessitates a tracheostomy to avoid stricture of the vocal cords from the endotracheal tube.
Complications of an Electrical Injury
■ Heart fibrillation or arrest
■ Respiratory arrest (breathing stops)
■ Fractures
■ Muscle damage
■ Cataracts (delayed)
■ Seizures and/or coma
■ Internal bleeding
■ Loss of arms or legs
■ Paralysis
■ Kidney failure
Electrical Burns
Over 90 percent of electrical burns occur to men on the job, and, although they account for only about 5 percent of burn injuries overall, these victims have a high death rate. The most severe complications are loss of a limb or long-term neurological symptoms.
The degree of injury depends upon:
• The amount of current passing through tissues
• The amount of heat production with high resistance of tissues
• Total contact time
Electrical energy travels along the course of blood vessels, nerves and bones and therefore creates deep tissue injury. Muscle contraction from the electrical current may fracture bones or dislocate joints, and the muscles themselves may be severely damaged, releasing large amounts of the muscle substance myoglobin into the circulation. Microscopic fragments of this muscle substance may clog the kidneys and produce kidney failure.
As a general rule, household current in the 5-milliamp (mA) range only causes pain, while current up to 50 or 60 mA will cause cardiac fibrillation, persistent contraction of the muscles of breathing (diaphragm, intercostals) and a feeling of suffocation. Burns at the site of entrance of the current may be deeper than those produced by flame.
The doctor's chore in the hospital when managing a severe electrical burn is to keep checking the viability of the arms and legs involved in the course of the current to determine if surgical removal of dead tissue is necessary. Also, the surgeon checks blood counts and other lab tests, urine output and kidney function tests and examines extremity pulses to be assured of adequate blood flow. Severe injury results in edema (swelling) which may squeeze off arterial blood inflow as well as block venous outflow from the limb, resulting in further gross swelling.
As with all major body insults, an electrical burn may have systemic effects and cause grave illness by affecting the heart, lungs and kidneys.
Lightning
Lightning injuries cause between 150 and 300 deaths per year in the United States. Static electricity in a cloud creates a potential difference, and high voltage of short duration results in lightning striking the ground. Different types occur, which cause various injuries. Depending on whether the lightning is a direct hit, side flash or ground current, different organs are involved. The basic principle is that the current takes the path of least resistance in the body, just as with a man-made electrical current. A few of the more dramatic lightning injuries include:
• Cardiac standstill (asystole)
• Spasm of blood vessels with cold, pulseless limbs
• Apnea (cessation of breathing) and paralysis of brain stem respiratory centers
• Neurologic symptoms, including paralysis, weakness, vision loss, seizures, brain damage and hemorrhage into the brain
• Fractures from intense muscle contraction
• Fetal loss in 50 percent of pregnant women struck
Environmental Temperature Damage
A discussion of body damage caused by temperature extremes wouldn't be complete without covering illness that is a direct result of severe environmental temperatures. To complete this chapter, we'll discuss heat stroke, heat prostration and hypothermia. It's important to understand what happens to people as a result of changes in ambient temperature. In some ways, these problems are fascinating and quite subtle in their effect. These illnesses can play a dominant role in any story that takes place in geographic areas known for their extreme climate.
Bef
ore we get to major systemic problems with temperature, it's worthwhile reviewing a few nagging complaints your characters may develop on the ski slopes or at the beach. Referred to as physical allergies, these conditions are caused by exposure to less extreme changes in environmental temperature. Various substances in the serum are responsible for these reactions whether induced by heat or cold. The agents that cause physical allergies are:
• Sunlight
• Moderate cold
• Moderate to severe heat
• Minor skin trauma
The skin reaction and appearance in people with physical allergies is:
• Intense itchiness
• Swelling with patchy areas called wheals (fluid-filled tissue) sitting within large areas of redness
Another fascinating reaction in some people leaves a ridge of swelling wherever the skin is rubbed. Using a blunt instrument, e.g., a spoon or the end of a fork, you may actually write on the person's skin. It's called dermatographia. The marks stay raised on the skin for some time. Did your murderer leave a message on his victim's back?
Heat Stroke (Sun Stroke)
This problem is characterized by the inability to rid the body of heat. Instead of sweating to increase surface cooling, sufferers demonstrate hot flushed skin as their core temperature becomes seriously elevated. Often preceded by a sense of fatigue, dizziness and possibly a severe headache, this condition may progress to convulsions, and death is possible if treatment is delayed.
Heat stroke is a potentially deadly condition. The elements of this condition that distinguish it from heat exhaustion are:
• The victim feels as if she is "burning up"
• The skin is hot, dry and flushed
• Severe elevation of body core temperature in the range of 104° to 106° Fahrenheit occurs
• Rapid pulse rate is noted with a relatively normal blood pressure Immediate cooling in the field is mandatory if convulsions and death are to be avoided. Hospital care includes continued cooling, careful monitoring of core temperature, medication to prevent seizures and large amounts of intravenous saline solution.
