Injuries

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In this section you can find information in Gunshots, Head Injuries, Knife wounds, Poisons and Broken Ribs


written by NAME DELETED, RN, CRNI

Disclaimer: Please note that the following are generalizations only. Every situation is different, with too many mitigating factors to include here. I have tried to list the most common fanfic injuries and medical conditions, with their signs and symptoms (s/s), best and worst case scenarios, probable treatments, and recovery times for each. If I have insulted anyone by being too basic, I apologize; fanfic writers come in all occupations and ages, so it was difficult to know where to start. Also please note that this is not a do-it-yourself emergency medicine textbook; it is intended only as a resource for writers to lend some authenticity to the medical details in their writing.


Gunshots

Gunshots: more than you ever wanted to know.

Regardless of what happens to our heroes on TV, gunshots are rarely neat, clean, predictable and restricted to "flesh wounds". When a bullet enters the body, it's a spinning missile. The amount of damage and relative size of the entrance and exit wounds depends on many factors: the calibre of the bullet, the distance from the victim when fired, and the organs, bone, blood vessels and other structures hit.

Striking bones causes the bullet to become misshapen, flattening out. The bone shatters, creating splinters that themselves can become lethal weapons, and altering the path of the bullet in an unpredictable manner. Sometimes the final resting place of the bullet in the body or the place where it exits is very unexpected. As a general rule, exit wounds are larger than entrance wounds - sometimes inches larger, if the bullet's shape has become distorted by the structures hit.

When Scully shot Mulder in the shoulder in "Anasazi", there was a nice, neat entrance and exit wound with not much of a problem beyond soreness. Mulder was indeed fortunate that his partner was not only "a good shot", but apparently had xray vision as well. As anyone can tell by feeling his or her shoulder, there's very little flesh, but there is a lot of bone. There are also numerous other structures that would be very easy and potentially devastating to hit. From the placement of the bullet, the upper part of Mulder's left lung could have been punctured, possibly causing a pneumothorax (commonly called a collapsed lung - see more about this in "Broken Ribs" and the section on "Tubes".) There are also important nerves in the area, like the brachial nerve, which controls the movement of the arm, so potentially Mulder could have been permanently paralysed in his left arm. There are major blood vessels as well, such as the subclavian vein and axillary and brachial arteries, the rupture of which could cause death from blood loss in a very short span of time. Then, there's the danger of infection. Bullets, because of the heat produced by firing, are themselves essentially sterile when they reach the body. But the bullet passes through clothing, hair, and skin, carrying particles into the wound which could be sources of infection.

Would such a shot have rendered Mulder unconscious? Possibly, from the psychogenic shock caused by the pain of the injury (or the fact that it was Scully that shot him). More likely, he would have been dazed and semiconscious. Or he could have merely staggered and shot Krycek anyway. Shooting someone holding someone else at gunpoint is risky, since the person shot could reflexively pull the trigger of their own gun.

Gunshots are more realistically portrayed in "Beyond the Sea". Usually on TV when someone is shot in the leg, about all that happens is the victim limps around and bleeds a little from a very neat entrance wound (and there is rarely an exit wound, for whatever reason). Mulder's injury in that episode was very realistically done. His femur (the thigh bone) was probably fractured or at least chipped, and there was a huge, life-threatening blood loss from the rupture of the femoral artery. Rupture of that artery (either from the bullet itself or from shattered bone fragments) could certainly have caused the spurting which left Mulder's blood spattered on the white cross above him. The measures depicted in the Emergency Room were completely realistic. Some might wonder why he was given oxygen, since he was shot in the leg, and not in the chest. One of the functions of the blood is to carry oxygen around the body. When there is a major blood loss, there are fewer red blood cells to do this, so 100% oxygen is given by mask to help the remaining red cells do their job. Until Mulder's condition was stable, he would be closely monitored in ICU. After a few days, when his blood loss had been compensated for by transfusions and IV fluids, he would have been moved to a surgical or trauma unit. The location of the fracture of the femur so close to the hip and groin would mean that it would not be placed in a cast. It would, however, have taken several weeks or months of physical therapy to get him in any condition to return to active duty.

In the Piper Maru/Apocrypha episodes, Skinner was shot in the abdomen at close range. There really aren't a lot of places in the abdomen one can be shot without fairly devastating and perhaps lifelong effects. [Please note that the stomach is an organ within the abdomen with a very specific function - the entire abdomen should not be referred to as "the stomach".] Damage to the large intestine (there's about 5 feet of it in there) could result in a temporary or permanent colostomy (more details on request. Just trust me - given a choice, you wouldn't want one.) The abdomen also contains about 21 feet of small intestine, the liver, the stomach, two kidneys, the spleen, the gallbladder, and the bladder, not to mention the reproductive organs in females. A bullet wound to the stomach (incredibly painful due to the spilling of powerful digestive acids onto surrounding organs, literally burning them) could result in having to eat by means of a feeding tube inserted into the body for several weeks or forever (see "Tubes" section). The major artery of the body, the aorta, also travels thorugh the abdomen. Rupture of this often means death within a few minutes. Then, there are nerves and also the bones of the spine and pelvic girdle.

Because of the unpredictable path of a bullet and the many organs crowded into the abdomen, the least that could be expected would be a long exploratory surgery to exhaustively trace the path of the bullet, looking for possible damage. Just a nick in the large intestine can produce bleeding and very nasty "dirty" wounds, infection and absesses if not found. Recovery time from a bullet in the abdomen could vary greatly, depending on the structures hit and the damage done, but certainly would not be less than six to eight weeks. Lesser mortals than Walter Skinner would probably just opt for retirement on disability.


Head Injuries

Head injuries - dazed and confused.

We've all probably lost count of the number of times Mulder and Scully have been hit on the head, knocking them unconscious. In the real world, at this point they'd probably behave a lot like punch-drunk prizefighters. Any blow hard enough to cause unconsciousness is also hard enough to cause temporary if not permanent damage. After regaining consciousness, the person would be dizzy, nauseated, and have a terrific headache and blurred vision for hours or days. They might also have lost the memory of the events immediately preceding the blow. This short period of amnesia could be permanent. Any head injury also carries with it the potential of post-traumatic epilepsy, in which the damaged area of the brain serves as a focus for seizures.

Any head injury can cause swelling, which is very dangerous in the brain, since it is enclosed (in adults) in an unyielding skull. The swelling literally has no place to go, causing raised intracranial pressure and further brain damage. It is for this reason that shock victims with head injuries are always positioned with their heads raised. Lowering the head would cause further accumulation of fluid and further swelling. Unchecked swelling will cause herniation of the brain through the foramen magnum (a hole at the bottom rear of the skull where it meets the spinal column) and death. Signs and symptoms of brain swelling include: severe headache, nausea, progressive confusion, vision disturbances, loss of consciousness, raised intracranial pressure, high blood pressure, seizures and deepening coma and death. Melissa Scully died from the swelling that took place in her brain after she was shot in the head. Treatment is aimed at reducing the swelling and inflammation with IV mannitol and other medications. Sometimes a hole is actually cut into the skull, to relieve the pressure and give the brain some room for expansion until the worst of the swelling subsides.

Blows to the head can also cause bleeding within the skull. One of the most common bleeds is called a subdural hematoma. The dura is one of the tough, protective layers between the skull and the gray matter of the brain itself. A blow can rupture a blood vessel, causing bleeding under the dura. This blood has nowhere to go, so it collects, putting pressure on the brain. Signs and symptoms would be the same as for brain swelling, the severity dependent on how large the bleed was, whether it was still active, and the size of the ruptured blood vessel. Sometimes with a slow bleed (a very small blood vessel which just leaks a little) symptoms may appear very gradually over several days or weeks. Unless it is a very slow bleed which has already stopped - either from the body's natural clotting mechanisms or from the pressure exerted by the hematoma itself - treatment is surgical. After CAT scans or MRI's have determined the site of the bleed, small burr holes are drilled into the skull, the hematoma is evacuated, and any vessels still bleeding are cauterized. Once the hematoma is gone, recovery is rapid and, if there has been little or no damage, complete.

Skull fractures give an indication of the force of the blow, the amount of brain damage that might have occurred, and the potential for swelling and bleeding. Skull fractures are sometimes just a crack in the bone. A "depressed" skull fracture means that the bone itself has been driven into the brain, which obviously is much worse. Bleeding from the nose and ears, or bruising around the eyes and behind the ears are extremely serious signs in a head injury. It almost always means one or more major vessels have ruptured in the brain. Chances of survival would be poor, and permanent damage would result in those who did survive.

Probably less is known about the brain than any other organ. Sometimes a single, apparently minor blow to the head which causes unconsciousness for just a few minutes can create lasting damage in the form of seizures, learning or memory deficits, and visual disturbances. Then again, there are cases of people who have had their brains completely impaled by speargun darts who have suffered few if any lasting effects.


Knife wounds and other impaled objects

The damage done by knife wounds depends on the kind of wound and the structures affected.

A slash wound to the arm, such as Mulder received in "Blood", would cause bleeding and possible muscle, nerve or tendon damage. For emergency treatment in the field, bleeding would be controlled by use of direct pressure on the wound itself (snap on the latex first). Once in the ER, if only the muscle and skin were affected, the blood vessels would be tied off or cauterized to stop the bleeding, and the skin sutured shut with silk, nylon or teflon sutures. [Surgical wounds from operations, especially of the abdomen, chest and leg, are usually stapled shut.] Tendon and nerve damage would necessitate surgery, with not always perfect results. The same slash wound across the throat, however, would sever the carotid arteries, the jugular veins and possibly the trachea, causing death within a minute or two.

Slash wounds, except to the neck or other areas where the major vessels lie close to the surface of the skin, usually do not cause death. The troubled girl in "Die Hand, Die Verletzt" would neither have caused enough damage nor bled enough to cause death in those few seconds. Crosswise cuts on the wrist do little other than to cause irreparable tendon and nerve damage, if anything. The artery lies deeper than most people are willing to cut. And even bleeding from the radial artery in the wrist would not cause death within a few minutes.

Knives can also make stab or puncture wounds. These tend to bleed less externally than internally. If the knife is still in the wound when the paramedics arrive, it is treated like any other impaled object. It is not removed, but rather taped and braced so that it cannot come out accidentally. The reason for this is that impaled objects do enough damage on their way into the body - they can do even more on the way out. Also, the impaled object left in place often helps to minimize amount of bleeding. It would not be removed until the victim was in the operating room. There, the surgeons would carefully remove the object as non-traumatically as possible and repair any damage immediately. Some impaled objects aren't as readily moved with the victim as arrows or knives. In such cases - such as a stationary metal pole or the steering column of a car - the object would be cut off as close to the victim as possible, freeing him, and then he would be transported with the impaled object to the hospital.


Poisons

Poisons run the gamut of signs, symptoms and severity. Overdose of otherwise harmless drugs cause toxicity (poisoning) as do the more commonly known poisons such as arsenic, strychnine and cyanide. Poisons can be ingested (drugs, mushrooms, nicotine); inhaled (carbon monoxide, cyanide gas, mustard gas); absorbed thorugh the skin (insecticdes) or injected (drugs, snake and spider venom). Below are a few examples of poisons and their signs/symptoms, treatment and likely outcomes.

Heavy metal poisons: These include arsenic, lead and mercury. They are usualy given over a long period of time, and are often detected by means of hair and fingernail samples, which demonstrate the long exposure. S/s would innclude nausea, vomiting, weight loss, lethargy, loss of mental acuity, confusion, and finally coma and death. The victim could survive if the poisoning were detected early enough, but damage could be permanent.

Strychnine: An extremely nasty poison which causes such agonizing and severe muscle spasms that the victim displays a sign call "opisthotonos" where the spine bends backward to such a degree that only the head and heels touch the surface of the bed or floor. Strychnine is usually fatal within minutes.

Rat Poison: Rat poisons today are made with a warfarin-type drug, which disrupts the body's clotting mechanisms. The rat (or poisoning victim) dies of internal bleeding. Symptoms would include shock, possibly external bleeding from the body's orifices, pain, and a rigid, distended abdomen. Prognosis would depend on early detection and aggressive supportive treatment (blood transfusions, IV fluids, vasoconstrictors) and the dose given.

Rattlesnake venom: Unlike most snake venoms which are neurotoxins, rattlensake venom acts a lot like rat poison - it interferes with normal blood clotting. Treatment would be as above, with the addition of antivenin, to counteract the effects of the venom.

Toxic mushrooms: Toxic mushrooms are very difficult to differentiate from edible mushrooms, which is why most cases of this sort of poisoning are accidental. Mushroom poison is an alkaloid neurotoxin, sort of like curare (arrow poison), acting on the central nervous system (CNS). The victim would display progressive clumsiness, shortness of breath as the muscles of respiration become paralyzed, hypoxia (lack of oxygen), confusion, slowed heart rate, progressive paralysis, coma and death. Treatment consists of gastric lavage ("Stomach pump" - See "Tubes" section) and supportive measures including IV fluids, CNS stimulants, and being placed on a respirator. Usually treatment isn't sought until the symptoms have become well-advanced, so in spite of medical intervention, the victim often dies.

Carbon Monoxide: This is a very dangerous pouison, sionce it is an odorless, tasteless, colorless gas and early symptoms are vague. This, too is a poisoning which is often accidental, caused by malfunctioning heating systems. Early symptoms include headache, nausea, flushing and lethargy. Since these symptoms mimic viral illnesses, people usually assume they've caught "whatever's going around". Later stages are characterized by increasing confusion, a bright cherry-red color to the lips and cheeks, coma and death. Other than removing the victim from the source of the carbon monoxide, treatment is extremely difficult. Carbon monoxide binds chemically with the red blood cells even more strongly than oxygen, so that oxygen can't bind to them. Thus, even flushing the system with 100% oxygen is often futile. Red blood cell replacement may be effective in some cases, along with aggressive supportive measures, such as intubating the patient and placing him or her on a respirator.

Overdoses S/s depend on the drug and amount taken. Overdoses of a CNS depressant, such as sleeping pills, tranquillizers, muscle relaxants and narcotics cause clumsiness, confusion, lethargy, slowed respirations, constriction of the pupils (with narcotics), progressive coma and death. Overdose of a CNS stimulant, like cocaine, causes restlessness, irritability, rapid heartbeat, high (sometimes very high) blood pressure, and irrational behavior. Death is often caused by heart failure or the rupture of a major blood vessel in the brain, lung or heart.

Overdoses are generally treated by getting rid of the ingested substance - in other words, forcing the patient to vomit. There are two instances in which this is NEVER done. One is when the patient is losing consciousness, because the risk of aspiration (inhaling vomit into the lungs) is too high. It is also not done if the substance is a petroleum-based product like gasoline, kerosene, and some insecticides, because the fumes can cause fatal lung damage. Sometimes activated charcoal is introduced into the stomach by means of a tube, to counteract the poison. Most often, gastric lavage is used as the safest and surest means of emptying the stomach.

Poisons are often not detected in the body after death. Even a toxicology screen tests only for those substances which are most likely to be there. Unless a particular test for a particular poison is run (and some of these are extremely complex), there may be no sign whatsoever of poisoning. So the more rare the poison, the more likely the poisoner is to get away with it. Also, some "poisons" are naturally occurring substances in the body, but are toxic when given in massive amounts. One example of this would be the EMT killed by Leonard Betts by injection of potassium (although he probably would have had to have given it intravenously and in far greater quantity than he did). Potassium is also extremely irritating to the veins and thus very painful to inject. Another example would be insulin, helpful in the right amount, but leading to death in severe overdosage. Unless an autopsy were performed and the right tests were ordered immediately after death, any signs of these overdoses would probably be gone shortly after death.


Broken Ribs

Broken ribs can be sustained many ways, such as in a fight, a car accident or from falls. Rib fractures are extremely painful and generally take about 6 weeks to heal. Treatment consists of analgesics (pain medications) and either taping or strapping the ribs such as with a velcro rib belt to protect and support them during healing. Sometimes, however, complications can result from broken ribs.

One of the more serious is called a pneumothorax. Without getting too deeply into the physics, the lungs are located in the pleural cavity in which negative pressure is maintained, allowing the lungs to expand with air from the outside (positive pressure) In a pneumothorax, the pleural cavity is punctured and the lung collapses, unable to expand until the negative pressure is restored. Broken ribs can cause such a puncture, as well as knife wounds, gunshots, impaled objects, flail chest (type of injury made when the chest impacts a steering wheel with great force, breaking all the ribs off at the sternum) and other injuries to the chest.

If the skin is broken (such as in compound fractures of the ribs, as well as any of the above causes) a "sucking chest wound" results. Not only does the lung collapse, but the positively pressured air from the outside is sucked into the pleural cavity, further compressing the lung, and sometimes even shifting the position of the heart. This constitutes a serious medical emergency. The victim would be extremely short of breath, possibly cyanotic (blue), in great pain and in shock. Field treatment would include covering the wound with an air-occlusive dressing, such as Saran wrap or Vaseline-impregnated gauze, securely taped to the skin. In the emergency room, a thoracotomy would be performed (an incision made into the chest) and a chest tube would be inserted into the pleural cavity. This flexible rubber tube would then be attached to tubing that would lead into a hard plastic container partially filled with sterile water. The air from the pleural cavity would travel down the tubes into the container, making air bubbles in the water. Almost immediately, the patient would begin to have less pain and breathe more easily. As the air gradually (over several days) leaves the pleural cavity, the lung re-expands with corresponding improvement in the patient's condition. X-rays would confirm the progress of the re-expansion, and eventually the chest tube would be removed.

Another complication of broken ribs is pneumonia. Pneumonia can have many causes, including viruses, bacteria, aspiration of stomach contents or foreign bodies, water (in drowning victims) and severely restricted movement. The latter is generally the culprit following rib fractures. Because the ribs and chest are extremely painful, the victim tends to breathe very shallowly, so that movement of the ribs is minimal. Unfortunately, air movement in the lungs is also minimal. When the air stays in the lungs, so do secretions that are normally moved upward in the bronchial tree by movement of the air, and eventually coughed out. Pneumonia occurs when these secretions consolidate in the air sacs of the lungs, creating an ever-expanding area of lung tissue which cannot fulfill its primary function of gas exchange. The patient may have fever (if infection is present), chest pain, shortness of breath and sometimes hypoxia. Treatment consists of IV or oral antibiotics, oxygen (usually by nasal cannula - See "Tubes" Section) and respiratory therapy treatments. The intent of these treatments is to liquify and mobilize the secretions so they can be coughed up and expectorated (medical word for spitting out). In some pneumonias (though not likely in the case of a patient with broken ribs) these treaments also include chest percussion, in which the nurse or therapist performs a clapping movement with the palm of the hand on the patient's chest and back, literally jarring the secretions loose. Sometimes this is combined with postural drainage, when the patient is placed with his head and chest lower than the rest of his body, thus using gravity to assist in the process.

____

here is a first-hand account (taken from the Usenet newsgroups alt.tv.x-files.creative) on what it feels like to break your ribs.

It feels about the way you'd expect it to feel. It pinches and hurts like a bitch. Breathing hurts. Driving over bumps in the road hurts. Lying down in any position besides flat on my back hurts.

The trip to the doctor involved some things I didn't expect. They took my pulse, looked unhappy and gave me an EKG. Apparently intense pain can sometimes make people's hearts give out. Not a comforting thought. I had to pee in a jar so they could look for "occult blood." It really is called that. The term just means "hidden blood" or blood that is not visible to the eye. I imagine Mulder would have a field day with the phrase, though. They sucked blood out of my arm, but I'm afraid I didn't ask why. My guess is that they were looking for some change in blood chemistry that would suggest some organ or other was damaged.

The doctor said I didn't have to have an X-ray if I didn't want. Despite the well-known fear of puncturing a lung with a bone shard, nobody seems to care much if a rib is broken or not. You can't put a cast on ribs and you can't splint them, so broken and bruised ribs get treated the same way, i.e., symptomatically. I have many special drugs now -- Darvocet and 600 mg horse-pills of Motrin. I cannot drive like this and I write strange letters to ATXC. : )

The doctor was interested in getting an ultrasound of my belly, though. It seems a good whack on your lower left side can rupture your spleen. (I imagine if someone got hurt on other parts of their chest the doctors would worry about whatever squishy bits were underneath). I couldn't have the ultrasound today because you need to avoid eating after midnight (q.v. "Gremlins") and especially must avoid fatty food. I do not know why.

For what it's worth -- I recently read a story in which Mulder gets his ribs cracked and is comforted when Scully pulls his head and shoulders into her lap. I would have to murder anyone who tried to do that to me now. I have to lie very, very flat. For some reason he also refused to take his meds in this story. I can tell you right now -- if prescription A wasn't working for me, I'd be on the phone with the doctor damn quick demanding prescription B. (This is not a flame of that story, which was a sweet hurt/comfort vignette and pretended to be nothing else.)

Then, in response to someone mentioning a story when Mulder didn't breathe deeply enough and ended up with pneumonia: Actually, my doctor said that I must "be sure to breathe at least 5 or 6 times an hour" or else I would develop pneumonia. I believe she meant "breathe deeply," but hey, whatever. It seems to be easier to get pneumonia than you'd expect.

Somebody else added: "I've had some surgery since then, various other icky problems, and i'll tell you what - *nothing* has ever hurt as much as those broken ribs. no walking, no driving, no breathing, no eating, no nothing, without pain. and it's all heightened by the inability to get a nice, deep breath, which makes it a million times worse."

Other comments were that laughing hurt, sneezing is worse, and there's a need to clutch a pillow to your abdomen all the time.


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