I need some medical advice!

[Miz Erie]

I'm writing a scene, and I need to know if it's plausible.

So here's the setup... I have a victim that has a depressed fracture of the occipital bone (just noticeable to the touch) from falling into the corner of a piece of furniture after being shoved forcefully. As he tried to defend himself with vertigo, he was startled and manged to fall on a large chef's knife, penetrating his right/left lumbar region but more medial than lateral. (I'm not very specific on the location.)

His attacker (Long story short, it's a stalker fan in love with a rock star, the victim from above, that has kidnapped and is holding said rock star captive.) tries to save him. He gives the victim an overdose of morphine combined with a heavy dose of unidentified sedatives so he can sew him up. (The sedatives have been shown in the story to be able to render the victim practically unconscious at the drug's peak with a half-life of about six to seven hours. I don't even know if there is such a drug.) On top of a head injury and blood loss from the stab wound (which I, again, have been less than specific but said enough to know he's lost two, maybe three, pints), stalker fan is pretty much killing his rock star, but hey, stalker fan isn't a doctor he's a recovering druggie. (Oh, and rock star's a little guy, about 5'4" and 140lbs.) Where I left the story off at is rock star is unconscious with slow, shallow breathing, and stalker fan has sewn his wounds closed with fishing line.

Now that I have lost everyone's attention, I get to my question. I want to know if this is plausible scenario. Rock star is never going to wake up. About seven hours after the injuries (six since the drugs were on board), rock star is going to seize. About three hours, give or take, later, rock star is going to go into respiratory distress. Stalker fan will be asleep, so no one is going to resuscitate him. Stalker fan wakes up next to a dead, cooling rock star.

I'm really stretching that timeline, I know. And forgive me if my jargon is off a little; I studied nursing for a while long ago but gave it up for engineering graphics which I gave up for writing.

So, anyone? Is this a plausible scenario?

[SnowBunny]

I'm no medical expert, but I do have some knowledge. It seems plausible to me.
If the rock star dies I think it's even more believable too.
While I was reading the descriptions I kept thinking along the lines of infection, etc. after the wound was sewn up, but with him dying hours later I don't think infection would play a large role.
Story sounds interesting. Reminds me of a similar plot style to Joe Hill (great author in my point of view).

[Miz Erie]

^If you're interested in reading it, I can link you to it. I take no offense if you don't. I'm writing it as fanfiction right now, but I'm going to rewrite parts of it and try to have it published. (I fell in love with the story, and it has just exceeded all my expectations.)

I'd love to know more about the Joe Hill plot style! I'm not familiar with that.

And I knew he was going to die in the story eventually. With the way I'm writing the story, though, I didn't want to drag it out for him to die of an infection. But I thought about that while writing it too! Thank you!

------edit------

I just realized that if you read it, you already know how it ends. Hahaha! But you're still welcome to if you'd like.

[ecwma]

I'm writing a scene, and I need to know if it's plausible.

So here's the setup... I have a victim that has a depressed fracture of the occipital bone (just noticeable to the touch) from falling into the corner of a piece of furniture after being shoved forcefully. As he tried to defend himself with vertigo, he was startled and manged to fall on a large chef's knife, penetrating his right/left lumbar region but more medial than lateral. (I'm not very specific on the location.)

His attacker (Long story short, it's a stalker fan in love with a rock star, the victim from above, that has kidnapped and is holding said rock star captive.) tries to save him. He gives the victim an overdose of morphine combined with a heavy dose of unidentified sedatives so he can sew him up. (The sedatives have been shown in the story to be able to render the victim practically unconscious at the drug's peak with a half-life of about six to seven hours. I don't even know if there is such a drug.) On top of a head injury and blood loss from the stab wound (which I, again, have been less than specific but said enough to know he's lost two, maybe three, pints), stalker fan is pretty much killing his rock star, but hey, stalker fan isn't a doctor he's a recovering druggie. Oh, and rock star's a little guy, about 5'4" and 140lbs.) Where I left the story off at is rock star is unconscious with slow, shallow breathing, and stalker fan has sewn his wounds closed with fishing line.

Now that I have lost everyone's attention, I get to my question. I want to know if this is plausible scenario. Rock star is never going to wake up. About seven hours after the injuries (six since the drugs were on board), rock star is going to seize. About three hours, give or take, later, rock star is going to go into respiratory distress. Stalker fan will be asleep, so no one is going to resuscitate him. Stalker fan wakes up next to a dead, cooling rock star.

I'm really stretching that timeline, I know. And forgive me if my jargon is off a little; I studied nursing for a while long ago but gave it up for engineering graphics which I gave up for writing.

So, anyone? Is this a plausible scenario?

To sum up: yes.

Now I'm going to go on a long, nerdy rant and give you information you might or might not know that could be beneficial to helping you write the scene. I'm a huge neurology nerd, so the head injury pleases me, but more on that later. I'm sure you know a good portion of this, because you were a nursing student, but I'm going to try to write this so that all of our readers might benefit. I mean no insult to anyone's intellect.

Make sure that the knife misses the lumbar arteries, otherwise he'll bleed out PDQ. (I'd have to look at the scene ver batim, but if you're still writing/editing, just make sure that you have it blocked out (imagined and mapped) well in your mind.) Especially ensure you miss the aorta. (Which I'm sure you know. )

As far as the skull fracture, what you're most likely looking at is called a basilar skull fracture. These can be nasty, but they give you an awesome visual, because they may present with Battle's Signs - a bruising around the eye sockets and over the mastoid process (behind the ear).

NERD BIT: If you're feeling particularly nerdy or want to look this up in-depth, Battle's Signs are technically two discreet signs - Periorbital Ecchymosis, or Raccoon Eyes, and ecchymosis of the mastoid process, or Battle's Sign. In much of minor medical education, they are clumped together. You will also see a CSF halo - put a piece of gauze to some blood coming from their ears, and it will absorb the blood, but also some very light yellow/clear/kind of fluorescent liquid - that's CSF. It comes in a lot of subtly different colors depending on what's wrong with your patient, but it's always beautiful, especially when backlit. If they ever let you into a neurosurgical ICU, ask to see someone who has shunt just so that you can see it, because description rather escapes me.

Our regularly scheduled programming: Other fun things that you'll get from this as an author is the ability to let your character bleed from his ears without actually having been hit on the ears. And boy can people with head injuries vomit like nothing you've ever seen.

Now here's the bit where my dealing with emergencies makes me a little useless, and for which I will add a disclaimer: every patient that I have seen with a basilar skull fracture has been very, very unconscious. They don't always have to be unconscious, and I've confirmed with a couple of colleagues that it's quite possible for them to have their wits about them. I just happen to be a magnet for patients who are particularly not-all-that-well-off.

The biggest concern I would have with a basilar skull fracture is regulation of basic bodily functions - heart rate (I've seen a lot of VTach with these fractures), blood pressure (which you treat secondarily and which varies depending on how bad the patient is), and... you guessed it. Breathing.

Infection is a bit of a concern with these kinds of fractures (as meningitis can occur), but we typically don't immediately start on antibiotics.

As far as the drug which is administered: what you're describing sounds like a benzodiazepine. It's a sedative which won't knock someone out per se, but will definitely relax them. (It will be beneficial to sleep, but it's not like propofol, which'll knock everyone out rapidly. You can remain conscious while on them.) I'd head for the Ativan (Lorazepam). It's rather marvelous, and lasts 6 hours.

Now, the great thing about benzodiazepines is that along with relaxing you, in some cases even enough to perform simple surgical procedures (they have a secondary benefit in that typically people won't remember anything when they're on them), they are also used in the management of... You guessed it, seizures. So if you give a high enough dose and don't taper down, especially on a head injury (which can have the effect of lowering your seizure threshold)... Voila.

Now the exciting bit. People are always shown sewing people up on the television and in movies... And they're usually very wrong. Because the typical suture (because in medicine, we can't say 'stitch' or 'stitch job') uses a very specific type of needle: that is, a curved one. Straight needle, you would need to pull skin up and stitch through it (very bad form, leaves a heckuva scar, looks terrible, and is often difficult to do with people who are in shape, like rock stars).

I'm not going to go into how it's normally done, because let's face it, your villain won't know any of that. But I will note that performing stitches with a straight needle will be: 1. awkward. 2. possibly difficult (I say possibly, because honestly, I've never tried it - I've always used the curved ones). 3. ugly.

So, I would mention him having difficulty, and maybe say something halfway through about how it always seemed easier in the movies, because it won't be a fun experience. (Not that it would anyway, I suppose...)

Also useful to note: between the two wounds, his head is going to bleed a lot more. A lot. Normally, when I see head injuries, there's a hematoma (a lump on their head), but if you're going for depressed, and you're going for blood loss, I assume that you're making the wound bleed. There's very little you could do descriptively to exaggerate that bleeding from what it would be in real life. These guys redefine bleeding.

But what kills your character, in the end, is probably related to CSF. CSF stands for cerebrospinal fluid, and the pressure that it needs to maintain has a narrower margin than blood pressure. So, one of two things happens: 1. Increased Intracranial Pressure (Higher CSF pressure), which is what I'm more used to dealing with. 2. Decreased ICP (because he's losing CSF, possibly through the ears and nose). Here's the fun bit: they present very similarly. Symptoms might include headache, spectacular vomiting with no nausea, one pupil being bigger than the other (he wouldn't be conscious for that), high blood pressure and slow heart rate (usually occurring together), and irregular breathing (fast then slow then fast then slow then...).

If you need additional information, feel free to ask. If you want to do your own research, I recommend Medscape. If you ever need an account to access something, send me a PM and we'll see if we can't get you some information.

[Miz Erie]

^I already love you!! *hugs* Maybe I should have asked if you liked hugs first... *blushes* (I shall edit this to actually reply when I have read it all.)

------edit------

I knew a lot that, but we'll get there. I already do a lot of research for my stories. And the scene with his getting sewn up is already done, but it'll be rewritten when I'm getting it ready to try to have it published.

You are welcome to read the scene if you'd like. I can link you to it. But I was blantantly vague on where exactly he was stabbed.

I wasn't sure if that was classified as a basilar skull fracture or not, but I thought so. I didn't say it because I didn't want to look dumb if I was wrong. As for the bruising, it would be difficult to see that. Rock star has been beaten pretty severely TWICE in the past week, so he's already got some nice coloring on his face.

I like the bleeding from the ears bit; I'll be using that, thank you!

Rock star had a bit of vertigo going on, but he was rapidly getting worse. He went from trying to protect himself to barely lucid by the end of the chapter. But the reason I have him with slow, shallow breathing is from the morphine overdose, which I know is a respiratory depressant. Combined with the sedatives, I honestly think he was lucky to still be breathing. But seeing as how stalker fan isn't really educated in such matters, I don't think he's going to be checking his pulse or BP. So I don't think I can incorporate that into the story.

I was thinking a benzo. Just a bit of info I don't normally share about myself: I have some serious mental health issues (hence why many of my characters do too), and I take four meds a day and valium as needed (which is rarely now that I'm on a good cocktail). I know about benzo! I had in the back of my mind that stalker fan was feeding him Xanax the whole time; I just wasn't sure that would give me the results I wanted, so I never called it by name. I feel good; I got that one right!

I actually did a few hours research before I wrote about stalker fan stitching up rock star. I was trying to find a good alternative to using normally cotton thread. I knew that he needed a curved needle, and I had already made note to have him bend his straight sewing needle at some point when I did the rewrite. But I did at least have him tie off each stitch. (I know that is a bad term, but I'm from the south in US, and we call them stitches, even medical personnel.)

I knew the scalp bleeds profusely. And I did mention in the original that there was a pool of blood under his head when stalker fan turned it to check that injury. I have in my notes that by morning (well, when stalker fan is awakened by the seizure at some early hour), stalker fan is going to notice that his head injury is leaking "watery blood" because he'd be loosing CSF. But stalker fan is stupid and refuses to call EMS because he doesn't want anyone taking rock star away.

I've also been doing a little research on rigors. Seriously, I cover all my bases. I don't care that it's fanfiction.

Anywho... thank you so much again for all this!! I will definately add you to my contacts!

[ecwma]

I have in my notes that by morning (well, when stalker fan is awakened by the seizure at some early hour), stalker fan is going to notice that his head injury is leaking "watery blood" because he'd be losing CSF.

WARNING FOR GRAPHIC CONTENT

I'd actually leave out the 'watery blood' bit... Remember, you've only got 125-150 mL of CSF at any given time. (Though it's replaced several times per day, as the average person will produce about 500 mL / day, so even if he's there for 12 hours, he'd only have a maximum of 400 mL of CSF to give, and CSF has clotting factors in it (cite: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC480446/), just like blood.) I've never personally seen so much CSF come with a head injury that I can look at the blood on the pavement floor bed gurney (or any other surface other than a bit of gauze for that matter), and tell that there's CSF in it. (Even, funnily enough, in head injuries wherein I can see separate venous and arterial blood - in retrospect, you'd rather expect to see it there, yet to my recollection, I haven't.) And I've seen some pretty fantastic head injury deaths (if you ever want a realistic brains-on-the-pavement/suicide/murder/open head injury scene description, let me know ).

If there are any HCP's out there who *have* seen a head injury with enough CSF to visualize, please let me know! I'd love to know what it looks like.

And this is not to say that it isn't possible - I'm sure it is, and that there are stranger things under the sun, I just wouldn't expect it or find it very typical, and I think that the lay readers will find it confusing and the providers reading it will roll their eyes.

Especially since if he's been dead (or bleeding) for any length of time, the blood will be coagulated - sticky, clotted, etc. It'll look a bit like he's actually lost some flesh, because it clumps to itself as opposed to sticking readily to the floor in the way you'd expect (don't get me wrong, it also sticks to the floor, but it's really unusual the first few times you see clotted blood because it kind of looks a bit like curds (if you can imagine, if you had incredibly firm cottage cheese) - not what Hollywood or Halloween or pop culture programs you to expect).

While very different in their etiology, gunshot wounds to the head are the main things that I'm thinking of when trying to imagine that kind of scene - after any length of time, blood will be a darker color (darker even than you might imagine, and the larger clots will look almost black), some will be pretty well-adhered to the floor, but not all and in your case I might not even say a majority, as there is logically more blood in a clot than in a thin coating on the floor.

In sum... think cottage cheese.

(And if that's not enough, check out these images: http://www.myfilipinokitchen.com/wp-...oody-Adobo.jpg (a little light for venous blood) ; http://www.catholicplanet.com/appari...im-2006-10.jpg (think a little less jello and a little more cottage cheese) ; http://www.dnr.sc.gov/marine/mrri/in...coagulated.jpg (blood clots still in a fish, but probably the best example here) )

You're all welcome for the visuals. None of this is meant to be unnecessarily offputting, but is instead intended to help create realistic imagery.

[James simpson]

just like ecwma I am not trying to make anyone look stupid just stating some facts that I know. Also Warning slightly graphic.

I've also been doing a little research on rigors.

What happens after death depends on how long the victim is dead before he is found. You will almost certainly have livor mortis (red/purple discolouration due to gravity. Essentially all the blood in the body pools at the bottom and it looks allot like bruising.)

It starts to happen between 30 mins and 2 hrs after death. after about 8-12 hrs it actually becomes "fixed" so it stops moving and your forensic pathologist can tell if the body has been moved, so it depends on how long you want your stalker to sleep before they find the body. The cold slows the process down though.

If the victim has his arms hanging down off the edge of the bed between 2-4 hrs petechiae (small spots all over the limb from hemorrage.) will form (18-24 hrs for the rest of the body)

Rigor Mortis appears between 2-4 hrs and gets to its max between 6-12 hrs. It is due to the loss of adenosine triphosphate in the muscle, and loosing allot of it before death can speed up the process. This can be done by the victim having convulsions, heavy/violent exercise (e.g. trying to avoid rape from your stalker) and a high body temperature (e.g. having a prior infection, maybe from the beating, causing a fever.)

[Maryn]

I'm not an expert at much of anything, but I have trouble with the plausibility of falling on a knife in such a way that rock star is stabbed. Cut, yeah, I'd be good with that, but stabbing requires it to be propped up quite firmly, enough to puncture rather than moving with the force of his falling on it.

I propose buying a roast and seeing if you can prop a knife up in some way which allows it to deeply pierce the roast when you drop it on the knife. You also get a nice dinner out of this.

Maryn, practical

[Jcomp]

Hi Miz Erie. Looks like this has received some helpful responses so far, so I don't want to disrupt that. And just to be clear, you didn't do anything wrong by posting this question here. But just for your benefit, I wanted to let you know that AW also has the Story Research forum that is often extremely useful when it comes to questions like this.

Again (I can't stress this enough), I have zero issue with this thread being in the Horror forum, and I want to thank the people who have responded here already for being helpful, but I thought I'd share the link to the Story Research forum in case you weren't aware of it already. I've used it a few different times since I've been here (to find out exactly how 911 dispatchers would respond to a call for a drug OD, and for advice on how to have my characters believably burn down a large derelict building, among other things) and I can't say enough about how useful it is.

Just an FYI. By all means everyone, carry on.

[Miz Erie]

^Thank you so much!! I looked for something like that, but I didn't find it. But I'm still learning my way around and where all the forums are. I'm sure I'll make good use of that area, as I love researching stuff and learning new things!

I'm not an expert at much of anything, but I have trouble with the plausibility of falling on a knife in such a way that rock star is stabbed. Cut, yeah, I'd be good with that, but stabbing requires it to be propped up quite firmly, enough to puncture rather than moving with the force of his falling on it.

I propose buying a roast and seeing if you can prop a knife up in some way which allows it to deeply pierce the roast when you drop it on the knife. You also get a nice dinner out of this.

Maryn, practical

I actually played with the mechanics to figure it out. First of all, instead of holding the knife that way one normally would, he was holding it so that the blade extended past his pinkie finger. Now, because he was disoriented (because of the skull fracture), he didn't try very hard to brace his fall with his hands. I got out on the trampoline and tried falling different way. If you don't start to raise your hands until you are halfway down, your hands can get trapped under you, causing you to fall on your fist. Because of our anatomy, our thumb would be away from our body when we landed on our fist.

Him holding the knife would create enough stability to keep it in place for it to puncture the skin and then the weight of his body falling would pushing further in his gut.

But all of that is contingent on the actual blade, which I admit I didn't think about when I was working out the scenario. In my house, we have a professional set of knives that are razor sharp. If someone were to fall on one, it would cut right through them. I don't believe most household have knives like that, though. But some people do keep their knives sharp, so it is still plausible.

(I'm going to reply to everyone, but I need to leave the computer for a while. I'll be back tonight!)

[SnowBunny]

^If you're interested in reading it, I can link you to it. I take no offense if you don't. I'm writing it as fanfiction right now, but I'm going to rewrite parts of it and try to have it published. (I fell in love with the story, and it has just exceeded all my expectations.)

I'd love to know more about the Joe Hill plot style! I'm not familiar with that.

And I knew he was going to die in the story eventually. With the way I'm writing the story, though, I didn't want to drag it out for him to die of an infection. But I thought about that while writing it too! Thank you!

------edit------

I just realized that if you read it, you already know how it ends. Hahaha! But you're still welcome to if you'd like.

Feel free to PM the section and I'll gladly read it.

[Rhoda Nightingale]

Just adding onto what Jcomp said, there's also the Share Your Work section after you reach 50 posts. Lots of invaluable feedback in there.

[ecwma]

Hey, there! Apologies for the delayed response - I've had some busy shifts.

As far as the believability of the stabbing (I think it's believable): I've worked a lot of stabbings. I'd like to hear from anyone here who's had a different experience, but a lot of the time, reconstructing what happened is a job and a half. There are multiple reasons for this - adrenaline, the inherently terrible memory of human beings, and our lack of ability to focus on multiple moving targets. A head injury would make it that much more difficult for him to focus on what's going on, and addict boy probably wouldn't be any more capable of focusing on all that at once.

Still, for some reason, when I first read it, I thought it was an intentional stabbing (blame the sleep deprivation). It would be difficult to fall on a knife that was lying on the ground, but I've seen stranger things happen, and if he was holding it, there really isn't much telling what would happen.

As far as whether the knife could stab him or not, you would be amazed at the damage you can do with an ordinary kitchen knife and a little adrenaline in your system. (I'd recommend that if you're going to try any recreation, you go and get fresh, raw meat from your butcher, because it's much easier to stab raw meat than processed meat, and I imagine it's a little closer to what living flesh is.)

***I AM NOT RECOMMENDING THAT ANYONE TRY STABBING ANY LIVING THING.***

In truth (and again, this is just my experience), most of the stabbings I've run have been with ordinary kitchen knives. People who have nice swords, nice knives, etc, don't use them on people. I've seen more worn-out paring knives, overused steak knives, etc, than anything else, and I've never seen someone stabbed with a nice, professional knife. I'm not sure why - some of these incidents occurred in kitchens with nice knives. Perhaps it's that that's the knife you're used to using, perhaps they actually think that they don't want to ruin their nice knives, perhaps there is no logic and it's all happenstance.

And if anyone was wondering about the muscle power required to stab people: I've seen very small individuals (read: individuals who don't have two digits in the 'age' column) stab people much larger than them with ordinary kitchen knives.

So my verdict is: believable. I'd love to hear others' experiences and thoughts, though.