PDA

View Full Version : Calling doctors: brain damage/coma after a car accident?



aruna
09-01-2008, 02:05 PM
Latecomers to thread: the "car accident" scenario is resolved; it's now another head injury, see last posts in thread!

Here's my scenario: there's a car accident, caused by the inattention of the driver. The hit the car in front at a sudden stop. ON the passenger seat is an 80 something woman, not wearing a seat belt. She flies against the windscreen, head cut open. Emergencies services arrive and whizz her, unconscious, to hospital. She is operated on for a few hours while her relatives wait anxiously. It's touch and go, but finally the surgeon gives the all-clear. She's out of danger, operation successful--but there might be lasting brain damage, can't be known at this point.
The next day she does not wake up out of anaesthetic. She is in a coma for 2 or 3 days, nobody knows if she'll ever wake up or be the same once she does.

I'm not going to give any medical details; I just want to know if there are any gross errors in that scnararion or anything else I could mention; maybe even a clever sound bite the doctor could say to the relatives?

Tnanks for your help!

jclarkdawe
09-01-2008, 04:24 PM
At that age, I'd expect some pre-existing conditions that would be also impacting here. If a passenger hits the windshield, especially to the point of bulging the windshield (There is a layer of plastic between the glass. The glass can shatter with the plastic bulging. This is the last step before the passenger goes through the windshield.), I would expect, especially with the age of your passenger, some serious cuts in other parts of her body. Reasonable to expect some additional broken bones, and with the brittleness of her bones, highly probable.

If she's on any sort of blood thinner (likely), bleeding would be rather massive and a major concern at the scene of the accident and the blood lose would contribute to the unconsciousness.

Best of luck,

Jim Clark-Dawe

sheadakota
09-01-2008, 04:54 PM
Hi Aruna- Jim is correct most elderly people are on blood thinners for one thing or another- if this woman hit her head she in all likleyhood had massive bleeding in her brain shown by a cat scan- nothing to operate on- I won't go into details on you, unless you want, but in my experience, this would not be a survivable injury.

If you still want your scenario, perhaps have her wearing her seatbelt. even with this she could suffer a serious head trauma that results in a subdural hematoma (blood clot on the brain). Then surgery would be needed and yes it would be likley that she does not wake up due to swelling and insult to the brain. Let me know if you need any more details, I would be happy to help

aruna
09-01-2008, 06:14 PM
Thanks! Yes, I forgot to mention that she also has a broken arm. I'll get back to you when I;ve worked on the scene some more. The blood stuff is v. good. I'll make it very bloody... maybe scraier looking than it actually is.

jclarkdawe
09-01-2008, 06:45 PM
The blood issue isn't how much blood is strewn all over the place, from an EMT's point of view. It's the blood loss and the masking effect her blood pressure medicine is going to have on this. At some point, the lost of blood volume is going to send her blood pressure plummeting. Very, very suddenly.

This is a patient with two large bore IVs if her system will survive them, secured airway, defib pads in place, and three or four guys working in the back of the ambulance. It's an "Oh, shit" type call.

As an EMT, you know this patient is going to crash badly at some point. The question is whether you get her to the hospital before this happens. (In other words, can you make it someone else's problem.)

Trauma team is going to be activated by the EMTs en route. We'd be watching for leakage from ears, eyes, or nose as well as some other signs of internal bleeding. I'm with Sheadakota at doubting survivability of your patient. Eighty-year-old people with seat belts and airbags aren't great for surviving accidents. Again depending on underlying issues, it doesn't take a whole hell of a lot to kill them off.

Best of luck,

Jim Clark-Dawe

aruna
09-01-2008, 07:02 PM
Great stuff.. thanks again.

ColoradoGuy
09-01-2008, 07:13 PM
Your scenario is fine. There is something called shear injury -- sort of like breaking the wiring in the brain -- that can occur with any injury of this sort. It's extent is wildly unpredictable -- sometimes a lot, sometimes none. When it's severe it leaves lasting disability. I've had many, many patients who have what by the usual criteria (head CT scan, mechanism of injury) should be modest injury just not wake up. Subsequent MRI scans (you need MRI to demonstrate it) show extensive shear injury. Other patients fly from the back of a pick-up truck at 60 mph and land on their head and end up just fine because they had no brain swelling or shear. So with brain injury you can pretty much do anything your plot needs. The brain's pretty mysterious.

GeorgeK
09-02-2008, 11:32 PM
You could do anything (assuming that you don't mention what particular areas are injured). The more we know about brains the less we understand them.

aruna
09-03-2008, 08:57 PM
OK, next question. Let's say she comes out of her coma on day 2. She's fine, no brain damage. Wants to go home. How long should I have her stay in hospital for treatment and observation? She'd have a bandage round her head, I presume; anything special to say about that? How long should it stay on?

This forum is such a godsend. I don't know what I'd do without you guys!

GeorgeK
09-03-2008, 11:07 PM
People in their 80's have a tendency to "sundown" when faced with injuries or surgeries stressful enough to land them in the hospital for more than a couple of nights. The sleep deprivation combined with all the meds that they aren't used to can make them go a little or a lot crazy at night. It's weird when you see someone lucid during the day and totally bonkers at night with complex delusions and sometimes hallucinations. The more frail their health, the bigger the injury, the more likely that they will sundown. The best treatment I found was to discontinue all possible medications and by day 3 after withdrawing all the new meds, the sundowning would go away. Unfortunately many physicians mistake the sundowning for a psychotic episode and start drugging the people with more meds, particularly Haldol. If you want to read something scary, read the "Physician Desk Reference" insert for Haldol.

Bandages really only need to be kept on until the wound is dry and changed often enough that the dressing isn't soaked, since blood is a wonderful nutrient broth for bacteria. I'd expect that by day 2-3, the bandages could come off.

ColoradoGuy
09-03-2008, 11:17 PM
What George said. The things that tend to keep head-injured folks like your character in the hospital after they're out of any critical situation are things like difficulties with balance, persistent vomiting, severe headaches. If she feels well and was doing well, they'd send her home.

aruna
09-03-2008, 11:27 PM
Thanks, you two! Next question: do you know if that term "sundowning" is used in the UK?

ColoradoGuy
09-03-2008, 11:31 PM
Thanks, you two! Next question: do you know if that term "sundowning" is used in the UK?
That I don't know. It's an old term, though. I started working in hospitals in 1967 and it was common then.

GeorgeK
09-04-2008, 11:27 PM
I don't know either, having never been to the UK.

aruna
06-25-2014, 09:33 PM
Another brain damage scenario; didn't want to start a new thread.

A young guy, about 18 years old, falls from above on to a wooden fence; one of the staves pierces part of his head.
It looks worse than it is; there's a doctor in the house, emergency services arrive soon, but to an amateur onlooker he looks finished, lots of blood.

They manage to save his life; he's treated for several months in a US hospital, but remains brain damaged, possibly wheelchair bound, can't speak but can recognise people, laugh, express wishes etc. Needs full time care for the rest of his life.

Does this work? Any tips to make it realistic? I'm a little bit worried about the fence. At first I had it as a metal one but the staves would be so close together two of them would pierce his skull and that might be too much. The fence can be anything, actually; it's beside the point. But it is a fall from above, at night.

Bolero
06-25-2014, 10:08 PM
Having a stave pierce someone's head is how they first started working out the different areas of the brain have different functions. A guy who was a railroad builder had a metal stake pierce his skull (think it was a frontal lobe but can't remember). He survived but his personality changed completely. He went from being a nice reliable family man, to an argumentative aggressive git.

Can't give you any more info than that, but where in the skull the injury occurs, and how deep, is crucial to how they are afterwards. If they are still essentially the same person in character, but physically disabled, that will be a particular area. Also have the suspicion, but no details, that speech loss and walking are different areas.

aruna
06-25-2014, 10:30 PM
Thanks.
It's not his personality that changes so much as his cognitive faculties. The plot necessitates that he become like a small child -- something in that direction? I can have him fall on any part of the head necessary!

melindamusil
06-26-2014, 03:56 AM
Aruna - IMO your situation works fine. True, it is possible to have something pierce the skull and walk away with no long term injuries - but it is perhaps even more likely to have a situation like you describe, with a serious brain injury and long term complications. (And that's IF the patient lives!) He'll probably be unconscious/on life support for at least a few weeks, if not longer. Then he'd probably be sent to inpatient rehab and, depending on how much he improves, he may even wind up in a nursing home.

Fwiw - this reminds me of a news story from a few years ago. Some kids were climbing a fence to get into a swimming pool. One of them was impaled on the fence. IIRC, he died pretty quickly.

Bolero
06-28-2014, 01:38 AM
I was curious myself - so googled. This website (from an organisation offering rehabilitation) seems to be a reasonable starting point.

www.neuroskills.com/brain-injury/brain-function.php

aruna
08-20-2014, 09:49 PM
OK, it's crunch time.

Back to the stave-through-head accident. It's now metal, not wooden. A metal spike, about an inch thick.

It happens in Guyana, 1960's. Medical care is sloppy and primitive; few good doctors. However, an American neurologist is available and he can give immediate first aid, after which the patient is taken to hospital in a car (ambulance has broken down). It is soon apparent that the hospital is not equipped to deal with this injury.

Oh: and they have to call the fire brigade to saw through the metal stave so he can be taken to hospital -- I am assuming this can't be removed on site!

Anyway: the US doctor is able to arrange for a medical plane to come from the US and take him back the very next day, so that he is given the treatment he needs and survives, however, with brain damage. I assume he would have to go with the metal still in his head?

Could somebody give me a rundown on the sort of thing the doctor would do immediately after the accident -- life-saving stuff. Not in any detail. Just the basic procedures.

Hope someone can help!

MDSchafer
08-21-2014, 05:02 AM
This is probably a good website for you to research.


http://www.myshepherdconnection.org/abi

tko
08-21-2014, 05:36 AM
With head injuries, doctor's might put the person in an induced coma, maybe 5 days or longer until any brain swelling subsides. I'm not a doctor, but a friend of the family is in this exact situation, and every is waiting until she wakes up . . .

aruna
08-21-2014, 09:52 AM
Thanks tko, but I'm not sure if that would be possible in the circumstances...? Perhaps once he gets to hospital, but I'm more concerned with what the doctor actually does immediately after the accident, ie, the guy is still attached to the fence. Stopping bleeding etc.

I'm thinking the fence stave would have a kind of arrowhead tip.
OK -- can a mod please change the thread title to reflect that it's no longer about the car accident? Or tell me how to do it? I did try but it only changed the title in the first post.

aruna
08-21-2014, 10:01 AM
Thanks MDSchaffer, and I checked out the website but it seems to be more about the general effects etc -- I really need to know what the doctor would do practically and specifically after this horrific accident. Just a sentence or two would be enough!

melindamusil
08-21-2014, 11:13 AM
Standard disclaimer, I'm not a medical professional, blah blah. I'm thinking of the "ABC's" of CPR - airway, breathing, circulation. I would imagine that the first thing he'd do would be to check those.

He'd splint any obviously broken bones, maybe put him on a crude backboard. Since he's in Guyana, I'm sure the doctor would be macgyver-ing quite a bit.

Blood loss would probably be a big issue. Does the patient have any significant lacerations other than the one on his head? Plus obviously he'd need a ton of support for the metal spike when they're cutting it - don't want it to move around if possible.

MDSchafer
08-22-2014, 04:13 AM
Thanks MDSchaffer, and I checked out the website but it seems to be more about the general effects etc -- I really need to know what the doctor would do practically and specifically after this horrific accident. Just a sentence or two would be enough!

Honestly, in the 1960's your victim would more than likely die, even if an American neurosurgeon was on scene. Neurosurgery was still in the early stages, it didn't really come about as specialty until 1910's or so. The first Neuro ICU was in 1960.

I don't know how realistic your scenario is. I do know in 1973 a surfer suffered a brain injury in Brazil and it took him five years to get back to the United States. So, the idea that a doctor could stabilize and ship the person to the US in a short time doesn't really seem plausible to me, but I have medical training in this area, and most people don't.

It's hard to know without some specifics about where your iron bar is located, and I don't have any knowledge about 1960's medicine. Generally speaking you would stabilize the patient and deal with the brain injury second. I'm assuming the injury is fairly high up, because if it's in the brain stem he's dead.

I would think a craniectomy to relieve swelling would come in pretty short order, but you'd really have to find a expert in '60's era medicine. Maybe go to a retirement home? Because there aren't a lot of surgeons from that era still around. I do know they still used iron lungs in the 1960's, so it would be incredibly difficult to transport someone.

Questions that would probably help you get some more detail. Is the guy alert and oriented? Can he breath without assistance? Where did the object penetrate and how far in did it go? What's his level of consciousness?

I've seen guys with rebar sticking out of their heads who are pretty much with it, and similarly people who are completely catatonic and on a vent from a cranial penetration.

aruna
08-22-2014, 07:55 AM
Thanks, that's great! This is the late 60s. I am relying on the fact that even if chances of survival are low, modern readers won't be aware of it. I'm even having trouble persuading my editor, a youngish one, that the MC, who witnessed the fall, ran away in panic convinced he was dead. The editor thinks she would have wanted to know if he survived or not. Sorry, but if I were 16 ears old and daw a guy with a fence pole sticking out of the top of his head and his face covered in blood, I would have assumed he was dead.

Speaking of blood: as a layperson I'm assuming that the stave in his head would prevent too much bleeding -- is this right?

Los Pollos Hermanos
08-23-2014, 08:49 PM
I can't help with the specifics, but my mum was a nurse in the 60s and 70s (in the UK and South Africa). I remember her mentioning that they were always told to leave any instrument of impalement (sounds dramatic!) in situ when the patient was being transferred to hospital, in case it was plugging a major artery and stopping the patient from bleeding to death.

I've read about cases where people have had to be taken to hospital with part the the metal railings they'd impaled themselves on (after the Fire Brigade had brought their cutting gear), so the railings could be carefully removed and the damage repaired during surgery.

Not an experience I'm in a hurry to experience from any perspective!