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Mariana
04-01-2015, 01:08 AM
Hi everyone!! It’s me with the Mafia boss again!! :


This time I have to write a scene where the wife of my Mafia boss gets shot in the upper leg, during a chase. The gunman is careful enough not to hit the femur artery because he wants her alive. He captures her and then he asks her guards to tell him where her husband hides. They tell him that they don’t know so he responds that he will let her die from bleeding, till they disclose his hideout. A 10 minutes chit-chat between the gunman and her guards follows and finally the woman passes out in the hands of the gunman. Later on she manages to get in the Hospital (in Class III Hemorrhage Shock) and survives.


So here is my question: “Is the 10 minute time between the gunshot and the faint correct”?


I chose to write that the bullet hit her great saphenous vein (because I read that venous bleeding is considerably slower and more moderate) but I still have no idea if I’m right or wrong. I'd preferred a gunshot wound on the thigh but do you thing that it’s more appropriate to choose a lower leg wound so that it could be less life threatened?


Thank you in advance :)

Muppster
04-01-2015, 01:19 AM
Here is the definitive work (http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=AD0359774) by Sperrazza & Kokinakis on predicting time-to-incapacitation of soldier vs projectiles. Pick out the activity (described in detail within, attack would be most conservative, defence least) and time frame, and look up the probability for various body-parts. PK of 0.5 is a 50% chance of incapacitation in the time frame, PK of 1 is a 100% chance.

lbender
04-01-2015, 01:50 AM
If he hits any major artery or vein, she'd be dead quickly. Aside from that, a medical professional frequently can't tell you exactly where on the body a particular artery or vein goes without checking. Everybody is slightly different. I'd find it hard to believe a gunman could be that precise.

Why can't you just have him shoot her and apply a bandage. Loosening it or tightening it will adjust the bleeding. he can have her survive as long as he wants.

Jamesaritchie
04-01-2015, 01:55 AM
There is no answer to this question. There are far too many variable. A person may lose consciousness in a few minutes, or may never lose consciousness at all. Two people with identical words won't even have the same results.

asroc
04-01-2015, 01:59 AM
Hi everyone!! It’s me with the Mafia boss again!! :


This time I have to write a scene where the wife of my Mafia boss gets shot in the upper leg, during a chase. The gunman is careful enough not to hit the femur artery because he wants her alive.

Does he have X-ray vision? The pictures you see in anatomy books are approximations and the area of damage a bullet can do to the body is several times larger than the bullet itself. You can get lucky, but you can't really be certain about what you will or will not hit.


He captures her and then he asks her guards to tell him where her husband hides. They tell him that they don’t know so he responds that he will let her die from bleeding, till they disclose his hideout. A 10 minutes chit-chat between the gunman and her guards follows and finally the woman passes out in the hands of the gunman. Later on she manages to get in the Hospital (in Class III Hemorrhage Shock) and survives.
Once she passes out from hemorrhagic shock she won't wake up again without outside intervention. Unconsciousness is one of the very last symptoms of shock and means "Someone fix this now because I can't keep my brain supplied with oxygen anymore and it's dying." So someone else has to get her to the hospital and he better be very fast.



I chose to write that the bullet hit her great saphenous vein (because I read that venous bleeding is considerably slower and more moderate) but I still have no idea if I’m right or wrong. I'd preferred a gunshot wound on the thigh but do you thing that it’s more appropriate to choose a lower leg wound so that it could be less life threatened?The great saphenous vein is a superficial vein that carries relatively little blood and is comparatively expendable (it's often removed for coronary artery bypass grafts or varicose veins.) There are other pathways the blood can take to the heart, so an injury to the great saphenous vein is not likely to be life-threatening. The femoral vein is more likely, but it runs alongside the femoral artery, so if that's injured, chances are the artery is as well and you're not going to get ten minutes out of it. Maybe one.

Mariana
04-01-2015, 02:09 AM
Thank you all for your answers :)

@Muppster: I can't have access to the article.. it says that the site is currently unavailable due to maintenance activities :( I'll try it later

@Ibender: Ok, I'll leave that part out and I'll write that it was just luck that he didn't hit an artery.
The problem is that this character (the gunman) is not a guy that cares about her or any other people, so I can't have him applying bandages. Apart from that, he doesn't want to spend so much time on the scene (or take her with him) because the police are coming. He knows that her husband is somewhere close, watching the scene, and he wants him to appear right now. If the woman dies in ten seconds or in ten minutes, he doesn't mind.

Mariana
04-01-2015, 02:48 AM
@asroc
Thank you sooo much for your answer, I was hoping to get a comment from you because I know you’re a paramedic :)


So, the “The gunman is careful enough not to hit the femur artery because he wants her alive.” I’m going to remove it and I’ll just say that he was just lucky not hitting the artery.

About the “great saphenous vein”, if the bullet hits that vein, how much time does the woman have till she falls unconscious?


And, finally, about the hemorrhagic shock:
I know it’s a serious life threading condition and because of that I chose to have a doctor among her guards. When the guards get her from the gunman the doctor (who always carries a bag with medicine for an emergency case like this) approaches, stops her bleeding, gives her an epinephrine injection and puts an intravenous fluid (0.9% NaCl with 5% dextrose maybe??) while he’s screaming for an ambulance because the woman is dying. Later on she gets in the hospital and after surgery she survives.


I’m on a completely wrong way?? I got information mostly for this link:
http://pennstatehershey.adam.com/content.aspx?productId=117&pid=1&gid=000167
where it says about the epinephrine injection and the intravenous (IV) line. The “0.9% NaCl with 5% dextrose intravenous fluid” I read it on another article which was saying that it can be used till the ambulance arrive, as long as there are no blood or blood products available.

asroc
04-01-2015, 04:31 AM
@asroc
Thank you sooo much for your answer, I was hoping to get a comment from you because I know youíre a paramedic :)

My legend precedes me... :chair



So, the ďThe gunman is careful enough not to hit the femur artery because he wants her alive.Ē Iím going to remove it and Iíll just say that he was just lucky not hitting the artery.

About the ďgreat saphenous veinĒ, if the bullet hits that vein, how much time does the woman have till she falls unconscious?

Well, like I said, chances are she won't. The superficial veins don't carry that much blood, their pressure is fairly low compared to the deep veins and especially the arteries. There's a also a network of them, so if one gets occluded, there's redundancies. A rupture of the great saphenous vein is probably not going to cause shock advanced enough to be life-threatening. You'd want a different vessel with higher pressure to reliably cause shock, but that's also more likely to kill the patient. Shock's a fluid state; it's just not a very solid foundation to base an interrogation on.



And, finally, about the hemorrhagic shock:
I know itís a serious life threading condition and because of that I chose to have a doctor among her guards. When the guards get her from the gunman the doctor (who always carries a bag with medicine for an emergency case like this) approaches, stops her bleeding, gives her an epinephrine injection and puts an intravenous fluid (0.9% NaCl with 5% dextrose maybe??) while heís screaming for an ambulance because the woman is dying. Later on she gets in the hospital and after surgery she survives.


Iím on a completely wrong way?? I got information mostly for this link:
http://pennstatehershey.adam.com/content.aspx?productId=117&pid=1&gid=000167
where it says about the epinephrine injection and the intravenous (IV) line. The ď0.9% NaCl with 5% dextrose intravenous fluidĒ I read it on another article which was saying that it can be used till the ambulance arrive, as long as there are no blood or blood products available.

No, that's not wrong. 0.9% NaCl ( = normal saline) is a core medication we use with many patients. In cases of shock it's used to keep the patient's blood pressure up. The ultimate problem isn't so much pressure as oxygen though, which saline doesn't carry, so the further advanced the shock state is, the more urgently the patient will need an actual blood transfusion. (I'm not sure that's a proper sentence.) If the patient loses consciousness she will need blood, and fast. Even a doctor usually doesn't run around with a couple of bags of o-neg.

Epinephrine may or may not be necessary. Our go-to drug in those cases is dopamine, though.

Mariana
04-02-2015, 01:29 AM
Thanks again for your useful comments! :)
I read all the above and I did another research today, trying to find the best and also reliable solution.

So, let me see if I got this right. When you say that she will need blood fast you mean that as soon as she faints, we start counting down till she dies or suffers a serious brain damage, right?? (even if she finally manages to survive).

One of the solutions that I’ve thought since yesterday is to put the doctor to ask for blood when he calls for an ambulance. Can he do such thing? Considering that he’s a doctor and he has already evaluated the injury of the victim, does he have the right to ask for something like that, in order to start the blood transfusion as soon as the ambulance gets there??

And one more: If the scenario that I’ve already thought doesn’t work in the end, can I write that something else caused her fainting (for example anemia or panicking) and the doctor misunderstood it believing that it happened from the shock??* But I assume that when he gets close to her and take her pulse he would realize that she’s not in hemorrhagic shock, right? :(


*I came up with that idea when I was reading the accident of Joe Riggs.
http://www.mmafighting.com/2014/8/25/6066985/joe-riggs-on-shooting-himself-i-thought-for-sure-i-was-going-to-die
http://www.foxsports.com/ufc/story/ufc-s-joe-riggs-on-scary-gun-accident-i-shouldn-t-have-lived-102014

If Riggs didn’t lose consciousness from hemorrhagic shock, so what was it? They said that the bullet went through his thigh wrecking his hip flexor. It narrowly missed his femoral artery but he states that it was spraying blood and he lost consciousness before ambulance got to his house.

Deb Kinnard
04-02-2015, 02:19 AM
This isn't specific to your question (I haven't the expertise), but in a general sense for a writer's guide to maiming your characters correctly, I can't recommend highly enough: BODY TRAUMA, by David Page, MD, ISBN 0-89879-741-1. It was written for us, by one of us, who's also got major chops as a trauma surgeon and sports medicine specialist.

Mariana
04-02-2015, 03:00 AM
@Deb Kinnard (http://absolutewrite.com/forums/member.php?u=21918) Thank you so much!!! I'll try to order it as soon as possible. It's so hard to get your characters injured every single time and in my novel I have plenty of them!

Does he have a personal blog too?? I had found a similar blog but I can't remember its name

MDSchafer
04-02-2015, 03:31 AM
[FONT=&quot]One of the solutions that Iíve thought since yesterday is to put the doctor to ask for blood when he calls for an ambulance. Can he do such thing? Considering that heís a doctor and he has already evaluated the injury of the victim, does he have the right to ask for something like that, in order to start the blood transfusion as soon as the ambulance gets there??

Doesn't work that way, even under emergency conditions. He can ask, but it's not going to happen.

Giving blood requires two RNs. Doctors can theoretically give blood in an emergency situation I suppose, but as a rule most MDs haven't ever hung a bag of blood, or even started an IV. There's a whole procedure for giving blood if you want to know I'll share. But it has to be two RNs, although occasionally a Nurse Practitioner will do it. I think an NP is the only other medical professional legally allowed to start an transfusion under normal circumstances, but I'm just taking an educated guess.

Mariana
04-02-2015, 04:09 AM
@MDSchafer Thanks for you information!!

Unfortunately, I'd suspected that it’s not easy to happen something like that. :(
Especially when there’s so much demand for blood and so little donors.

So,.. another one of my scenarios just failed!! :(

Mariana
04-02-2015, 04:21 AM
There's a whole procedure for giving blood if you want to know I'll share.

I'd love to!! :) Or you can just send me some links to search! Thanks again!!!!

asroc
04-02-2015, 05:10 AM
Thanks again for your useful comments! :)
I read all the above and I did another research today, trying to find the best and also reliable solution.

So, let me see if I got this right. When you say that she will need blood fast you mean that as soon as she faints, we start counting down till she dies or suffers a serious brain damage, right?? (even if she finally manages to survive).

One of the solutions that Iíve thought since yesterday is to put the doctor to ask for blood when he calls for an ambulance. Can he do such thing? Considering that heís a doctor and he has already evaluated the injury of the victim, does he have the right to ask for something like that, in order to start the blood transfusion as soon as the ambulance gets there??

He can certainly ask for blood, but emergency ambulances usually don't carry PRBCs. Whether the medics are allowed to start a transfusion depends on where this is supposed to be set. In some states they might only be allowed to maintain a running transfusion, in other places they need additional training in Critical Care transport, elsewhere it's part of regular medic school. I was taught how to do it but I've never done it in the field since my service only responds to emergencies and we donít carry blood.


(Every doctor has started IVs. The last time might have been in med school, but theyíve all done it.)


And one more: If the scenario that Iíve already thought doesnít work in the end, can I write that something else caused her fainting (for example anemia or panicking) and the doctor misunderstood it believing that it happened from the shock??* But I assume that when he gets close to her and take her pulse he would realize that sheís not in hemorrhagic shock, right? :(Shock can be somewhat difficult to diagnose, especially in the initial stages and without an obvious source of hemorrhage. Often it's obvious, sometimes it's not. If the doctor isn't an emergency physician he might not recognize it.



*I came up with that idea when I was reading the accident of Joe Riggs.
http://www.mmafighting.com/2014/8/25/6066985/joe-riggs-on-shooting-himself-i-thought-for-sure-i-was-going-to-die
http://www.foxsports.com/ufc/story/ufc-s-joe-riggs-on-scary-gun-accident-i-shouldn-t-have-lived-102014

If Riggs didnít lose consciousness from hemorrhagic shock, so what was it? They said that the bullet went through his thigh wrecking his hip flexor. It narrowly missed his femoral artery but he states that it was spraying blood and he lost consciousness before ambulance got to his house.Based on the description he did seem to be in hemorrhagic shock following an arterial rupture. As the femoral artery goes down in the thigh it splits into a deep and a superficial part and gives off several branches. Some of them are pretty large and can cause arterial spray and shock. Doesn't need to involve the femoral artery itself.


Overall, your scenario can work. The thing is, it's not really believable that the bad guy planned it to happen like this, because shock is unpredictable. And the great saphenous vein is not likely to cause it. But there are plenty of other blood vessels in the thigh.

MDSchafer
04-02-2015, 05:33 AM
So, after further thought there's a couple of scenarios where you could actually get blood out to the field. Some medical flight services are starting to stock O-Neg and plasma on their birds. It's rare, but it's starting to happen. It's believable that if the guy was an attending and knew the helicopter at his hospital carried blood he could get it scrambled in time. Typically, life-flight services are staffed by RN's with advance training, although I've seen paramedics working them.

The other scenario is critical care. One of my friends was Paramedic before getting her BSN. She occasionally rides the bus working critical transport because the money is pretty good. She can give blood in the field if she has it under a special protocol, but as far as I know never has..

In a nut shull the basic blood transfusion protocol require a nurse to check the blood with the blood bank. Once the blood is in the patient's room the RN needs to verify the patient and the product with another RN. Although, I've been told this protocol varies by state. Also, you need a big needle, a twenty gauge or higher is typically what's used.

Transfusing blood can be a risky thing, so it's not done in the field; even in most emergency situations. I found this from a text book. I think it's pretty readable and gives you some good information
http://www.atitesting.com/ati_next_gen/FocusedReview/data/datacontext/RM%20AMS%20RN%208.0%20Chp%2044.pdf