Help me injure my character! (Trauma vs illness)

StoryofWoe · Dec 6, 2015

I have a woman in her mid-forties with very little body fat who needs to end up in the hospital for an extended stay and a surgery or two. My first thought was a car accident or being hit by a car. She's not particularly adventurous, no impromptu zip-lining excursions or krav maga battles atop trains. She works in an office setting, so she's more likely to be injured on her way to and from work.

Here's a breakdown of the criteria I'm attempting to conform to:

- She needs to arrive at the hospital in critical condition; there must be a real and present threat of death.

- I may place her into a coma for a short while (a few days to a week), though she does need to be conscious for at least a few days. If she does end up in a coma, would they keep her in the ICU or move her elsewhere? I'd imagine this would be contingent on the severity of her injuries, which leads to my next point...

- She will require major surgery (possibly an organ transplant) about a month after the accident. I'm aware that many people wait years for a transplant, but the story timeline requires this to take place relatively quickly. She'll need to stay in the hospital or a nearby care facility during this time.

- The surgery goes well, thus putting her on the road to recovery and allowing the MC (not the one injured) to feel comfortable leaving the injured woman to pursue other pertinent matters.

- I would like her to be released from the hospital shortly after the surgery (would a week or two be reasonable, assuming all goes well?) where she'll be looked after by family members and possibly a visiting nurse.

I'm still in the outlining stages, so there's quite a bit of wiggle room. Any and all help would be much appreciated.

mrsmig · Dec 6, 2015

Don't know that it would result in an organ transplant, but a fall down the stairs would be a simple solution. Results can range from bruising to death. Concussion from the fall could cause coma, and whatever got busted on the way down might require surgery and an extended hospital stay.

King Neptune · Dec 6, 2015

Add a broken hip to the fall, and that could require a hip replacement operation when she was otherwise recovered from the fall. That isn't an organ replacement, but they could find almost anything when they start looking closely.

StoryofWoe · Dec 6, 2015

Ooh, I hadn't considered a fall. She does visit the occasional construction site, so I could maybe work something in from that angle. Thank you!

Cobalt Jade · Dec 6, 2015

Being hit by a car while riding a bicycle can cause all sorts of nasty injuries. Bones that require screws and plates to heal.

ColoradoGuy · Dec 6, 2015

The only medical entity that I can think of that would fit your criteria would be acute, fulminant hepatitis requiring urgent liver transplantation. Patients with that go to the top of the organ list. They typically are in hepatic coma with encephalopathy for the days before the transplant. Here is some more information.

StoryofWoe · Dec 7, 2015

Cobalt Jade, that's something I hadn't considered, though I know people who have been hit while biking. Great suggestion!

ColoradoGuy, thanks for the link to more info. I did a search for acute, fulminant hepatitis, and it sounds like the kind of thing that would have to be a long time coming. As in, it wouldn't be caused by physical trauma, but could be exacerbated by it and then revealed at the hospital afterward once the patient's liver shows signs of failing. Am I mistaken?

ColoradoGuy · Dec 7, 2015

StoryofWoe said:
Cobalt Jade, that's something I hadn't considered, though I know people who have been hit while biking. Great suggestion!

ColoradoGuy, thanks for the link to more info. I did a search for acute, fulminant hepatitis, and it sounds like the kind of thing that would have to be a long time coming. As in, it wouldn't be caused by physical trauma, but could be exacerbated by it and then revealed at the hospital afterward once the patient's liver shows signs of failing. Am I mistaken?

Acute fulminant hepatitis can come on quite quickly -- I've seen a couple of cases evolve over a few days from the patient being mildly ill to coma to transplant. That's why it's called acute and fulminant. But it has nothing to do with trauma, really. I can't think of any traumatic injury that would be treated with a transplant. If you wanted to use that entity you could have blunt abdominal trauma, as with a car accident, that led to tests of liver function and scans of the liver. But it would be a coincidence.

MDSchafer · Dec 7, 2015

StoryofWoe said:
I have a woman in her mid-forties with very little body fat who needs to end up in the hospital for an extended stay and a surgery or two. My first thought was a car accident or being hit by a car. She's not particularly adventurous, no impromptu zip-lining excursions or krav maga battles atop trains. She works in an office setting, so she's more likely to be injured on her way to and from work.

Here's a breakdown of the criteria I'm attempting to conform to:

- She needs to arrive at the hospital in critical condition; there must be a real and present threat of death.

- I may place her into a coma for a short while (a few days to a week), though she does need to be conscious for at least a few days. If she does end up in a coma, would they keep her in the ICU or move her elsewhere? I'd imagine this would be contingent on the severity of her injuries, which leads to my next point...

- She will require major surgery (possibly an organ transplant) about a month after the accident. I'm aware that many people wait years for a transplant, but the story timeline requires this to take place relatively quickly. She'll need to stay in the hospital or a nearby care facility during this time.

- The surgery goes well, thus putting her on the road to recovery and allowing the MC (not the one injured) to feel comfortable leaving the injured woman to pursue other pertinent matters.

- I would like her to be released from the hospital shortly after the surgery (would a week or two be reasonable, assuming all goes well?) where she'll be looked after by family members and possibly a visiting nurse.

I'm still in the outlining stages, so there's quite a bit of wiggle room. Any and all help would be much appreciated.

Basically, real medicine doesn't work that way you want it to. Coma's are very serious things. I know in movies, television, and poorly written books comas are treated like long naps, but in reality they're not. I worked in brain injury rehab for two years. The best way to explain it is that you're waking up from a heavy dream over the course of six weeks to six months, and you keep coming in and out of consciousness until, after long weeks of hard work, you reach a new normal where you typically don't remember anything leading up to the incident, or anything after. Typically, only brain damage causes comas.

If someone needs an organ transplant in a short period of time alcoholism or an acetaminophen overdose is typically the culprit. People do accidentally overdose on acetaminophen, it's a common ingredient in cough syrups, and if they're taking that and Tylenol for pain you can go over the maximum safe dose and damage your liver.

Lukemia, depending on when it is discovered, can require immediate care. If your character has advanced non-hodgkin's lymphoma it could be discovered on Monday and by Thursday she'd be hospitalized for an significant period of time, and would likely require a bone marrow transplant.

Another possibility is that she goes in for some sort of MRI or CT with contrast, doesn't get enough fluids and the iodinated radiocontrast media causes kidney failure.

ColoradoGuy · Dec 7, 2015

MDSchafer said:
Basically, real medicine doesn't work that way you want it to. Coma's are very serious things. I know in movies, television, and poorly written books comas are treated like long naps, but in reality they're not. I worked in brain injury rehab for two years. The best way to explain it is that you're waking up from a heavy dream over the course of six weeks to six months, and you keep coming in and out of consciousness until, after long weeks of hard work, you reach a new normal where you typically don't remember anything leading up to the incident, or anything after. Typically, only brain damage causes comas.

I practice critical care and have been treating coma for 30+ years. It's an imprecise term and comes in as many varieties as your story needs. That's not your problem here.

If someone needs an organ transplant in a short period of time alcoholism or an acetaminophen overdose is typically the culprit. People do accidentally overdose on acetaminophen, it's a common ingredient in cough syrups, and if they're taking that and Tylenol for pain you can go over the maximum safe dose and damage your liver.

No. Acetaminophen overdose has been an extremely rare cause of acute liver failure for decades, ever since we discovered n-acetylcysteine as an antidote. It is a common overdose, but is virtually always deliberate, such as a suicide attempt. Liver failure from alcoholism is chronic. Currently the most common reason for requiring a liver transplant is hepatitis C infection, but that is also a chronic illness.

Lukemia, depending on when it is discovered, can require immediate care. If your character has advanced non-hodgkin's lymphoma it could be discovered on Monday and by Thursday she'd be hospitalized for an significant period of time, and would likely require a bone marrow transplant.

Again no. Stem cell (or marrow) transplantion is never done immediately. Patients with some forms of leukemia and lymphoma these days do proceed right to being considered for transplant, but they first must have a successful induction phase with elimination of detectable cancer with chemotherapy, plus in some cases radiation. Listing for transplant (assuming there is a donor) allows much higher doses of chemotherapy, doses that would be lethal if transplant were not available to rescue the marrow.

Another possibility is that she goes in for some sort of MRI or CT with contrast, doesn't get enough fluids and the iodinated radiocontrast media causes kidney failure.

Yet again no. Idiosyncratic reactions are always possible, but I have never heard of acute renal failure from contrast requiring kidney transplant. At worst the patient could need a brief period of dialysis. We have very, very standard and effective ways of insuring adequate hydration and verifying good kidney function when we use contrast.

The bottom line is that, as I mentioned above, I really can't see a way of working in a transplant easily. I spent a couple of decades taking care of patients who have received liver, bone marrow, kidney, heart, and lung transplants, both during the immediate period surrounding their transplant and for the complications they can get months to years later. It's standard PICU stuff.

MDSchafer · Dec 8, 2015

ColoradoGuy said:
No. Acetaminophen overdose has been an extremely rare cause of acute liver failure for decades, ever since we discovered n-acetylcysteine as an antidote. It is a common overdose, but is virtually always deliberate, such as a suicide attempt. Liver failure from alcoholism is chronic. Currently the most common reason for requiring a liver transplant is hepatitis C infection, but that is also a chronic illness.

I don't know the data you've seen, but I just looked it up on the Mayo Clinic data base and they report that acetaminophine poisoning is the leading cause Acute Liver Failure in the US, and the data says most people claim it's accidental. We see a couple of cases a year where people are taking Tylenol and a cough syrup with acetaminophine. How easy it is to reverse depends on how long they let it go and what comorbidities they have.

Also, and I just thought of this, but to help the OP, eating the wrong mushroom can require a liver transplant, there was a publicly documented case of that in Canada this summer, but it happens once or twice a year.

ColoradoGuy said:
Again no. Stem cell (or marrow) transplantion is never done immediately. Patients with some forms of leukemia and lymphoma these days do proceed right to being considered for transplant, but they first must have a successful induction phase with elimination of detectable cancer with chemotherapy, plus in some cases radiation. Listing for transplant (assuming there is a donor) allows much higher doses of chemotherapy, doses that would be lethal if transplant were not available to rescue the marrow.

I didn't say the marrow transfer happens quickly, but the hospitalization can, and does, especially with the more aggressive strands of NHL. Transplants can wait, typically the first cycles of chemo don't. I know of people who had their diagnosis on Tuesday and were admitted to a hospital Friday for the first round of chemo.

ColoradoGuy said:
Yet again no. Idiosyncratic reactions are always possible, but I have never heard of acute renal failure from contrast requiring kidney transplant. At worst the patient could need a brief period of dialysis. We have very, very standard and effective ways of insuring adequate hydration and verifying good kidney function when we use contrast.

Yeah, but it happens. There's a class action lawsuit moving forward about a bad reaction to gadolinium. Also, I said Kidney failure, I didn't say transplant.

Maybe you missed the part where I said medicine doesn't work the way the author wants to. I was merely giving some suggestions that would require rapid hospitalization.

GeorgeK · Dec 8, 2015

The OP is asking for an acute injury requiring hospitalization and ultimately requiring a transplant a month later. I've seen a few cases that went that way. In every case it required a living related kidney donor with a high degree of match. That completely bypasses the transplant list because the donor says, "I'll donate to my relative, not as part of a general match."

Septic shock can result in total kidney failure, and there are many potential causes for that but those people are likely to be in the hospital that entire time and I get the impression that the OP wants the patient to go home for a while in there.

Contrast nephropathy can do it and I've seen that. CG is right in that there are safety protocols to try and prevent it, but mistakes happen. Dr's forget to write the order. Nurses forget to carry out the order or fail to read them because they didn't look at the second page of orders (that's actually becoming a severely larger and larger issue as the hospitals constantly push understaffing and lie to Joint Commission about nurse to patient ratios and float nurses in from other floors where someone who has been working in admissions for day surgery the last ten years is suddenly in the ICU). In those cases the sickest patient on the floor gets care and the rest may be ignored. Interventional Radiologists doing arteriograms use the wrong contrast or wrong concentration. Patients have anaphylactic reactions and become severely hypotensive (although the treatment for that generally involves a lot of fluids which also can treat the overdose of contrast). It usually requires several mistakes in a row, but does happen.

Contrast nephropathy results in acute kidney failure. They place either a quentin catheter or CAPD catheter and dialyze waiting for the kidneys to improve. They don't improve and the decision is made to arrange for transplant list and an AV fistula for potential permanent hemodyalisis and then the patient says, "Hey my sister is willing to give me a kidney."

Coffee Monster · Dec 8, 2015

GeorgeK said:
Contrast nephropathy results in acute kidney failure. They place either a quentin catheter or CAPD catheter and dialyze waiting for the kidneys to improve. They don't improve and the decision is made to arrange for transplant list and an AV fistula for potential permanent hemodyalisis and then the patient says, "Hey my sister is willing to give me a kidney."

I am not a nephrologist, but I have taken care of patients with contrast nephropathy, and I have never seen this done/discussed. It may just be my lack of experience, but the idea of an "emergent transplant" for contrast nephropathy--or for any acute kidney injury for that matter--sounds a bit off. Initiating dialysis is not always a permanent proposition, and end stage kidney disease is typically not declared until a patient receives an extended period (3 months if I recall correctly) of renal replacement therapy, as recovery is possible from certain insults. This is especially the case if the patient is otherwise young and healthy, and did not have chronic kidney disease to begin with, which sounds like the OP's character. Transplant is serious business, requiring not only surgery, but chronic immunosuppressive therapy, and I would only think to pursue this route if it was clear that a patient's kidneys were truly and irreversibly shot.

In other words, if I saw this in a story, I would have to raise an eyebrow, since this is not standard practice by any means.

ColoradoGuy · Dec 8, 2015

Coffee Monster said:
I am not a nephrologist, but I have taken care of patients with contrast nephropathy, and I have never seen this done/discussed. It may just be my lack of experience, but the idea of an "emergent transplant" for contrast nephropathy--or for any acute kidney injury for that matter--sounds a bit off. Initiating dialysis is not always a permanent proposition, and end stage kidney disease is typically not declared until a patient receives an extended period (3 months if I recall correctly) of renal replacement therapy, as recovery is possible from certain insults. This is especially the case if the patient is otherwise young and healthy, and did not have chronic kidney disease to begin with, which sounds like the OP's character. Transplant is serious business, requiring not only surgery, but chronic immunosuppressive therapy, and I would only think to pursue this route if it was clear that a patient's kidneys were truly and irreversibly shot.

In other words, if I saw this in a story, I would have to raise an eyebrow, since this is not standard practice by any means.

Agreed. I've cared for more than a few patients with contrast nephropathy and, as you say, I've never seen a case proceeding to permanent renal failure requiring transplant. The fact there is a lawsuit over gadolinium overdose proves nothing other than lightning strikes. It's not a plausible scenario for a plot unless you want lightning.

As I mentioned above, the only possible transplant situation I can think of in which the patient moves quickly to transplant is acute fulminant hepatic disease. I can't recall the precise statistics, but I believe something more than half of those cases are presumed to be viral but no precise cause is identified. Various toxins, including drugs, account for a chunk more of them. Or things can work in concert. For example, I've seen a couple of cases of valproate (an anti-seizure medication) overdose in association with viral hepatitis destroying the liver.

As I wrote above, acute acetaminophen overdose as a cause for immediate transplant is now very rare. I spent 15 years on the Mayo liver transplant team and never saw a case. And don't forget: liver failure is not necessarily permanent requiring a transplant. Many patients with acute liver failure recover in time because the liver has great regenerative capacity. I do recall several cases early in my career from massive acetaminophen overdoses in the late 1970s-early 1980s, the era before n-acetylcysteine use as an antidote. However, the antidote must be used within a couple of days of the overdose to work. So if the patient were to wait too long to come in there is little we can do.

George is correct about sepsis knocking out kidneys. I see that a lot in the ICU. But as the Coffee Monster points out generally renal replacement therapy with dialysis for a time lets them heal. Unfortunately patients with acute kidney failure from sepsis have a very high mortality just from the other effects of the infection, particularly on the lungs.

GeorgeK · Dec 8, 2015

Coffee Monster said:
I am not a nephrologist, but I have taken care of patients with contrast nephropathy, and I have never seen this done/discussed. It may just be my lack of experience, but the idea of an "emergent transplant" for contrast nephropathy--or for any acute kidney injury for that matter--sounds a bit off. Initiating dialysis is not always a permanent proposition, and end stage kidney disease is typically not declared until a patient receives an extended period (3 months if I recall correctly) of renal replacement therapy, as recovery is possible from certain insults. This is especially the case if the patient is otherwise young and healthy, and did not have chronic kidney disease to begin with, which sounds like the OP's character. Transplant is serious business, requiring not only surgery, but chronic immunosuppressive therapy, and I would only think to pursue this route if it was clear that a patient's kidneys were truly and irreversibly shot.

In other words, if I saw this in a story, I would have to raise an eyebrow, since this is not standard practice by any means.

Like I said it requires several mistakes in a row. It's rare but I've seen it several times during my career. It's also the kind of thing that never makes it to court. They always settle. A month later is not emergent but is long enough to determine if kidneys are so severely damaged that they are not going to recover. Most people have enough function that it is worth the wait, like you said, generally at least 3 months if not longer, but in extreme cases of massive overdose of contrast and inadequate hydration, there are a variety of tests that one can do to determine function. Also a previously healthy person going through acute renal failure generally has trouble tolerating dialysis and are the highest risk for complications. Sometimes it is obvious that the kidneys are shot and if a donor is there, they are having significant issues with dialysis, you treat the patient the way that you can. This would not happen with the regular transplant list, like I said

ColoradoGuy said:
Agreed. I've cared for more than a few patients with contrast nephropathy and, as you say, I've never seen a case proceeding to permanent renal failure requiring transplant.

And I've never had to consult an ICU Intensivist for contrast nephropathy. Those patients have always been transferred to the nephrology wing, not the ICU. Your specialty is outside the loop depending upon the community. In my experience these patients are seen first by a nephrologist and urologist and then if there is drastic obvious damage, the transplant team plus or minus a general or vascular surgeon for an AV shunt. Well technically the first to see them is their primary care physician and then they consult the rest of us.

ColoradoGuy said:
generally renal replacement therapy with dialysis for a time lets them heal. .

Generally yes, but generally is not always

I've also seen white clot syndrome take out both renal arteries as well as a renal artery stent that migrated to the contralateral side. The original site occluded due to the lack of the stent and the contralateral occluded due to the foreign object. I took care of kidney problems. Now I don't recall ever having seen an acute acetaminophen overdose. I didn't take care of liver disease. We each have our specialties and the longer you are in it the more weird things specific to your specialty that you will see. That said chronic borderline dosage of acetaminophen used for chronic pain can in some people damage the kidneys more than the liver. I've seen that and the reason as you pointed out is that the liver has pretty good regenerative properties whereas the kidneys do not. You only have so many nephrons and as they die they do not get replaced. One of the metabolites of acetaminophen is nephrotoxic, so in chronic dosages approaching 2 grams per day, the liver can heal whereas the kidneys can be taking a hit

StoryofWoe · Dec 8, 2015

Thank you all for your informative responses! You've given me so much to think about (and research). MDSchafer is right: medicine rarely conforms to the author's whims. Now I really wish I'd taken more anatomy and physiology courses in college.

Just to clear up a couple of things: I mentioned the coma as an option, but I'm by no means married to the idea. What I need is a reason for my MC (a young, healthy woman) to be called back to her hometown to care for the injured party, who is a relative. I hadn't though of including an organ donation from the MC to the injured party, but the discussion here has me considering it. The only problem is that would require a recovery period for my MC, who needs to be doing other things during that time period.

Also, I would prefer the injured party remain in the hospital from the day she's brought in all the way through the major surgery, which should take place about a month later. Sorry if that wasn't clear.

Now I have to determine whether or not I want the catalyst for hospitalization to be some kind of trauma (car crash, or, as was suggested earlier, a fall) or sudden illness leading to kidney failure. I should probably change the title of the thread to reflect this.

If I decide to go with a fall, would it make sense for the injured party to remain in the hospital for a few weeks to a month prior to what I presume will be a second major surgery? Also, I want there to be a real risk of death, at least initially.

Again, thank you all for your input.

Ravioli · Dec 9, 2015

Car crash, rib fractures, rib piercing/shredding lung?

GeorgeK · Dec 9, 2015

StoryofWoe said:
Also, I would prefer the injured party remain in the hospital from the day she's brought in all the way through the major surgery, which should take place about a month later. Sorry if that wasn't clear.

Do you want the injured party to have a complete recovery?

Deb Kinnard · Dec 9, 2015

You might resort to the excellent book I've mentioned here before: David Page, MD's "Body Trauma." Written by a writer for writers, with many different scenarios to really trash a character dependent on the needs of the story. ISBN # 0-89879-741-1. I would recommend the book to anyone wanting to maim 'em right.

Cobalt Jade · Dec 9, 2015

If I decide to go with a fall, would it make sense for the injured party to remain in the hospital for a few weeks to a month prior to what I presume will be a second major surgery? Also, I want there to be a real risk of death, at least initially.

You might have the character receive some plates or screws in the bone, get them in physical therapy in the hospital, and then have the plates or screws fail for some reason or need replacement.

StoryofWoe · Dec 9, 2015

GeorgeK said:
Do you want the injured party to have a complete recovery?

For the most part. Sensitivity in the area, slightly limited range of notion, some tingling when it rains, a limp, etc. would be all right, though.

StoryofWoe · Dec 9, 2015

Deb Kinnard said:
You might resort to the excellent book I've mentioned here before: David Page, MD's "Body Trauma." Written by a writer for writers, with many different scenarios to really trash a character dependent on the needs of the story. ISBN # 0-89879-741-1. I would recommend the book to anyone wanting to maim 'em right.

Thank you for the rec! I'll definitely check that one out.

StoryofWoe · Dec 9, 2015

Ravioli said:
Car crash, rib fractures, rib piercing/shredding lung?

Ooh, another contender! I did some preliminary research on punctured and collapsed lungs on webmd (which will not be the extent of my research, I swear). These two points stood out:

Or more commonly it can occur after an operation or by lying immobile for long periods.

And:

In most cases, people develop ARDS while in the hospital for other health problems, such as a severe injury or illness.

If I decide to go the trauma route, whether it's a car crash or a fall, a collapsed lung could maybe be the reason for my character's second surgery while she's still in the hospital.

Ravioli · Dec 9, 2015

Most welcome :hooray:

Sincerely,
the sadist hated by her own characters

Shadowflame · Dec 10, 2015

StoryofWoe said:
If I decide to go the trauma route, whether it's a car crash or a fall, a collapsed lung could maybe be the reason for my character's second surgery while she's still in the hospital.

A collapsed lung usually does not require surgery--as far as I know. It's relieved with a needle in the lung cavity which releases the air trapped. Usually the lung inflates on its own once the pressure is relieved.

Help me injure my character! (Trauma vs illness)

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