Hit by a car, head injury - looking for some details between the trauma and organ donation

fov

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My character (a healthy 29 year old) is hit by a truck while crossing the street and sustains a head injury. Within a couple of days she is going to be brain dead and will donate her organs. Leading up to this, she is physically unconscious, but through the magic of fiction, her thoughts are still going and she's aware of some of what's going on around her.

I'm wondering:

1) What would she look like after the accident? I have her lying still on the ground with her eyes open, the back of her head bleeding onto the pavement. Should she be bleeding somewhere else (nose/mouth)? Should she be struggling to breathe? Not breathing? Should a bystander start CPR? This takes place in a city, so there are people around (one of them calls 911), and I think the paramedics would arrive within minutes.

2) What would the paramedics do for her when they arrive? I understand they'll check her airway, breathing, and circulation, and then transport her to the hospital, but what would they be saying/doing as they do this? I'm especially looking for some accurate words and phrases they would be saying as they tend to her, which she'll "hear" as what's happening to her body intrudes on what's going on in her head.

3) The next time we encounter her, a day after the accident, she's in the ICU on a ventilator. She hasn't yet been declared brain dead. A friend is by the bedside reading to her. What could happen in this scene that would trigger the friend to worry and call in a nurse? An alarm going off on a machine? A physical symptom? I know she'll be checked by two doctors before she's declared brain dead, but I'm looking for the thing that would take her from "she's unconscious and we don't know if she's going to make it" to "it's time to call in those two doctors to determine if she's brain dead."

4) She's going to donate her organs. I know that once she's declared dead, she'll still be on the ventilator and seem like she's alive (breathing, warm) until she goes into surgery and the organs are removed and ventilator turned off. Besides that, what would she look like two days after the trauma? Would her face be bruised? Would the doctors have done anything to try to relieve brain swelling that would change her appearance -- head bandaged, hair shaved? Besides the ventilator would she be hooked up to any other machines or IVs? Just looking for a few details to make it realistic.

5) And an added bonus: she's pregnant, but not far along (just took a home pregnancy test that morning, no one knows but her). Is there any reason she'd be tested for this at the hospital? Is it believable that the trauma could lead to miscarriage while she's unconscious? (I don't see why not, just checking!) Basically I'm looking for a way for her family to find out she was pregnant, since she didn't have a chance to tell anyone.

Thanks in advance if anyone's able to help!
 

neandermagnon

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Someone can have a fatal head injury and not look injured at all. Sometimes with a fatal head injury there's a lucid interval (where the person is conscious and appears normal or only mildly concussed) before the person loses consciousness and dies, sometimes quickly after losing consciousness (depends how badly the brain's bleeding).

There are some really good resources on head injuries on this rugby website: http://www.englandrugby.com/my-rugby/players/player-health/concussion-headcase/ - it's aimed at rugby players (I play rugby) to be aware of the signs of serious head injuries, when to get medical attention, importance of not returning to playing too soon after a head injury, etc. There's a lot of information here that could be applied to stories involving any kind of head injury, and perhaps more importantly, for people in any walk of life to be more aware about concussion/head injury and when to get medical help, etc.

I'm not a paramedic so I can't help with the second question. There are medical documentaries on British TV channels, e.g. about the air ambulance and 999 which follow emergency service crews as they do their job. There are quite a few so I can't remember the titles but you could try looking them up on you tube whether there are any scenes etc that might help. The USA emergency services won't be that different - maybe the USA has similar medical documentaries? - the only difference I'm aware of is that adrenaline (the drug) is called epinephrine in the USA.

3) if she's already unconscious then the best bet would be an alarm on the machine. If she's conscious then pick any of the red flag signs for brain bleeding from the rugby website concussion tutorial (linked above).

4) what she looks like depends on what other injuries she's suffered. As mentioned above, you can have a fatal brain injury with no other observable injury to your body. However, if she's been in a serious car accident, then that would cause injury. If there was no airbag and she wasn't wearing a seatbelt in a high speed crash then there's a reasonable chance she went flying through the windscreen, so facial bruising and lacerations. if there was a seatbelt but no airbag then maybe her face smashed into the steering wheel - facial bruises etc. Even with a seatbelt and airbag she'd have bruising to her torso where the seatbelt restrained her, although the seatbelt + airbag would reduce the risk of serious head and facial injury (that's what they're for) so a serious head injury would be less plausible (though not impossible) with an airbag. With an airbag but no seatbelt you may as well not bother as you'd just fly over the airbag (they're designed to protect the face from impact when wearing a seatbelt).

There are plenty of other scenarios - even more serious injuries include decapitation and the skull being completely crushed. it really depends on what happened in the accident and what hit her or what she hit, how fast the car was going, from what direction the car was hit/hit something, etc. If you're looking for a scenario where the driver suffers a fatal concussion and noticable facial injuries, then the most likely would be that her face hit the steering wheel or windscreen and the impact caused a bleed to the brain. That way you'd get facial bruising and a fatal head injury. Depending on the speed of the impact, if she's not wearing a seatbelt she may go face/head first in the windscreen but not actually go through it. Also, impact to the side of the head is more likely to cause a fatal brain bleed than the front, top or back.

Bruises change colour as they heal but they'd still look very fresh the next day. Her whole face could be swollen.

Doctors would operate to try to releive the brain swelling/bleeding so she may well be covered in bandages too. You'll have to ask a trauma doctor/nurse for further details.

5. I don't know if they'd test for pregnancy but a doctor may notice signs if she's far enough along. You'll have to ask a trauma doctor. Any kind of trauma can result in miscarriage, or not result in one. Sometimes miscarriage is random. The uterus isn't under conscious control and women can miscarry and even give birth while unconscious (but not while brain dead). A miscarriage very early in pregnancy looks and feels the same as having a heavy period. It's only because of ultra sensitive pregnancy tests that anyone knows they're pregnant that soon. Due to this, I'm not sure this is a good scenario for them finding out that she's pregnant. Maybe they can find some other way, like reading her diary or going through her stuff back home? I know people don't do that when someone's alive but after they die it's totally different. They would want whatever they could find to try to remember her. She wouldn't necessarily have a miscarriage at all but after she dies the embryo would die too. Then they find out she's pregnant through diaries or other stuff she has at home. Maybe she even has the pregnancy test at home, or took a picture of it on her phone or something.
 
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MDSchafer

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ER and former neuro nurse here.

1. There's really no uniform look for car v pedestrian accidents. I've seen everything from head lacs and open fractures to a few cuts and mostly internal injuries. So she can look like anything you'd want. I'd stay away from bystander CPR, typically getting hit by a vehicle won't out and out stop your heart.

2. If it’s in a city the EMTs aren’t really going to do much. The EMT role is decided by how far you can be from a hospital. In the county I work in they’re never more than 30 minutes from a hospital so they tend to scoop and run in situations like this. They’d put her on a backboard, put collar around her neck and try to start an IV or two for us. If she has an obviously broken extremity they’d put a cardboard splint on it to hold pressure.

3. People call nurses into rooms for all sorts of minor things. An IV pump could start beeping, that’s pretty common, or the vent could alarm, which isn’t a super serious thing most of the time depending on the machine and the settings. Typically brain death is a pretty certain diagnosis. When we intubate patients we sedate them, all of which happens pretty quickly in the ED. Once they get the patient up to the ICU they’ll give them a “Sedation vacation,” and if there’s no effort against the vent, or movement they could start moving towards brain death.

4. It depends, they could have done what is known as craniectomy to relieve pressure. Depending on how much bone they take it can dramatically alter their appearance. I’ve seen cranies where they took a half of the skull from the top to just above the ear. They shave the hair on that side as well, but typically not the hair on the unoperative side.

5. Yes, trauma can cause miscarriages, and pregnancy testing probably varies from facility to facility. Some hospitals routinely do a urine test on every female with significant medical issues, some don’t. I don’t know if my hospital has a strong policy, but I would think we’d run a pregnancy screen.
 
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fov

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Thanks so much for the responses. She's out of commission as soon as the car hits her so this won't be one of those things where she seems fine and the head injury sneaks up. But, because she is still conscious in her head (a few scenes actually play out in her head), I might be able to work some of the symptoms of a head injury into those scenes to give the reader clues about what's going on. I'll check out the rugby website.

And thanks MDSchafer for your answers, very helpful!
 

DrDoc

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Your head trauma patient can look any way that works for your story. If your patient's brain is slowly dying, as opposed to all the trauma occurred at the time of the accident, you could have a lot of fun with your story. Remember, doctors can't really tell if the thinking part of the brain is dead by using the standard clinical tests. These tests all look for a reflex, and it's the accumulation of failed reflex tests that allows physicians to conclude, using indirect evidence, that the brain is dead. So, in theory, your patient could be conscious all the way up to when they turn the breathing machine off.

This sounds like an interesting story!

Keep us posted.

Regards,

DrDoc
 

fov

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Thanks! I just sent the chapters I've been working on to my writing group, so I'll know soon how well my attempts with this are working...