Monday, January 13, 2014

Wound Care 101 for Characters

Blood Loss and Wound Care for Characters: 

As with most things, there is pretty much a sliding scale for wound severity. It stretches from "put some antiseptic on it and slap a bandaid/bandage on," to "okay, you're not going to die from blood loss, but a doctor, so stitches and an antibiotic would be handy", to "you need a surgeon to look at that yesterday."

Here's a pretty line to demonstate:

The way you look after/treat wounds therefore varies accordingly.

Before I start though, a few things that just need to be said. I am in my last year of an Emergency Health Degree, and hopefully will be gainfully employeed as a paramedic sometime next year. For those in countries where paramedics doesn't need a degree, think of it as the equivalent of a nursing degree, just specalised in pre-hospital care rather than long term patient care. I am not a doctor, or qualified in any way shape or form yet, so most of what I talk about you could probably find in a variety of textbooks. Think of me a filter. This way you don't have to read all the textbooks.

And it goes without saying that the only people that this advice should be used on are imaginary characters. This is not any type of real medical advice - if you need that, you should be seeing your GP or someone else in the flesh.

That being said, here we go. This post will focus on cuts and bleeding wounds. I might do another one on specific wounds (head wound, eye injuries, ect) later.

Given the sliding scale, there are some pretty universal treatment under pinnings.

  • Pressure
For any wound that doesn't involve surgery, this is the be all and end all. A lack of pressure = a lack of clot = bleeding. For all wounds that to involve surgery, there will be pressure applied to visual holes and tears until surgery is viable. 
  • Saline soaked dressings
There's some research onto why these work, but the general consensus is that they work well. One of the explanation behind it is that  saline (0.9%) dressing is isotonic, and thus does not the damage done to exposed tissue. The idea is that if you have an open wound, or an evisceration, or an eyeball pop out, you want to keep the tissue from drying out, and you want to prevent further damage via contact with the dressing you use to apply pressure. So gauze, soaked in 0.9% isotonic saline is preferable. You can but it from the supermarket, people use it to clean their contacts. You are using this saline soaked gauze either to protect the tissue from drying out, or as "saline packaging" - so your essentially applying pressure to an open wound in the least damaging way possible. A dry bandage goes over the top of all this.
  • Managing Blood loss
There are several ways to manage blood loss. One of those ways, as mentioned, is applying pressure and stopping the bleeding. If, however, the bleeding cannot be stopped, or there is too much blood lost, other measure are generally taken.

Basically, the body needs a certain amount of volume in it's blood vessels to keep all the good stuff circulating. If that volume drops too low, your heart won't be able to speed up enough to correct for it, and you won't be able to breath in enough oxygen to pack into what little volume you have left going around your blood vessels.

This loss of the "good stuff" (oxygen, nutrients ect) leads to debilitation and death if left long enough. So thus the volume lost should be replaced. Or you can "load" a patient up pre-emptively if you think they're going to loose a lot of blood.

There are several liquids used to do this. The one's I'm familiar with are isotonic saline and blood. Regardless, the principals are basically the same: If there is not enough volume of liquid in a person's veins to move all the "good stuff" around, you replace that volume via an IV drip. Thus you increase that volume, then "good stuff" can move where it needs to go, and everyone's happy.

Well, not entirely. Fluid replacement is contentious. Everyone agrees it should happen, but when it's not blood you're using to replace the blood you've just lost, there are all sorts of argument about how much fluid should go in and when it should start to go in. Internal injuries are also difficult, because internal bleeds release blood into the body cavities - if you can't stop the bleed, than all your fluid replacement isn't going to do much, as whatever you put in will end up coming out through that same internal bleed that you can't do anything about.

And at the end of the day, anything that's not blood only really buys you enough time to get to the surgeon. Depending on the injury, sometimes blood can only buy you enough time to get to a surgeon.

So, some guidelines. Here's our scale again:

Let's call this side "Injury A"                              This "Injury B"                                And this "Injury C"

If your character has injury A, your main issues are going to be pressure, pain relief, and infection control. Whether or not you use saline soaked gauze depends on whether the injury counts as an "open wound." So you look at whether there's exposed tissue, and go from there. Pharmacy meds should do for pain relief, and topical infection control (antiseptic creams ect), should work. You should clean the wound with a dribble of water - no taps, as that will just damage the wound, dry it, put antiseptic cream on it, and then bandage as appropriate.

Injury B generally means the wound is big enough that you've lost a fair amount of blood, may need stitches, and topical antiseptic will probably do more harm then good. You don't want to damage any exposed tissue, so don't go putting creams on it. Wash it, saline packaging (so gauze soaked in saline as the dressing), pressure, and get to the doctor for for stitches, possibly an oral antiseptic if it's needed. Your character may or may not need some form of fluid replacement or transfusion.

Anything between Injury B and C is probably going to start affecting your character's conscious state. They may become woozy, there may be amnesia issues, and they may loose consciousness. As discussed before, loosing consciousness for period over 5-10 minutes is bad, loosing consciousness for over half an hour starts to imply long term disability as a result. This Injury needs all that Injury C needed, except you've got to worry a lot more about fluid replacement or blood transfusions. The patient is also probably going to need surgery, within the next hour.

So yes, I hope that helps. To define - anything over about 750ml of blood loss is significant, more than 1.5 litres and you're looking at a loss of consciousness. It doesn't take much blood loss to upset everything.

If anything in this doesn't make sense, feel free to comment. Feel free to ask questions too. I might not be able to provide all the answers, but I have access to people at university and on placement who might.


Susan said...

You know what? Unbelievably helfpul. Not a blog post I would have ever put on my list of "I wonders" and yet one of the most helpful posts I've read in a long time. I have a character with a pretty gruesome injury, and I was actually having anxiety about how I had her treating it.
I'm feeling a lot more confident with this in my back pocket.

Sian said...

I'm really happy it helped. I like doing these posts, because they both help me revise what I've learnt, and it annoys me no end when people get things wrong.

But this comment just made my day :)

Anonymous said...

Yeah, that's what I felt as well - not something I'd have gone out of my way to look up, but I'm really glad I read it, even if it only trickles into my work. Thanks, Sian, and I'm adding a bookmark so I can come back and go over it all again as I work some wounds into my WIP.

Sian said...

I'm glad you found it helpful. I think a trickle is more than enough, honestly - I don't think any story needs 10 pages of detail on wound care, (it is fiction after all). But if you have the basics in the back of your mind, the consequences of what your character do should be more realistic (IMO).