Wounds and trauma

[Adam Wiggins]

Here, as promised, is some of my corespondance with the folks who helped
us with our wound system, two experienced nurses (one is ER (past) and
OR (current), the other is ER (past) and recovery room (current)).
Most of our discussions were verbal (over the phone and in person) but
I did have the following lying around; it's snipped from some e-mail
we exchanged when I first started milking them for knowledge.
At the very least, it persuaded me to look deeper into the subject -
funny how this stuff is so much more interesting when put into a
real and useful context.  I remember being bored to death during
anatomy and biology classes in college...

--(snip)--

Pain is most definitely subjective...it's completely true that some people,
especially the Irish, are stoic and will not complain about pain  Hispanics,
on the other hand, generally are verbal and emotional and you'll know right
away when they're having pain, physical or mental.  Those two ethnic groups
stand out right away...others are a mix of their own personality and how
they've learned to cope in life.  As a recovery room nurse, my goal is to
treat pain of all types, whether it is verbalized or not, so I work at being
adept at picking up pain signals; an increased blood pressure, heart rate,
signs of restlessness, wrinkling of the brow, and other more overt ones like
moaning or verbal complaint.  People truly tolerate different levels of pain
- even as children - there are those who are and have always been "wooses"
and others who are "troopers."

Losing consciousness is not relative to pain, as movie directors would have
us believe.  Losing consciousness is a result of two things I can think of
off hand; decreased oxygen to the brain and direct injury (or medication i.e.
anesthesia) to the brain's area that controls level of consciousness.  

Decreased oxygen to the brain occurs because of various reasons.
  1.)  Inability of the lungs to work well enough to accomplish the intake of
oxygen.
       a.)  chronic disease. Emphysema causes barrel chestedness and a
decreased
            elasticity of the lungs so they are mechanically unable to expand
enough to
            take in room air very well.  Pneumonia is viral or bacterial in
origin and these
            bacteria or viruses create exudate, i.e. pus or fluid, that gets
in the way of
            gas exchange taking place - oxygen in, CO2 out at the alveolar
level  within
            the lungs.  These are examples - many more exist of course.If
these con-
            ditions get bad enough, oxygen to the brain can decreased enough
for a per-
            son to lose consciousness.  In the hospital setting, this is when
someone
            gets put on a ventilator - a device that forces oxygen into the
lungs at such 
            high volumes that some oxygen gets to the brain, hopefully enough
to main-
            tain the brain tissue without permanent damage.
       b.)  acute trauma.  Someone taking a piece of rebar into their chest
is going to
             have a collapsed lung.  Only one lung is doing the work of two
lungs, certainly
             possible to maintain life, but if a chest tube isn't put in
pretty soon a collapsed               lung starts to cause the heart to go
into strange rhythms (called arrhythmias)
             and then you're dealing not only with a crappy lung but with a
wildly beating
             heart.  If that heart goes crazy enough, not enough blood gets
to the brain
             and loss of consciousness occurs.
        c.)  Acute disease.  Sudden heart attack (MI) causes aforementioned
arrhythmias
              at the very least and complete asystole (heart stoppage) at the
most.  When 
              the pump dies, the oxygen in the blood to the brain stops and
loss of con-
              sciousness occurs very rapidly.  A stroke means a clot has
lodged in a big
              vessel somewhere or in the brain itself and cut off blood to
the brain.

The word "shock" really refers to either cardiogenic shock (heart problems to
the extent that the heart is having trouble pumping enough oxygenated blood
to the brain) or hemorrhagic shock (usually associated with trauma and the
resulting massive blood loss).  A person can lost consciousness in either
case, and emergency room personnel treat each of them in distinct ways.  The
person in both cases doesn't lose consciousness because of pain however; they
do so because of not having enough 
oxygen pumped to the brain (bad pumper not able to pump adequate blood, or
not enough oxygen carrying fluid (blood) to circulate up to the brain.  This
last one,of course,
refers to amputation or other trauma to the body where an artery is severed
and the person bleeds big time.

At any rate, when procedures are undertaken to get enough oxygen to the
brain, whether it be put a bad lunger on a ventilator or stop bleeding and
transfuse, the person will regain consciousness and you just hope you worked
fast enough to prevent too many brain cells from dying off.  If you weren't
able to work fast enough, or if the person didn't get help soon enough, of
course the brain starts dying off.

--

I didn't receive your original request on the trauma stuff but Wende gave me
a copy of hers.  So I'll add my two cents worth.  First some definitions.
 Trauma refers to any invasive injury versus a disease process.  So trauma
can be as minor as a splinter and as major as limb amputation or a bashed in
head.  Shock refers to complete cardiovascular collapse.  This occurs when
there's not enough blood circulating, when there's not enough o2 getting to
the brain and/or the heart stops beatng.....any combination of mechanic or
metabolic events which disallow the most basic phisiologic processes to
continue.  Losing consciousness due to pain is probably more of a Hollywood
effect that a fact.  I suspect one would loose consciousness first from
psychological pain than from physical pain.  One looses consiousness from
impact to the head, which can be very momentary or lengthy depending on the
impact or from oxygen levels falling too low.

One's response to pain is highly variable from person to person.  Partly
genectic, partly cultural, partly motivational.  I've seen people endure
incredible amounts of pain and fuction in a crisis situation and I've seen
people (usually big, tough, gang types) whine over very little, like having a
iv started.

The timing for these things occurring is highly variable depending on the
degree of the trauma and the location of the injury.  Adrenalin kicks in
immediately.  It's easiest to describe as the flight or fight hormone.  It
causes the body to shut down any unnecessary functions and redirects all
metabolic effort to the survival needs, ie, digestion stops, blood supply is
heavily diverted to the brain, heart and muscles reqired to fight or flee
from danger.  The peripheral vessels constrict as part of this effort to
divert blood to the most required functioins.  The heartbeat is enhanced and
such.  

Blood loss will begin to affect performance after about 1 unit (500 cc, 1/2
liter).  The average adult has about 6 liters of blood total.  After the
first liter is gone impairment would increase steadily.  The heartrate will
increase dramatically trying to move the remaining blood around fast enough
to make up for the falling blood pressure....then we start approaching
 oxygen levels to the brain dropping, now we/re getting into approaching
shock.  Heart rate becomes very high, color drains,  whooziness sets in,
person gets cold and clamly...known as "shocky".  Eventually LOC (loss of
conscioucness) results...we are now in deep shit.  the time it take this to
happen depends on what is bleeding where.  If the aorta or heart is ruptured
it's quick, altho not as quick as if a legs is ripped off.  that is if the
heart/aorta is bleeding into a closed cavity (ie, impact can rupture
heart/aorta into the closed chest cavity) because the enclosed space into
which the bleeding is occuring forms a tamponade slowing the bleeding
process.  If you have an unoccluded femoral artery bleeding (ripped off leg)
you can bleed into shock and death within minutes.  

I guess I would need to look up more details on adrenalin more correctly
called epinephrine.
I know it kicks in immediately and can stay in production for some time if
needed.  It's definitely hooked up to brain stuff and a person' s perception
of danger.    We use epinephrine frequently in medicine, it's one of the
drugs injected directly into the heart muscle during a cardiac arrest.  It's
what the druggies injected into the girl's heart when she was overdosed in
Pulp Fiction.

You ask Wende what the effect would be if a women fell 15 feet.  That depends
on how she landed.  If she landed in the position that would bread her neck
she would be paralyzed from the break downward...couldn't even breathe...like
Christopher Reeve.  If she fell on her rib cage and broke
 ribs she might puncture her lung or maybe not.  And so on.  It is highly
variable.

---

A generalized word for bone setting is "orthopedics"; for blood/flesh wounds
is "surgery" and for disease is "illness or sickness."  Simplistic, I know,
but those are the more vague generic words for those 3 that have no
connotations and cover a broad range as you requested.  Skills can include
midwifery, healer, faith healer, opthomology, urology, gynecology,
opthamology, podiatrist, psychic, accupuncturist, naturalist, accupressurist,
massage therapist, psychologist, psychiatrist, therapist, spiritualist,
counselor, dermatologist, neurologist, cardiologist, chiropractitioner,
audiologist, speech therapist, occupational therapist, physical therapist,
phlebotomist (blood letting in the old days; a lab tech who draws blood
today).  I can't remember the word for reading the bumps on one's head to
tell the person's fortune.

------
Blunt trauma...hmmmm....  Getting smacked with, say a shovel in the flank can
cause things like hematuria (blood in the urine) that disappears in a few
days, all the way up to something fatal like a lacerated liver or spleen.
 The spleen deal would cause a person to bleed to death in the old days...now
we see a hard belly (evidence of bleeding) and a person goes straight to the
OR.  A ruptured spleen would present with abdominal pain, 
internal bleeding that would eventually lead to a falling blood pressure
(with eventual loss of consciousness because not enough oxygen would be
pumped to the brain) and a rigid belly (lots of blood in the abdominal
cavity).  Getting shovel smacked could also result in contusion of any of the
internal organg...ruptured bowel results in peritonitis (infection in the
belly and before anitibiotics always resulted in death), contusion of the
heart could cause arrhythmias (previously discussed).  Blunt trauma to the
head can cause contusion (bruising), concussion (fractured skull) or internal
bleeding (head injury with bleeding in the brain, again, previously
discussed).  Taking a hit to a limb can cause anyting from a bruise (really
just a little under the skin bleeding) to a compound (open) fracture, with
bone broken and protruding through the skin.  Edema (swelling) always occurs
with injury.

---

Field treatment.  Let's see.  If it is an extremity that is swollen, one of
the best things you can do it raise the arm or leg higher than the person's
heart.  That in itself reduces swelling a bunch.  If swelling is caused from
a hematoma (bleeding under the skin), pressure needs to be applied so the
bleeding and swelling stop.  Then ice, as you said.

Fire, cold and electricity.  Fire first.  Burns were most likely treated with
"poltices" - herbal type remedies that very likely only soothed rather than
healed burns, much like in the 50's when we were told to apply margerine to
burns.  Yes, having a finger burned off, while not fun, probably cauterizes
it and if kept clean, would have a chance of not becoming infected.  Third
degree burns, down to the muscle layer, most likely were never survived )
assuming it covered a large portion of the body) because a person's
electrolytes (K+, Ca++, Na+ and Cl-) get so screwed up and they go into
cardiac arrhythmias and die because of that.  Third degree burns are very
very painful - raw nerve endings exposed to the air.  Not fun.

Cold next.  View the human body as a slab of meat in the freezer.  If there
long enough, it freezes hard and circulation stops to the "meat" and will
never have circulation again; hence amputation of toes and fingers, parts
that are frostbitten easily.  If caught soon enough, circulation can be
restored and parts not lost.  If, however, a whole body is outside in
freezing temperatures, hypothermia sets it, metabolism slows, a person falls
asleep and quietly dies.  Supposed to be a good way to go, other than the
first hour or so when you're nice and conscious and so cold you're shaking
and miserable.  Freezing to death is just like freezing that piece of meat.
 Cold can cause nerve damage, but of course nerves are cells just like muscle
is, and if nerves are damaged it can cause timgling and numbness that will
never go away.  Sense of touch does become worse, pain can be constant and
shooting pains can occur.  What does it take to freeze to death?  If a slim
person is in the cold, they'll freeze faster than an obese person (there
really is something to having one's fat keep one warm).  A person will freeze
more quickly in colder temperatures of course - 12 degrees much faster than
25 degrees.  So it depends on the body composition, length of time in the
cold and actual temperature of the environment.

Electricity.  I don't know too much about that except that some people who
are electrocuted by either lightening or power lines do have an entry point
and an exit point of injury on their bodies, i.e. a burned place where the
electricity went in and went out.  I'm not sure how much wattage it takes to
kill someone.  I remember when I was small, my Father would come home with
some horror stories of accidents at work (he was an electrician with Arizona
Public Service and did some work on power lines occasionally).
If electricity didn't kill you, you'd be dazed and have whatever injuries
that were caused by falling down when shocked.  There was a guy out in Apache
Junction, an old retired guy, who came out of restaurant a few months ago
after having had lunch with his wife.  A big storm was going on, and he
doesn't remember anything except walking out of the restaurant and waking up
in the ambulance.  His only injuries were burns on his hand and foot
(entrance and exit sites) and his bashed up face fromfalling down on the
asphalt street.  I remember it because it was written up on the front page of
the paper.