Friday, August 24, 2012

A Scene in a Small Rural ER

As promised, this week I'm adding a new feature to CICERO'S CHILDREN called THE WRITER'S ER that will highlight questions from authors concerning medical scenes in their books. As a long-time ER nurse and instructor in ACLS, PALS, and BLS, I have the experience to answer most any question thrown my way. And if I'm ever stumped for an answer, I have friends in the medical field, especially in the field of pre-hospital care and ER care, who I can turn to for help.

That said, the first question I received this week was from Marilyn Meredith, author of over thirty published novels. Marilyn writes the Deputy Tempe Crabbe series under her own name, and the Rocky Bluff P.D. series under the name F. M. Meredith. She is a member of Epic, three chapters of Sisters in Crime, Mystery Writers of America, and serves as the program chair for the Public Safety Writers of America's writing conference. 

Marilyn has been an instructor at many other writing conferences. You can learn more about her books at http://fictionforyou.com. Please visit her blog at http://marilynmeredith.blogspot.com. . 

Marilyn wrote: "I have a character who is a young police officer and she’s been shot in the thigh and shoulder—bled a lot but neither serious. Another officer stopped the bleeding at the scene, she’s taken to the ER, and then where? I want her friend another female officer to be able to see her before they take her to the operating room. One of the nurses is a friend of the 2nd officer (her husband is a police officer too.) She would’ve had x-rays, right? And be getting IVs? Is there a window of time where her friend could speak to her?"

I emailed my answer to Marilyn who graciously consented to let me post her question here. (I'm including a bit more information below then I originally gave to Marilyn. That's because I wanted to clarify what I wrote about the different levels of trauma centers.)

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Yes, Marilyn, there's a window of time when the friend would certainly be allowed to speak with her. That window could be quite large depending on where the injured officer was taken. Are we talking a small rural hospital, or a small, medium, or large city hospital? Population determines the size of a city, with the criteria differing from state to state in the U.S. In a large city, an officer with multiple GSW would be taken to a Level I trauma hospital where surgeons of all specialties are on duty 24/7. Generally speaking, a medium sized city might have a Level I trauma center if it served a larger population outside its city limits. It would definitely have a hospital certified as a Level II trauma center with surgeons of all specialties available to come in within 30 minutes of being called by the ER doc. An example of a medium-sized city that has both a Level I and a Level II trauma center is Aurora, Colorado (population 325,078). One hospital in the city serves as a Level II trauma center for all patients, while another hospital serves as a Level I Pediatric Trauma Center dedicated to injuries in children.

Small cities could have a Level II or a Level III trauma center, Level III being a hospital that can provide care to most trauma patients, but doesn't have a full range of specialists. Level III ERs transfer patients to a higher level trauma center if they require more intensive emergency treatment by a specialist. An example of this would be a gunshot wound to the head that required the services of a neurosurgeon.

There are always exceptions to the city size rule. The population of Park Ridge, Illinois is only 37,775, but it has a Level I Trauma Center. Lutheran General Hospital opened in 1959 when there was still much open land in this Chicago suburb. Over the years it grew, and grew, and grew, until today it is a 645-bed medical center and one of the largest hospitals in the Chicago area. You could probably find the same story playing out in small suburbs of other major cities. But when we're talking about rural areas such as you'd find in states like Utah, Nevada, Oregon, or even in parts of California, you're looking at your hospital being a Level III trauma center. Examples of this would be Yreka, CA (population 7,765) and Wildoma, CA (population 32,176). Both cities are served by Level III trauma centers

In a Level I or Level II hospital ER, the ER doc would not call in a surgeon for a basically non-serious GSW until he had completed his examination and had X-ray and lab results, because he/she would need to know if a surgeon was needed and what kind of surgeon was required. He'd probably call in an orthopedic surgeon if the bullet shattered bone, but the possibility of nerve damage could require a neurosurgeon as well. If your hospital is in a rural area serving maybe 15,000-20,000 people, the hospital would probably have a Level III ER and would transfer the patient to a higher level facilitya Level I or II hospital—if the necessary surgeon wasn't available there.

Even in a Level I or Level II hospital trauma center, your officer would be in the ER for at least 2-4 hours prior to going to surgery if the shooting occurs during the day and if, as you say, those wounds are minormeaning no major arteries were hit and bleeding is controlled. I say "during the day" because the OR suites are already in use during the day, and the only way your victim would be pushed to the front of the OR schedule is if she is bleeding so badly that her blood pressure falls and she goes into shock, the wound is to the chest or abdomen, or the gunshot caused a partial amputation of a limb or some other life-threatening event. She'd probably go to the OR faster in the evening when the OR isn't in regular use. I'd still count on at least 2 hours from arrival in the ER to going to the OR in the evening.

Your victim would have at least one IV in place with a liter bottle of .9 normal saline running slowly, plus an IV line with a heplock in place, that line not being used at present but reserved for use if needed in surgery (more fluids or blood products). X-rays would be taken to look for bone damage and, if the bullet did not exit the wound, to see placement of the bullet in the body. Lab work would be done, a CBC (complete blood count), PT and PTT for clotting evaluation, and probably chemistries (electrolytes, etc), plus a Type & Screen for possible blood transfusion. 

Shoulder wounds can be life-threatening because you have the subclavian and brachial arteries and veins running below the clavicle and down the arm. In order to make them minor wounds, your victim needs to be shot clean through the deltoid muscle on the outer fleshy area of the upper arm. If the bullet doesn't touch the bone but lodges in the muscle, the ER doc can remove the bullet without calling in a surgeon. If the bullet goes clean through without damaging the bone, the ER doc will clean the wound, close it with sutures, apply a dressing, and discharge the patient with antibiotics (may give IV antibiotics also before discharge). If the bullet penetrates the upper arm bone (the humerus) breaking that bone or causing bone splinters to lodge in the surrounding muscle, an orthopedic surgeon would be called in for surgery to remove the bullet and clean up the splinters and/or repair the fracture with plates and screws. Your officer would be out of action for several weeks if the bone was broken, but less time if just a few splinters were removed, maybe 10 days and no heavy lifting for another week. If shot through the clavicle or shoulder blade (scapula), generally no surgery would be needed unless it's for the removal of bone splinters. Treatment for a shoulder blade is a sling. Treatment for a clavicle is a figure eight strap. 

For the thigh wound, if you want it to be minor, the wound must be on the outside of the leg. The femoral artery and vein run down the inside of the leg, and both bleed like mad. Hitting them with a bullet, especially the femoral artery, could cause your officer to bleed out very quickly. Go for the outer fleshy part of the thigh. You'll probably have to have the bullet hit the femur (the upper leg bone). It's hard to miss the femur unless the officer has really fat legs. :) If you want your officer back on her feet quickly, just have the bullet graze the bone so the surgeon just has to remove some splinters. The femur is the strongest bone in your body and doesn't break easily in a younger healthy person. Your officer will be on crutches for a day or so, then may use a cane until she has no pain when weight bearing.

So again, if the wounds are minor, your officer will wait around in the ER for several hours, during which any of her friends can visit her. If she's going to be transferred to another hospital for surgery, it'll depend on how long it takes for an ambulance to arrive for the transfer. We're still talking a couple of hours here because of all the tests, etc.

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And now a heads up to writers like Marilyn and I who include ER scenes in our novels. Be careful of the kind of injury you create for your hero or villain. If you set your stories in rural areas, don't expect to have a thoracic surgeon or a neurosurgeon living right down the block from your hospital. Big money guys like those  tend to stay in the big cities where they have plenty of work to do every day. If you're not sure what kind of hospital ER you should portray in your story, check out hospitals in real areas similar to you setting. For more information on trauma centers, check out the following links:

http://www.facs.org/trauma/verified.html A partial list of trauma centers by American College of Surgeons.
http://www.traumamaps.org  A map of the U.S. showing trauma center availability.
http://www.cdc.gov/traumacare/ Info from the CDC.
http://www.calena.us/California%20Hospitals%20and%20Trauma%20Centers.htm   The Emergency Nurses Association of California's list of state trauma centers.  

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IF YOU HAVE A MEDICAL QUESTION DEALING WITH PRE-HOSPITAL CARE OR CARE IN THE ER, AND WOULD LIKE TO HAVE IT ANSWERED HERE, CONTACT ME AT KLEWORKS@AOL.COM. I'D LOVE TO HEAR FROM YOU.



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  1. Thanks, Mary. That was exactly what I needed to know for the book I'm working on now.

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