Guide to Traumatic Emergencies

Medicine has changed much in the past 1000 years, but the human body has not. There are better ways of dealing with disease, dressings that are less difficult to bandage and have a better chance of preserving the wound, and doctors can probably resuscitate most people from a heart attack. However, the human body has not. Bodies still react to getting shot, stabbed, crushed, blown up, and punched in the same way they did thousands of years ago. The practice of medicine with regards to trauma has been refined, but there is no ‘miracle’ cure for pulling a bullet out of a chest, or reattaching a leg. It still requires bloody hands, a scalpel, nerve, and a lot of blood and drugs for the patient. This Reader’s Digest guide will serve to give patients an idea of what a wound really means and OS doctors an accurate idea of how people get hurt physiologically, and 21st century definitive care for them, which can easily be ported to 31st and later, with Millennium, 41st century use. There's even a guide for all you lawyer-folk who want to sue us.

Roles and Responsibilities
Doctors, nurses, paramedics, firefighters, technicians, surgeons all have certain roles and responsibilities that their titles bring. Most hospitals, militaries, and governments have a ‘duty to act’ clause. Meaning, as a medical care provider, you have a duty to act no matter what the patient has done, to you, your family, or to those around him. With a duty to act in place, there are several forms of negligence that are lawfully recognized:

Malfeasance: You performed a skill wrong.

Misfeasance: You performed a skill that you were not trained for. An example is a vascular surgeon delivering a baby and the baby dies, or a paramedic cutting someone's chest open to remove a bullet.

Nonfeasance: You had a duty to act, and did not act.

Abandonment: You place your patient under the care of someone lower than your level (the feeding chain goes Doctor->Nurse/Paramedic->EMT-Basic->First Responder), or leave your patient without care in an uncontrolled environment.

The most basic requirements for a lawyer to successfully bring a case against a medical professional are as followed:

1.	There must have been some form of negligence 2.	There must have been an injury to the patient 3.	It must be proven that the negligence caused the patient injury

Some jurisdictions require more, but that is an excellent baseline for any lawyer characters wanting to sue a doctor. Know your negligence, know your injuries.

Another limit that medical professionals have is consent. Anyone over the age of 18 can refuse to be treated, with certain limitations. A doctor may place a mental health hold on anybody receiving care in the field or in a hospital, to be signed off on by the doctor. The hold form literally takes away the rights of the patient for their own safety, for example, after a traumatic incident, or for substance abuse. Unconscious patients always give consent.

Basic anatomy and physiology
The biggest thing that needs to be understood about A&P is a lot of stuff can break, and when that stuff does break, it can be bad. This will be more of a list of what can be hurt on a person, and what cavity it’s in.

Head: Skull (divided into the frontal, parietal, temporal, and occipital plates), brain, eyes, orbit, nasal bone, zygomatic arches (cheek bones), maxilla (top of mouth), mandible (bottom of mouth)

Neck: jugular vein (important in pnuemothorax or collapsed lungs), carotid arteries, trachea, esophagus

Chest: clavicle, trapezius, sternum, 12 sets of ribs, lungs, heart, aorta, carotid arteries, diaphragm, trachea, stomach, primary, secondary, and tertiary bronchi

Abdomen: Small intestine, colon, appendix, spleen, pancreas, liver, kidneys, bladder, aorta. This area is under a lot of pressure.

Pelvis: pelvic bone (ilium, ischium, pubis), aorta, femoral arteries, groin area

Legs: femoral arteries, femur, petal arteries, tibia, fibula

Arms: brachial arteries, humerus, radial artery, radius, ulnar artery, ulna

Vital Signs
Even in the 31st century, vital signs are the number one indicator of how well a person is doing. Picking up vital signs may be easier with technology, but they are still an absolute need. There are two parts to vital signs: how well you’re breathing, and how well you’re circulating. If you aren’t breathing, then we need to know if it’s an airway problem or your lungs aren’t working.

Breathing: respiratory rate and rhythm (MUSH purposes, normal or abnormal), lung sounds (will be covered more thoroughly with chest trauma)

Circulation: pulse, blood pressure (will be explained more in shock), skin condition (color and texture)

Shock
Medical shock is described as this, and ONLY this – inadequate tissue perfusion to your brain, lungs, heart, or kidneys. To say you’re ‘in shock’ from getting all cut up is absolutely untrue, unless you’ve lost a good 2 liters of blood from your little arm cut. There are multiple types of shock, but they all present the same way. With the violence in OtherSpace, only two types of shock are truly important: hypovolemic (loss of blood) and neurogenic (head injury) shock. They all present with a low blood pressure, high pulse, and high respirations, an altered level of consciousness (from confused to unconscious), dilated pupils, and skin that is cool, clammy, and diaphoretic (wet). This is all from your body’s sympathetic nervous system – its fight or flight response – going into effect, as it recognizes impending death. Eventually, a shock patient will crash and their pulse and respirations will drop. This is called refractory shock – and the patient will now die. Patients can be in shock and have no signs of anything wrong for minutes to hours – they are in compensatory shock. The symptoms listed above present during progressive shock. An important note for children characters and doctors working on them – children are fine, and then they are dead. There is no progressive stage of shock.

Head trauma
Head trauma can cause all sorts of problems. The most important thing to know here with head trauma is when you get hit in the head, have a skull fracture, whatever, your brain SWELLS. In the incident of a closed head injury, this will eventually force the brain towards the one opening in your skull – the foramen magnum, putting pressure on the medulla oblongata and pons, which controls your breathing, pulse, blood pressure, and level of consciousness. Why is this important? Neurogenic shock that results from this does not present like other forms of shock as far as pulse, respirations, and BP goes. Head trauma victims go through what’s called Cushing’s Reflex – a high BP, low pulse, and low respirations. Open head injuries see less of this problem – their brain can swell wherever it wants.

Definitive care for a head treatment includes drugs to lower swelling, drilling a hole in the skull to allow pressure out, and neurosurgery to repair damaged arteries if it is needed.

Thorax/abdominal trauma
Thorax and abdominal trauma is another area that can kill a person in minutes. Beginning with the thorax, broken ribs can penetrate the pleura of the lungs, causing a pnuemothorax (collapsed lung). Eventually, this will turn into a tension pnuemo, where both lungs are collapsed and the person cannot breathe anymore. Emergency treatment is quick – using a large needle to poke a hole in the pleura and release the pressure. Definitive care includes the insertion of a chest shunt until the pleura mends itself. If there is blood involved, chest surgery is required to find, and stop, the internal bleeding. Hard enough blunt trauma can also cause the aortic arch to tear. This kills a patient if it is not found fast. Definitive care includes stitching it up.

Abdominal trauma includes liver damage, a ruptured spleen, a GI (gastrointestinal) bleed, a burst appendix, or kidney damage. All of these require immediate surgery to fix, and then continued observance. The best way to test for any of these is to palpate the abdomen – if it is hard as rock, there is blood under there, no question about it.

Extremity trauma
This is where the most ‘wrongs’ are committed on OtherSpace. You NEVER, EVER, EVER tourniquet a wound. That is just medieval. You –will- lose the limb, and that was the point, in order to cut blood flow off so that it could be removed. We like to reattach things. The proper way to dress an amputation is covered in soft tissue injury. Slowing blood flow is done with an easy trick – set a blood pressure cuff above the wound, inflate it so that a little blood can trickle through. The trickling is the important part – it preserves circulation to the area. Other things can include broken bones, which are easy to set. A huge misconception is that things bleed, and bleed, and bleed. Arteries are made of smooth muscle, and when they are severed, they spasm shut.

Penetrating trauma
Discussing the kinematics of penetration would take up pages, but the simple version is this: velocity is much more important than mass. KE = mass * velocity^2. That is a very important idea when considering a penetration wound. We have taken people into the OR with a knife sticking out of their heart, quivering with the heartbeat, and they have survived – unless they are on the table and in the right environment, do not remove anything penetrating into a person! However, a bullet is a far nastier day. It bounces all about in your body, and just because you have an entry and exit wound does not mean it had a straight line. A bullet also creates a temporary mushroom cavity, causing even more soft tissue damage. Definitive treatment is immediately opening them up, looking around, fixing the damage, and giving them lots of blood.

Soft tissue injury
There are multiple types of soft tissue injuries to be described in detail here. Unless otherwise noted, the emergency treatment is a wet, sterile dressing wrapped in a dry bandage. Definitive care includes stitches, surgery, skin grafts, and blood.

Lacerations: Simple, jagged cuts

Avulsions: Removal of skin and muscle – ripping the meat from the bone (this is why you don’t wear rings around a lathe). Gloving. This is always an amputation.

Contusions: Bruises. Let them go away.

There are many others, but treatment is all the same, mostly. The wet part is important – a dry opening in the body causes more damage, and more scarring.

Burns
Burns are nasty. They are everywhere in OS. We work around things that explode. Grenades. Bombs. Reactors. Energy weapons. Burns are very common, and they are not to be taken lightly.

Burn levels:

First degree: superficial burns. Sunburns. No treatment.

Second degree: Partial-thickness burns. Notable for their blisters. Treat with cream, antibiotics.

Third degree: Full-thickness burns. Remaining flesh becomes translucent, white, pale. No pain – but you’d better bet there’s pain around, because around every third degree burn is a second degree burn. Skin grafts, scrubbing, are major treatments.

Fourth degree burns: Bone and muscle burns. Amputations, most of the time.

Apply a wet dressing to the burn sites, but if there is over 30% burns, then apply wet dressings to only 30% to prevent hypothermia. Burn center patients will be there for a while, and it is the most painful experience a person will ever have.

Conclusion
This guide was very short, but any questions on injury and treatment can be referred to Marcus. Thanks for reading!