Young Writers Society

Hi Stella, I need to disable someone .

My character needs to sustain a substantial leg injury which will permanently effect him enough that he has no hope of resuming his old, highly physical career.

I am afraid that some DEVASTATING injury will come off like anvil ex machina, given the nature of how he gets it: a good old parking-lot curb-stomping from the antagonist in the beginning of the story. No landmines or whatever, here, just torn ligaments and/or shattered knee cap.

Question is: can't you heal from said torn ligaments in such a way that you could resume your old life after enough time and PT? I need it to be very clearly perrrmmmannnennnt because I need to CRUSH his wee heart D:<!

Hi @Tecumseh ! Sorry for the delay in getting back to you but I basically went and tried to think long and hard about this because I wanted to give you a really full answer but then I started to feel like I needed more information from you such as: how active is he? If he's, you know, a spy or something that just needs a good level of activity, then he'll be able to heal from his soft-tissue injury to a good enough standard to keep going. If he's a pro-athlete or someone who doesn't just require good function but incredible function then that's different, and something like an ACL tear or a shattered knee cap and torn meniscus could be enough.

Other than that, I had a thought about nerve injuries - in particular the common peroneal nerve that runs along the outside of your leg. It causes 'foot drop' which is what it sounds like, you can't lift your foot at the ankle. It's really common but it usually resolves completely and the only way I can think of you making sure that never happened was to have something actually sever it - a knife, a broken bottle, something to the outside of the knee.

And then the obvious one, but I'm worried you think I'm going nuclear here: amputation.

I'm not saying the guy cuts off his leg. But with enough force he could cause an open fracture, or he could cut down to bone, and your protagonist gets an infection. If you managed to delay his hospitalisation and beginning antibiotics that could cause him to need an amputation to stem the bone infection - osteomyelitis. Fractures could also cause compartment syndrome, where his muscles get squeezed and start dying and turning into mush, and if it's not treated early, the muscles are beyond repair. It can also cause nerve damage. He wouldn't have an amputation for that, but his function would probably be diminished quite a lot, from muscular and nervous reasons.

Essentially I think you're going to have to break his leg to cause any real lasting damage - to me common peroneal nerve honestly seems a bit of a cop out because it's really common and most people continue with their lives. I just googled and tibia fractures (and even tibia AND fibula fractures) can occur in assault. I'm not crazy.

Sorry, I feel like I've answered your question really badly :/ Please feel free to call back to me and tell me I've done a bad job and ask it again!

You have done an excellent job and you are volunteering your time, stahp. Also thank you for your response!

His concept is simply that he has a physically demanding and dangerous job that keeps him away from home, such as in the fishing industry, or as a roughneck offshore. I haven't nailed it down, but I do have its requirements: it needs to keep him away from home, and it needs to be dangerous and physically demanding.

His sense of self-worth stems from his physical prowess and that he can handle this job, and he thinks that this career is the way he can hold his family together because it makes them financially stable. His job, however, is actually eroding his connections with his family because he is gone so long, and when he's forced to quit, he realizes how things really are at home. He can either feel sorry for himself or he can cowboy up and fix it.

The wound in particular does not have to be his leg. I chose his leg because when I consider how I felt when I broke my hand to how I felt when I broke my foot, I lost some degree of independence in both cases but I felt it so much more often and more profoundly when I broke my foot. So, I felt that limiting him in a similar fashion would be more effective to his arc. Just, somewhere in the general leg direction.

I actually did have two drafts with amputations but tossed them out of concern that they were not believable simply because they were extreme. It is definitely an extreme thing and I think its rarity would probably be off-putting to an audience even were it realistic not because of it being disability but because of it being "too much" disability.

One part of me thinks I could make it perfectly believable. There's an economic crisis in the setting and the state of medical care is suffering in its wake, to the point where hospital staff has to boil and re-use needles, make catheters last far longer than they should, use starkly outdated equipment, and McGyver solutions for patients, like, "So we don't have a spirometer. How about you see if you can't blow up this balloon?" The rest of me says "Amputation is still extreme enough to stand out as some sort of cop-out because, well, it's amputation."

But, in an environment like what I described, it probably WOULD be totally reasonable if he got something like compartment syndrome, wouldn't it?

Hi @Tecumseh ! Thanks for getting back to me, sorry I know it's a pain when someone answers your question with more questions.

So actually I had an orthopaedics tutorial this morning and we were talking about tib-fib fractures and I was thinking of your case having read your reply with blurry 6am eyes. With the limited resources, him getting compartment syndrome or indeed osteomyelitis (if they don't have the right antibiotics) are both possibilities. The other option that I got to thinking about was just a poorly healed fracture. Mal-union is a complication of fractures where essentially the bones heal in the wrong way. It doesn't happen so often now because if we can, we fix fractures of big bones with nails and plates. But in your resource poor setting, could it be possible for him to just be put into a cast and maybe not re-Xrayed after reduction?

Basically what I'm thinking - but this is your story of course - is that they give him some morphine and manually reduce the fracture (ie. Push/pull his foot back into place) and they think it's all good, and if they don't do an XRay at this point the fact the bone is in the wrong place wouldn't be noticed. He's put in a cast/boot (after a few hours in a backslab/half cast to avoid said compartment syndrome), and he has that on for twelve weeks or however long and when he takes it off, he still can't weight bear, he still has pain and he still has a limp. The bone has healed in the wrong position and the only way to fix that is to rebreak it surgically.

Does that sound like something that could work? The type of fracture this would happen in would be spiral/oblique rather than transverse - eg there's a twisting element to it as well, so for instance he has his foot planted on the ground and is turning when he's hit. You probably don't have to put in such details but if you can have him on his feet (maybe fleeing the attacker) when he's brought down.

It's up to you of course. Amputation is definitely an option but I can see your point about worrying it's not relatable - but I wouldn't necessarily panic as off the top of my head I can think of two popular heroes - Augustus Waters and Peeta Mellark - who have leg amputations, and I'm sure there are others. But I do understand your concerns and if you've decided it's not for you I think mal-union would be a good alternative - so think of a painful, shortened, limping, non-weight-bearing leg. Would that do?

I know that I've been focusing a lot on bones, but that's because I believe (as a budding psychiatrist) that there's a huge psychological component to continuing pain following a soft tissue (eg ligament, muscle) injury, and I get the feeling what you're looking for is a really obvious physical disability from the injury, rather than a mixture of the organic and somatic.

Hope that's of more help!

Also I adore your ideas for a health system in crisis I might just have to read some of this story.

Sorry it took a while to respond!

Thank you very much for your help! I am not stapling him to a specific one just yet since I'm still sculpting but these are the concrete options, now, thank you very much!

I would like to go with the original idea that did have amputation just because I'm prone to trying to stick to my original ideas, but in the name of 'kill your darlings' I'm going to look at the alternative routes.

Also thank you re: the setting idea. I made the health system pretty alarmingly bad because the government is collapsing in a revolution. I was hoping to use his experiences at the hospital as a bit of a metaphor for just how bad his actual personal family situation is decaying, so the content can be interestingly related to his character arc rather than just a big info dump of how bad things are in the setting.

I am struggling with how to convey quickly just how bad the healthcare situation is without needlessly info-dumping, and I think I'm going to put him in a communal recovery room to do this, so he is far more likely to witness telling and concerning things and foreshadow that his own stay at the hospital will not give optimal results. However, deciding what is likely for a layperson like me to notice about a hospital is kind of hard, and so is deciding what is likely for a hospital or doctor to allow in a crisis.

I think one way for a hospital to cut corners would be resorting to using soda bottles for urine collection. My protagonist can look at the edge of a bed and see this liter bottle that very suspiciously looks like it should be holding Pepsi and go "That doesn't look right." It's not orthodox, but, I mean, it's not horribly unsanitary either?

Also I figure maybe I could have a side-character vent very quickly because of the severity of the situation. I am reluctant to do that because I don't want to write the whole 'HELLO, PATIENT. I AM EXPOSITORY DOCTOR. ALLOW ME TO SOMEHOW WORK IN THE FACT THAT...', but at the same time, what's going on behind the scenes is incredibly limited resources, so nurses go to warehouses to scour for parts, and boil/bleach gloves and needles to be able to use them again.

Surely someone would at least get frustrated enough to growl to themselves some little line like, "I TOLD him this would give her hepatitis," or "I TOLD him we should have changed the catheter sooner," or whatever without it feeling shoehorned in.

Hey @Tecumseh! Sorry, I've been super busy with my studies the past few days.

Funny thing is, right after I read your post, I went to see a patient and his urine was being measured in an open bottle xD I mean, the urine isn't going anywhere, so you're right, that's not the most unsanitary thing in the world, and the Pepsi bottle or whatever is a good idea!

Other things you mightn't think about:

Phlebotomy: e.g. taking bloods. This is something that will happen a lot in any ward setting. Firstly, the gloves are extraneous - the gloves are to prevent the clinician from giving themselves a needlestick and getting HIV/Hepatitis. But your MC might not know that but could still note that bloods are being taken without gloves. Secondly, needles get really blunt after four or five goes. This doesn't mean you can't use them, but they hurt. I remember talking to a man who was using heroin while in prison and explained that they all shared like three needles between thirty of them (I know, don't get me started), and it was like putting a rusty nail in your arm. ICK. Hopefully it won't get that bad but remember that a reused needle will be blunt, and a patient nearby might remark on how sore it is and "I don't remember it being this sore" "That's what happens when you have to sterilise and re-use needles." Or something similar. Thirdly - these days, we swipe clean an area that we're taking blood from with an alcohol/chlorhexidine wipe. As you can imagine, these are pretty expensive. You could go for some old fashioned iodine - yep, that yellow/brown stuff instead.

Painkillers. I was thinking about what they could cut down on that wouldn't you know, kill people, and painkillers was one that came to mind. These days in a hospital, any pain your patient is in, is too much pain. It's unacceptable for them to be in pain when under your care, essentially (unless they refuse painkillers which people do and that's fair and that's their prerogative, or if you've given them appropriate pain relief and the pain is still there, because whatcha gonna do)? But, pain won't kill anyone. So you could have people asking for painkillers and being refused and, because I assume the area he's in is for orthopaedic trauma, maybe he could witness/hear a shoulder being clicked back into place or something, without any morphine.

Staff. You know what the most expensive, most useful piece of equipment in an intensive care unit is?

The ICU nurse.

ICU has a nurse/patient ratio of 1:1, HDU of 1:2. In the rest of the hospitals here in Ireland it varies probably from 1:4 to 1:6, but we have a surplus of nurses (because we love them <3) compared to other countries, so maybe look that up. Point is, you could make a point of one nurse caring for a room of twelve people. You could have one doctor seeing your character at all times in their visit, progressively looking more tired, or making offhand comments about how they haven't slept in a week.

Surgery. Theatre is pricey to run, between the staff, the materials and the energy costs required. Maybe they've cut down to emergency surgery only, and someone is refused for something that isn't acutely life-threatening.

Investigations. MRI scans and CT scans are similarly expensive. Maybe the hospital is using XRay for everything? (even things it can't really diagnose at all). Blood tests cost more than people think, maybe a junior member of staff writes in his chart that he's to have daily bloods and a senior crosses it out and makes it every two days? Working in a resource poor setting is actually really interesting because it makes you depend on your own clinical diagnosis skills. I met a junior doctor in Kenya who was a more experienced clinician than probably a lot of seniors here - because to get so much as an X Ray, he had to send them to the next town over and it cost his patients money they didn't have. So instead he relied on listening to their history and examining them. It's skilful, and I'm tangential.

As for how to work your exposition in, if you've ever been on a hospital corridor, remember that staff hold their conversations there all the time. They try not to do it in patients' actual rooms, but the corridor of the ward is fair game. So it's not unreasonable that he might over hear a conversation. Maybe on top of everything they've cut down on the DVT prophylaxis - stopping people getting blood clots in their legs and eventually their lungs - because making every patient wear stockings is costing too much, and they've lost a bet and a woman has died from a pulmonary embolism. Or they decided not to operate on someone with a bowel obstruction and just watch and wait even though they felt reaaaaally uneasy about it, and boom, the person's bowel perforated and they're dead. Or maybe as you say, the needles transfer hepatitis C to someone. Remember that if your MC is nosey enough, they'll overhear everything that happens in the room - do you think curtains keep out noise? Nope! Hospitals are great for the keen eavesdropper.

Setting: The character is being held in place and stabbed through the torso, preferably solar plexus area, but it can be changed (other locations would be bellybutton area ooor heart/chest)

Cause of injury: A sword about 3 inches/7.62 cm wide goes through the person being held in place, entering the front and existing at the back. I'm wondering if it's possible her spinal artery got nicked, and if yes, enough to bleed?

Mandatory results: The character has to survive, which makes me think the heart has to get ruled out. Lung might not be? Past that, whatever's effective. I was also thinking she'd lose consciousness.

She herself is around 120-130 pounds, normative amounts of body fat, no surgeries/scar tissue, and a tendency towards low blood pressure.

Medical access: It's a modern day story where magic exists in a select group of people, so the wound would be sealed very quickly, within 5 minutes of the sword being pulled out. However, the magic involved cannot do things like replenish blood (it can, however, act as life support if necessary). There is another magic that is basically a deux ex machina for physical ailments, but I'm putting limits on it where it can only help stabilize whatever happens.

One member of the group is also a 5th year med student in a 6 year program who has a preference for urgent care and about 6~ years EMT experience

Thank you very much.

I've been in a hospital for about a week (visiting, not a patient), but it was a huge autopilot blur where I noticed basically nothing at all. The only thing I really remember is other patients when I visited their rooms since I stayed there so long, but the doctors and nurses not so much.

You've been very helpful!

Hey Stella! I was wondering what type of injuries could happen if say, a character jumps from a top floor and ends up being blown back two floors below? It's a little like what happened to Elvita Adams except for this scene, the character tackles someone else, sending them both off the top floor. Here's an idea of what it looks like, more or less.

Oh hey friends. Your questions will be keeping me company on my bus journey home from college for the weekend

@Rosendorn - please feel free to refer to my previous answers about stab wounds on pages one and two for more info

so I had a thought about your predicament last night and even asked my boyfriend about it - whose first response is, "Three inches? That's huge! That's a great sword. You don't stab someone with that, you slice them in half." I have to admit, he's right. Three inches is, in the grand scheme of stab wounds, a very large stab wound - when you consider the liver, for instance, is about 10-12 cm in height and your heart is the size of your fist which for someone like me is about three inches across, and your aorta is 2-3cm across. Organs -- a lot smaller than you think!

But I came to the conclusion that with a wound that size, a midline wound (i.e., in the centre), would be catastrophic. First of all, running straight down the back of your back is, uh, your spine, which I get the feeling you're not looking to transect. In front of that is your aorta - cut her aorta and she dies in less than a minute, and to the immediate left is the inferior vena cava - I mean it's probably not as bad but I'd imagine you die pretty quick. The spinal arteries are pretty, uh, whimsy in comparison, but I can't see how stabbing you through the front is going to damage one of those without all this other stuff getting in the way.

Anyway, presuming you're not looking to transect her spinal cord with a sword, you could always go to the immediate right. In the epigastrium (I never knew that's what "solar plexus" meant! Apparently the solar plexus is what I've learnt as the celiac plexus, but we call the anatomical area the epigastrium - the more you know ), this would mean damaging the stomach, maybe the first part of the small bowel (it and the stomach are one and the same), maybe the pancreas and bile ducts. Presuming you've missed the aorta and the spinal cord, none of these are huge bleeders - the spleen, further over into the top left corner of your abdomen is - but they will release all of their contents into your abdomen and cause lots of irritation and infection. Gross.

I get the feeling that you're really looking to stab her through the centre of her body, but stabbing someone there and keeping them alive, if you are dead set on running her through and through is probably implausible. Unless magic.

I'm not sure what medical facilities are available to them but your medic character is going to attend to her according to the trauma guidelines every med student learns, ABC - Airway, Breathing, Circulation. If she's losing consciousness, they'll want to give her an airway - he won't know how to do this unless he's spent time with anaesthetists (I tried to intubate once in a controlled setting in theatre and it's absolutely freaking terrifying, let alone the fact that in this situation it'd be his friend, in a stressful situation, with no help around them and if she's been stabbed in the stomach she may be vomiting blood but also he probably won't have the materials there to intubate so this tangent is useless). Next, Breathing - he'd want to give her oxygen: blood loss means you lose your oxygen carrying abilities, so more oxygen is better - we lash every trauma patient onto 100% via a mask. And Circulation - he wants to stop her bleeding and replenish her circulating volume.

I know last night in chat you were talking about transfusion but transfusions are dodgy and wouldn't be done unless absolutely necessary, and besides, probably not until she's received at least 2L of some other fluid via a vein. So he'd want to site two wide bore cannulas, one in each elbow, and just start pouring fluids into her.

Whether or not these measures are possible, there's still other things you can do that you would do even during active resusciation. Pressure on the wound, pressure, pressure, pressure. Stop her blood going onto the floor. Elevate her legs to keep all her blood going to the important places and just squeeze those wounds as tight as you can, whatever way you can.

With such a big wound she's going to probably need surgery. Or magic. One or the other.

@EscaSkye - xD That's one of the most bizarre stories I've ever heard. But cool! So really, it's going to be a sort of side on impact she's going to get, rather than the force of her whole body being pulled towards the ground by gravity, it's just the force of the wind pushing her in. I didn't do physics, but I'm going to guess that the injuries are going to be a lot less severe. The lady in the article hurt her hip, and I think that a pelvis fracture or a shoulder fracture might be the most believable - essentially the point of the body that hits the floor/wall/whatever first if that makes sense. It could be her head and she could get a brain haemorrhage and a broken neck and die but I feel like that's not what we're looking for? I would say the pelvis (which would be decidedly the more serious of the two) or a broken shoulder/humerus would be your best bets. But honestly, you can play with this - if you have an idea of what sort of injury you want, and you want to ask me if it's plausible or whatever, feel free to get back to me

Hope I helped, guys!

-Stella x

I don't have a question right now, but I have to say I've been learning more from this thread then like anything else ever. You're awesome, Stella!

Hey Stella, it's me again xD, hope you've been good.

Anyway, to the query.

I want my character's eye to go grey (preferably like a cataract).

Can this happen through trauma? If not, what happens to the eye if you were to theoretically get kicked in the eye-socket, hard enough to crack/crush it?

Thanks

Hey Deskro! Sorry I took so long to get back to you, this week has been really crazy for me.

Unfortunately, although ophthalmology was a couple of years ago, from what I remembered, you can't get leukocoria (a white or grey eye) from trauma, but I wiki'ed (https://en.wikipedia.org/wiki/Leukocoria) and one of the things that is mentioned but not elaborated upon is 'corneal scarring'. Your cornea overlies your eye and it can, apparently, which I didn't know, scar to a sort of cloudy grey colour which might be what you're looking for. This happens if your cornea is cut or burnt, and that'll probably cause damage to your vision as well. Unfortunately the scarring will be treated only by corneal transplant.

In terms of being kicked in the eye, again this is a while back for me, but about three years ago I did a project on orbital blow-out fractures. Basically your eye is kept in its socket - the orbit - and the orbit can be broken in several different but quite distinct ways - to the side, to the bottom. Usually it's the bottom, unless the force came from the side. If it's in the bottom of the socket, your eye looks physically dropped down. A foot would be too big to cause an isolated orbital fracture though, I think - the most common cause is squash balls, and I would assume cricket balls, but most other things are too big to be that targeted if that makes sense? But it could happen. Though what's more likely would be a complex facial fracture or broken nose. That said, you can 100% go for an orbital fracture, after all this is fiction, so suspension of disbelief and also, most people won't know any of this stuff enough to think "hm, that seems an unlikely way for his face to go."

The most dangerous thing about an orbital blow out fracture is that you can impinge on the nerve and artery of the eye and the nerve can quite literally snap. Gross. Treatment is, again, surgical, this time by lifting the eye back up, fixing the hole and putting everything back into place. I don't really know what they did for eyes before surgery - guess that's why there are so many one-eyed people in historical movies!

I'm sorry that this isn't a topic I'm 100% au fait with, but hopefully that's enough to keep you going

Hey Stella! In my current novel I'm planning on having my characters exposed to carbon monoxide and subsequently suffer carbon monoxide poisoning, although not to an extent where it's fatal. From a bit of the reading I've done so far, I've read about exposure to CO causing hallucinations and the sensation of being 'haunted', which is mostly what I'm interested in for my story. How long-term does someone have to be exposed to CO to start developing 'haunting'-like symptoms (and any other symptoms I should think about) - I'm guessing concentration would speed up the process? Is it a matter of being exposed for weeks/months or could symptoms start showing quicker if there's enough CO in the air?

Also, how long would the treatment process take, if my character were to have CO poisoning? I sort of know the vague process (we studied it briefly in chemistry last year in terms of equilibrium, so I kind of know the chemistry behind it, but not the actual biological effects! XD), but any information about how long my character would be in hospital, what would be going on, etc would be super helpful. Basically any insight about this would be super helpful XD.

Thanks in advance!

Hey @TriSARAHtops! Carbon monoxide poisoning, wow, that's a cool plot point!

Essentially the main symptoms of CO poisoning are those of having the flu or, well, being hungover. In fact I remember a teacher telling me in school that young people on cheap holidays can often suffer because when they wake up in their cheap rental flat with a dodgy boiler in the morning, the headache they have isn't unusual.

You're right that concentration plays a big role. When CO binds with haemoglobin, you probably learnt it has much more affinity for haem than oxygen does, so it makes it really hard for oxygen to upset it and push it out of the way. But because haemoglobin can bind four oxygen molecules at once, CO actually increases the binding affinity at the other three sites - which sounds like it would be a good thing, except that that means it can't let go of the oxygen at tissue level to oxygenate your tissues. The result is hypoxia/ischaemia -- cell death.

I didn't know about the "haunting" thing, but memory loss and confusion are two main symptoms and hey, why not combine those to make it something even cooler? To make it work for your story, you're probably looking for chronic exposure rather than acute - your characters come home each night to a dodgy boiler and breathe in a little bit more just as the stuff from that day is being eliminated (it lasts say about 24 hours). This can start suddenly, or build up - it just depends on what the concentration of CO is, as you said, so you just need to decide what you want and what mechanism they're going to be exposed to it.

In terms of treatment, like most patients we throw people with CO poisoning onto 100% oxygen - it can't hurt. I can't imagine they'd be in hospital more than a day or two - but depending on their symptoms it could be longer, like if they have serious psych problems, they might have to stay to be reviewed by other teams. Anyway, brought in through the emergency department, they'd be assessed - a history taken, exam done. I would like to assume at this point they know it's carbon monoxide, otherwise they could spend a while trying to work out why a young person has malaise and confusion (in an older person, the answer is infection). If their history is known, yay, much easier! Anyway, they're given 100% oxygen via a non-rebreather mask - that's a mask with a bag on it, unless they're unconscious in which case they'd be intubated and the same thing done in ICU.

Another more hippy method is hyperbaric O2 therapy. A quick aside - I only know about this stuff because once upon a time my handbag got stolen and some guys at the hyperbaric O2 therapy place found it. Basically, this pushes oxygen into the body by giving it at really high pressure - I don't understand physics, but that's the gist of it. That's a quicker way of doing it, but hyperbaric O2 is not readily available in hospitals but always something fun to keep in mind.

Also, not that it's probably relevant since you don't want this to be fatal, but the bodies of those who died of CO poisoning have a "cherry red hue" - CO makes your blood redder than normal. Fun fact.