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  What Wounds Would Result from an Attempted Suicide with a Gun Placed Under the Chin?

  Q: If a character commits suicide by firing a handgun placed under his chin, and the gun is loaded with "hot loads" (overpowered magnum rounds intended for use against vehicles and similar targets), what kind of ballistic results could be expected? Would the resulting injury produce a relatively small hole due to overpene-tration, or would the mushrooming effect obliterate most of the skull; in other words, is there sufficient resistance to the bullet to cause it to mushroom? Is there a chance of survival, or is this technique highly effective? Aside from "gray matter," is there likely to be much blood?

  A: Yes, this is effective and virtually 100 percent fatal provided the gun doesn't slip and the angle change. I saw a man years ago who placed a shotgun under his chin and pulled the trigger. He had angled the barrel slightly forward and opened his face as if someone had cleaved it with an axe. The shot never entered the skull and he was neurologically intact and awake when the paramedics arrived. A plastic surgeon and a neurosurgeon put him back together. But short of such an odd occurrence, this type of approach is uniformly fatal.

  Typically, the entry wound is relatively small and the exit wound large, likely removing the entire skullcap and most of the brain. There would be a great deal of tissue and blood. However, a bullet coated with Teflon or otherwise manufactured to "penetrate armor" probably would not "mushroom," and therefore both entry and exit wounds would be small and there would be less tissue and blood. Still effective, but less messy.

  Can a Traumatic Miscarriage Prevent Future Pregnancies?

  Q: I have a character who is three months pregnant. She is injured in an automobile accident and suffers a miscarriage. Later the doctor tells her she can never have children again. Is this possible? What would have to happen to her to make future pregnancies impossible?

  A: Yes, your scenario is possible.

  First, let's deal with the accident and the miscarriage. Blunt trauma to the abdomen as occurs in auto accidents (AA) can result in miscarriage. In AAs the seat belt itself can injure the lower abdomen and thus the uterus. If no seat belt is worn, collisions with the steering wheel, dashboard, or seat back (if she is sitting in the backseat) can result in similar injuries. Falls down stairs (a Hollywood staple for this scenario) and kicks or punches, as can occur in domestic abuse situations, can lead to similar injuries.

  During pregnancy the fetus floats inside the uterus in amniotic fluid, which serves as some protection from trauma. But if enough force is applied, the fetus can be injured or killed. Or the placenta that nourishes the fetus and is attached to the inner wall of the uterus can be torn loose. Bleeding into the uterine cavity or loss of placental support for the fetus can result in fetal death and miscarriage. In severe trauma the uterus can rupture, and the fetus and even the mother can be lost. As the uterus expands during pregnancy, its walls thin, and it becomes increasingly prone to this catastrophe with each passing month.

  If the uterus is intact but the fetus is no longer viable, a dilatation and curettage (D and C) must be done to remove the dead fetus and placenta. Dilatation means the dilating or opening up of the cervix, which the surgeon must do to reach the inside of the

  uterus. Curettage is the removal of material from the walls of a cavity—in this case the fetus and placenta from the uterus. If the uterus ruptures, a true medical emergency exists, and surgery must be performed immediately to save the mother. Often the uterus must be removed under these circumstances, though at times it can be repaired and salvaged.

  To make future pregnancy impossible, either the uterus itself or its delicate lining would have to be damaged to the point that implantation (the attachment of the fertilized egg to the uterine lining) can no longer occur. Or the uterus could be scarred in such a manner that even if implantation does occur, the uterus cannot support fetal growth and development. After trauma and a D and C, either of these is a possible outcome. Obviously, if the uterus is removed (hysterectomy), pregnancy is precluded.

  If your character suffers a uterine rupture in the AA, she would have severe lower abdominal pain and vaginal bleeding, and it is likely she would go into shock: She would be pale, cold, sweaty, delirious, or unconscious, and have a very weak pulse and low blood pressure. The paramedics would begin IVs, give lots of fluids such as D5LR (5 percent dextrose in lactated Ringer's solution), administer oxygen, and speed to the nearest hospital or trauma unit. She would be taken to surgery almost immediately for an emergency hysterectomy. Recovery, if all went well, would take five to seven days in the hospital and then six to eight weeks at home. Of course, the tremendous psychological stress this would cause might take years to overcome.

  What Are the Symptoms of a Concussion?

  Q: If my character is struck on the head with an object and knocked unconscious for ten or fifteen minutes, what symptoms will he have when he wakes up? Amnesia? How long will these symptoms last?

  A: In medical terms, this is called a concussion. It is a transient loss of consciousness or alteration of consciousness (dazed) associated with some degree of amnesia. This typically occurs in blunt trauma to the head as you describe or in deceleration injuries that occur in auto accidents, falls, and so forth.

  The mechanism of the loss of consciousness appears to be a disruption of the electrophysiologic function of the reticular activation system (RAS). This is an area at the base of the brain that is responsible for maintaining consciousness. The blow seems to scramble its electrical circuits for a while, resulting in loss of consciousness. The mechanism of the amnesia is unclear.

  The symptoms associated with such injuries vary, but headache, dizziness, and amnesia are common. Lethargy and confusion are less common. Ringing in the ears and blurred or double vision are even less common. Also uncommon are seizures.

  These symptoms may last a few minutes, hours, or days. In some people they may last for weeks or months. Professional football quarterbacks and boxers seem particularly prone to concussions. Steve Young and Troy Aikman each missed from one to several weeks of football after their many concussions because their symptoms—mostly dizziness and headache—lasted that long. A knockout (KO) in a boxing match is simply a concussion.

  The amnesia may be just for the period of unconsciousness, may continue for a short while after the injury, or may be retrograde so that the victim doesn't remember things that occurred prior to the injury. For example, people who suffer concussions in auto accidents may not remember getting in the car, leaving home, or where they were going.

  If the victim suffers a seizure after the blow, a complete neurologic evaluation should be undertaken to rule out the presence of damage to or bleeding into or around the brain. Skull and neck X rays, CT scans or MRIs, and hospital admission for observation are recommended in this situation.

  The treatment for an uncomplicated concussion is time and the avoidance of any further trauma. For headache, Tylenol, aspirin, Darvocet, or Vicodin may be prescribed as well as other analgesics (pain relievers). For dizziness, Dramamine, Meclizine, and Antivert are often used. These are the same medications used for motion sickness. Typically, the victim returns to normal in a few minutes, a few hours, or a few days.

  What Happens When You Get the "Wind Knocked Out of You"?

  Q: My character suffers a blow to the stomach and gets the wind knocked out of her. What really happens? How long will it take her to recover?

  A: When someone receives a severe blunt force injury to the solar plexus—the area of the abdomen between the lower end of the sternum (breastbone) and the umbilicus (belly button)—she actually stops breathing for a few seconds. Many of the nerves that leave the spinal cord and spread out to all parts of the body pass through relay stations called "ganglia" (the singular is ganglion). Several of these ganglia lie behind the stomach, near the aorta. The major ones are the celiac ganglion and the superior and inferior mesenteric ganglia. Together they are often referred to as the solar plexus.

>   A sharp blow to this area causes these ganglia and nerves to release massive and erratic impulses for a few seconds. This in turn causes the diaphragm to spasm, or cramp. The diaphragm is a muscular partition between the chest and the abdomen, and its movement draws, air into the lungs and forces it out of the lungs. When it spasms, the person cannot breathe, and thus the wind is knocked out of them.

  The symptoms are pain (from the blow and from the spasm of the diaphragm—think leg cramp or charley horse)—and the feeling of smothering from the inability to breathe. Often the person's eyes

  will water, she will bend over or drop to the ground, and she will try to take in air, which can't occur until the diaphragm relaxes and returns to normal function. Fear plays a great role here, because the person feels as if she may never be able to breathe again.

  Fortunately, within a few seconds (five to twenty or so), the nervous system regroups, the diaphragm relaxes, and breathing resumes. These few seconds are, of course, an eternity for the one who can't breathe. After that it takes a few minutes for the victim to recover completely, and then she would be able to do anything. She may experience mild residual soreness from the blow and the diaphragmatic spasm, but overall she would be normal and have no long-term injury.

  What Injuries Occur When Someone Is Thrown Down a Stairway?

  Q: My protagonist tosses two twenty-something hoods down a short set of concrete steps. Following this encounter, for plot purposes I need each hood to be physically incapable of pursuing my protagonist for different lengths of time—one for several days, and the other for a full week or so. The former must be conscious during his period of incapacitation or hospitalization, but not necessarily the latter. Additionally, the former must recover to the point where he can still do my protagonist serious bodily harm should the two meet again. Can you offer some suggestions for the type of injuries the two hoods could suffer and meet my plot criteria?

  A: A tumble down stairs offers several realistic opportunities for injury. Either of your hoods could suffer any of the traumas I'll detail, the difference being severity.

  Fractures

  Concrete stairs can fracture bones—arms, legs, shoulders, hips, ribs, and skulls. Any of these could prevent the hoods from immediately chasing the hero, particularly skull, leg, and hip fractures. Each of these would require several weeks for full recovery.

  Hip: A hip fracture would require surgery and the hood would be laid up for months. He would be conscious after his fall but wouldn't be able to chase your hero for at least four to six months.

  Skull: With a skull fracture the victim could be conscious or out for minutes to several days. Your choice. Recovery would be a couple of months, and while it wouldn't be advisable for him to fight anyone, he could. In fact, if he were a tough guy, he might be able to fight in a few days. Hell of a headache, but possible. I doubt most readers would buy this, though. A skull fracture might work for hood number two.

  Leg: A fractured femur (upper leg) is similar to a hip fracture and would require surgery and months of recuperation. A fracture of either the tibia or fibula (lower leg bones) may or may not require surgery but would require a cast for four to six weeks.

  Shoulder: Fractured shoulders often need surgery, but if the shoulder joint is only dislocated, probably not. He would be out of action for several weeks if surgery was required but only a day or two if dislocated. However, he would be in considerable pain and would be "one-armed," if that works for you. In shoulder separa-tions or dislocations the arm is typically strapped against the body for a few weeks until the torn and strained ligaments heal.

  Arm: A fracture of the humerus (the upper arm) is a similar situation to a shoulder fracture. A fracture of the radius or ulna (lower arm bones) would require a cast for several weeks. The victim would be left to fight with only one arm, though a cast makes a great weapon.

  Rib: Assuming the fractured rib didn't puncture the lung, he would be very sore for a few days and fairly sore for a few weeks. He could renew his pursuit of the hero after several days. This might work for hood number one. The pain from a fractured rib can be severe and is usually sharp and stabbing; it is made worse with breathing and movement of the shoulders or chest. The villain could fight but would be in considerable pain.

  If the rib punctured and collapsed the lung, his hospitalization and recovery would be longer and more complicated.

  Head Trauma

  A concussion would work well since the victim would be "out" for minutes to hours and then would be okay except for a residual headache. Other residual symptoms might be dizziness, mild nausea, blurred vision, and a stiff neck. These could be mild or severe, and could last for a day or two or up to several weeks. The victim could return to battle in a day or several days if you wish. Either works medically Think NFL quarterback.

  Muscular Strains

  A muscular strain of the back, especially the lower back, would make immediate pursuit impossible but would likely abate after several days of treatment with pain medications and muscle relaxants. Then he would be able to attack the hero with little limitation. Or he could have continued pain and stiffness, which would hamper his ability to pursue and fight.

  Internal Injuries

  A fall down concrete steps is similar to an automobile accident. All sorts of internal injuries could occur. Lacerated livers, ruptured spleens, and fractured kidneys would require surgery and a prolonged recovery. A contused (bruised) kidney might work for you. Here the trauma of the fall bruises the kidney, causing flank pain and bloody urine. Recovery would be a few days to a few weeks, after which he could chase and fight with your hero. A little sore, but functional.

  Hood number one could have a muscular strain, concussion, rib fracture, or contused kidney, and would not be unconscious during recovery and would be able to fight again in a few days.

  Hood number two could have more serious fractures (hip, leg, shoulder, skull) or a more severe concussion (even with a bleed into the brain), a rib fracture with or without a punctured lung, or internal injuries. He could be in a coma for almost any period of time, or he could be awake throughout. His recovery could take weeks to months.

  What Injuries Occur in a Fall onto Rocks?

  Q: For my story, I need to know what general or specific damage might a man incur if he is shoved off a cliff, falls 60 feet, and lands on craggy rocks. Is a 60-foot drop long enough to guarantee death?

  A: A 60-foot fall onto craggy rocks is universally fatal unless a semi-miracle occurs. People have jumped from planes with parachute failure and lived to tell about it. These cases are extremely rare, however, and the people usually land in a recently plowed field or something equally as forgiving. Needless to say, this is not a common occurrence.

  The fall would break arms and legs and skulls and spines; mush kidneys and livers and lungs and spleens; and rupture stomachs and colons and bladders and aortas. A mess, to say the least.

  With this type of fall you generally have carte blanche regarding the types of injuries you want the victim to suffer as long as they are severe. There are no minor injuries in this situation.

  If the body is discovered during the period of rigor mortis rigidity, it will be stiff and "frozen" in the position the victim was in at the time of death. Remember, rigor comes on during the first twelve hours and then resolves over the next twenty-four. If the body is discovered before or after that general time frame, it would be limp, and when the victim is lifted, the bones might crunch and grind as if he were a bag of marbles.

  Of course, many of the fractures might be compound, meaning the broken bones puncture the skin, and the abdomen or chest may have ruptured. Also, the craggy rocks may cause lacerations and deep tears in the tissues of the arms, legs, abdomen, and chest, or they may penetrate the skull directly rather than the skull's being fractured from the impact. Not pretty.

  What Is the Likely Cause of Death in a Fall Downstairs?

  Q: Is it possible for a female character, age thirty-four, to fa
ll down a flight of fourteen exterior steps and die? She is drinking heavily all night and wearing five-inch spike heels. Is there anything special she would need to fall on? What would cause death? I thought she could hit her head, but do you have any other thoughts? If someone shoved her, would there be any way to tell during an autopsy?

  A: This type of death happens every day, especially to people "under the influence." Steps, ladders, and bathtubs are the most

  dangerous places in the average house. A fall down fourteen steps could result in severe and deadly injuries, and in many ways it is similar to an automobile accident.

  Death can result from many different injuries. Rupture of the liver, spleen, or another internal organ can lead to internal bleeding and death. A fracture of the femur (the upper leg bone) would be a likely injury and could also be lethal. When the femur is shattered, its sharp edges can lacerate the large arteries and veins of the leg, and massive blood loss and death can follow. If the bone punches through the skin (a "compound fracture"), bleeding would be through the puncture and out of the body. But even if a compound doesn't occur and the skin remains unbroken, massive and lethal bleeding can still occur. The thigh can hold a few quarts of blood, which may be enough to cause shock and death.

  However, a head or neck injury would be best. Either a broken neck or an intracranial bleed, which is bleeding in and around the brain with or without a fracture of the skull, would fit your scenario well. Death can be instantaneous or may take minutes, hours, or even days.

  A shove would not likely leave any marks that the coroner could identify. At autopsy the M.E. would find an intoxicated woman with either a neck fracture or a bleed into the brain, and could easily conclude the death was accidental.