tmp3EC8 Read online

  A: The shoulder is one of the most—if not the most—complex joints in the body. Its range of motion is wide. It can hinge like the knee, rotate like the hip, and even whirl around in a circle like a windmill. It is basically a ball-and-socket joint, with the ball being the head of the humerus (upper arm bone) and the socket being formed by the glenoid cavity and the acromion of the scapula (shoulder blade). The above-mentioned portions of the scapula, the several ligaments that hold the humerus and the scapula together, and an inner lining of cartilage, which provides a smooth friction-

  free cuplike enclosure for the "ball" of the humerus to move within, form the joint capsule.

  A dislocation occurs when the ball is forced out of the socket. Direct trauma to the shoulder or a severe torquing of the arm are the usual causes. Football players, gymnasts, and children yanked up by their arms are common victims of this type of shoulder injury.

  The pain is immediate and severe, but once the dislocation has been "reduced" (the ball returned to the socket), the pain is minimal at that time. However, over the next several hours bleeding into the joint occurs, the muscles around the joint spasm (contract) in an attempt to stabilize the joint, and the pain returns. Any movement in any direction results in a knifelike stabbing pain in the shoulder. The first three or four days are the worst, but pain and limited motion may last for weeks or months. I have personal knowledge here—nine times. Football is a great sport.

  Reducing the dislocation (manipulating or popping it back into place) can be accomplished in several ways. Sometimes merely raising the arm outward will pop it back into place. If another person is present, that person can drape the injured arm over his own shoulder (with the victim standing behind him) and lift the victim up on his back by bending forward. This pulls the humerus forward and outward, and often it will slip back into the socket. This can also be accomplished by laying the victim on his back, grasping his wrist, placing a foot against his chest near his axilla (armpit), and pulling his arm out to the side. This will pull the humeral head outward, and it often reseats itself in the socket. (Don't try any of these unless you know what you're doing because if it is done improperly, further injury may occur.) In your situation the victim could tie a rope around his wrist, attach the other end to a tree or rock, and pull the arm out to reduce the dislocation.

  The sooner the shoulder dislocation is reduced, the better. Once the muscles spasm, reduction may be very difficult. Also, the nerves and blood vessels that go out to the arm pass beneath the shoulder, through the axilla. The pulse of the subclavian artery can be felt in

  the armpit. The dislocation can damage these vital conduits, and short- and long-term problems can result. Vascular damage can lead to ischemia (poor blood supply) of the arm, hematoma (a large collection of blood) formation, and possibly the development of an aneurysm (swelling of the artery). Nerve damage can cause loss of motor function (paralysis or weakness) and abnormal sensory function (numbness, tingling, loss of coordination, or diminished sense of touch and feel).

  If the shoulder cannot be reduced, the injured person's limitations would be severe. He could not move the shoulder, and if the nerves were damaged or stretched, he might not be able to use his hand. If the dislocation was reduced, he would be able to function well for a few hours until the spasm sets in. After that the shoulder would be "frozen" and very painful with even the slightest movement. He should be able to bend his elbow and use his hands without a problem.

  The typical treatment of a simple dislocation is to reduce it, place the arm in a sling, which is strapped to the chest to prevent shoulder movement, administer pain medications, and give it time to heal. If the injury is more complex, with severe damage to the joint capsule or with vascular or nerve injury, surgery may be required.

  It would take several months for the shoulder to heal completely, but with a simple dislocation he should be able to move the shoulder carefully and do most things after a couple of weeks.

  What Are the Symptoms and Treatment of a "Sucking Chest Wound"?

  Q: I have a question about sucking chest wounds. I've written a scene in which a Vietnam War veteran applies a modified field dressing to his buddy's chest wound roughly ten minutes after the injury is sustained, but I

  wonder if I'm stretching credibility by having my victim able to conduct a conversation with my hero. What do you think? Is the injured man likely to survive?

  A: First, let's look at "sucking chest wounds." I know, I know, having any wound to the chest sucks, but there is a real medical entity that goes by this moniker. Any object that penetrates the chest wall and leaves behind an open wound would result in a sucking chest wound. In a gunshot wound (GSW) to the chest, the bullet typically makes a small hole as it travels through the tissues of the chest wall. These tissues are elastic and tend to recoil and collapse around the path of the bullet, closing it off and obliterating any opening to the outside. This may penetrate and collapse the lung, and it may be fatal, but it isn't likely to produce a sucking chest wound. The exit wound, however, may be large enough.

  A larger wound, such as from explosive shrapnel or a spear or a highway guardrail in an automobile accident or the above-mentioned GSW exit wound, will not close in this fashion simply due to the larger diameter of the wound. This leaves an opening to the outside.

  Breathing, drawing air into the lungs, depends on the production of a negative pressure within the chest as the diaphragm lowers and the chest expands. This pulls air into the lungs. During exhalation this process is reversed, and air is forced back out of the lungs. Close your mouth, pinch your nose, and try to breathe in and out. Negative pressure during attempted inhalation and positive pressure during attempted exhalation are produced, but no air moves because you have created a closed system and there is no opening to the outside through which air can enter and exit.

  With a wound that produces a large enough opening in the chest wall, the normal expansion of the chest during inhalation sucks air from the outside, through the wound, and into the chest cavity, in the space between the lung and the chest wall. With exhalation air is forced back through the opening and out of the

  chest cavity (Figure 5). The lung on the injured side will collapse, and a sucking sound is made with each inhalation and exhalation as air moves back and forth through the wound—thus the name "sucking chest wound." Fortunately, each lung is self-contained on its side of the chest, so that the lung on the uninjured side will remain inflated and function normally.

  No, waiting ten minutes for help isn't a problem. Even an hour is okay if the person is otherwise healthy. The victim would survive and be able to speak with only one lung for quite some time. He would be short of breath, cough a lot, and be in pain, and fear would be a big factor, but he would live.

  The dressing applied should be "occlusive"; that is, it should seal the opening in an airtight fashion. A porous gauze wouldn't do. There are several types of plastic-coated bandages that stick to the skin and make an airtight seal. Also, a sheet of plastic wrap, a plastic

  food or trash bag, or a piece of cellophane would work. If only gauze is available, it should have some salve such as petroleum jelly, butter, or mud applied to it; that would make it airtight or nearly so.

  If the lung itself wasn't also punctured, some re-expansion of the lung would occur while the victim awaited transport to a facility for definitive treatment. Once at the hospital a surgeon would repair the wound and place a thoracostomy tube (or chest tube). This large-bore plastic tube is slipped through the chest wall and into the chest cavity between the lung and the chest wall. Suction is applied to the tube in order to reinflate the lung. After a few days the tube is removed. The victim should recover and do well if this is his only injury.

  /

  ENVIRONMENTAL INJURIES AND THEIR TREATMENT

  What Happens When Someone Dies from Exposure?

  Q: What does it mean when someone dies of exposure— not freezing to death, just exposure?

  A: "Exposur
e" is a broad term that covers deaths from freezing, heatstroke, starvation, and dehydration. In short, if the victim is in the middle of nowhere and doesn't die from injury or illness, then exposure is what did it. He didn't have food, water, or shelter. So to answer your specific question, if cold or heat isn't a factor, then lack of food and water is the likely culprit.

  What Happens When Someone Dies from Dehydration?

  Q; What's it like to die of dehydration? Delirium? Extreme thirst or the opposite? Does the mind fool the victim into seeing mirages? How long would this process take in an elderly woman lost in the mountains during the summer?

  A: Dehydration is when the body loses water. This loss occurs due to sweating and through the lungs during normal breathing

  (called "insensible loss," since we are unaware of water lost in this fashion). The drier the air is and the more rapid the breathing, the more water will be lost through the lungs. Literally quarts of water can be lost this way. Any activity such as walking, running, carrying a backpack, or climbing increases the rate of breathing and, thus, insensible water loss. Hot and dry climates lead to more rapid water loss, though the dry air in winter mountains can cause considerable dehydration even though the temperature is low.

  The time required for dehydration to appear depends on these and other factors. The process can take only hours if the weather is very hot and dry, or it can take a few days if it is cloudy and cooler.

  In severe dehydration the blood pressure falls as the loss of water from the body reduces the blood volume. Also, electrolytes such as sodium, potassium, and magnesium are lost through sweating, which can lead to muscle weakness and cramps.

  Thirst, an early symptom, doesn't appear until considerable loss of water has occurred. This means that by the time thirst develops, the person is already well into dehydration. Thirst is followed by fatigue, shortness of breath, weakness, muscle cramps, nausea and sometimes vomiting, delusions, delirium, and finally collapse, coma, and death.

  With a high ambient temperature, body temperature can rise dramatically, and once it gets above 103 or so, the mind isn't as sharp as it should be. The victim will not be able to think well and may literally wander in circles or hallucinate. Mirages can be seen as a result.

  Of course, mirages are due to the physics of light. Heat rising from a desert or a road bends light rays due to changes in density of the air (hot air is less dense than cooler air). The result is that you see blue sky below the horizon, and it looks like a body of water. Often a person who is dehydrated and confused will rush blindly toward it but can never reach it because it doesn't exist and because the optical illusion keeps moving away, so to speak.

  The young and the old are particularly susceptible to dehydration and heatstroke since they tend to have less muscle and tissue

  mass in which to store water. They dehydrate faster and show the signs and symptoms of dehydration earlier and more severely.

  In your scenario both the summer heat and the altitude would conspire to hasten your lady's dehydration. The heat would increase sweating, and the low water vapor pressure (meaning the air is dry) that is found at higher altitudes would accelerate insensible loss of water through the lungs. Another factor would be her degree of hydration at the time her adventure began. If she was already a little dry, she would get into trouble more quickly. Also, as explained above, the more active she is, the faster she would dehydrate. If she sits in a cool spot and waits for someone to find her, she might survive for several days. If she attempts to walk over hilly terrain, she might not last twenty-four hours. Obviously, if she has any underlying heart or lung disease or perhaps diabetes, her survival time would decrease.

  What Is the Treatment for Dehydration?

  Q: What's the first aid treatment for dehydration? In my story a forest ranger comes across a severely dehydrated and weakened hiker. He carries the young man to safety. But what would he actually do? Dribble water between his lips and get him to a hospital? Then what? An IV with a glucose drip?

  A: That's right. Get water in any way you can safely do it, such as sips or dribbles at first, depending on the condition and level of consciousness of the victim. Other treatment depends on whether heat prostration or heatstroke is present.

  If the environment is cool or cold, as in the mountains or snowy areas, wrap the victim in blankets, towels, or sweaters since dehydration in these circumstances often leads to a drop in body temperature. Typically, the victim of this type of dehydration feels cool

  to the touch and appears pale. If the dehydration is severe, the blood pressure will be low and the pulse weak and thready, and confusion and disorientation are likely. Giving fluids (preferably warm liquids) and warming the victim are the major frontline treatments.

  In your story, heat prostration and heatstroke are more likely since the ambient temperature is high. These two entities are similar, with the latter being more severe. Both are caused by dehydration and rising core body temperature. Common victims include runners, football players, construction workers, military personnel, and anyone who exerts himself in hot climates, such as your hiker. Sweating in these situations is typically profuse, so dehydration can occur rapidly.

  We use the term "heat injury" as a broad category for anyone who develops significant dehydration and an elevation of body temperature. Early in heat injury (heat prostration) the victim may sweat, but as the process continues and the core body temperature rises, sweating ceases, compounding the problem by the loss of the body's natural radiator system (resulting in heatstroke). The reason this occurs is that the body's innate self-preservation actions divert what blood volume there is toward vital organs such as the heart and brain, and away from the skin. But it is blood flow through the skin that acts as the radiator to dissipate the rising body heat. The body actually works against itself, and the core temperature rises rapidly. Body temperatures of 105 to 108 are not uncommon. Thus, victims of heatstroke may appear flushed and often feel warm and dry to the touch. Heatstroke has a high mortality if not treated quickly and aggressively.

  Whether the victim is suffering from heat prostration or heatstroke, the treatment is directed toward lowering the body temperature and replacing the lost fluids. These measures should begin immediately and should not be delayed in order to transport the victim to a hospital. Cool the victim by sponging with water or any cool liquid, and fan with a towel, shirt, or anything

  handy. This lowering of the core body temperature is as important as relieving the dehydration by giving fluids. In fact, when a victim of heatstroke appears in the hospital emergency room, we often place him in a tub of ice water to rapidly lower the core body temperature. The brain does not tolerate the high temperatures seen in heatstroke, and irreversible brain damage occurs quickly.

  A victim who is in a coma or delirious or confused and combative is another problem. Pouring water into the mouth of a comatose person or one who will not cooperate may lead to aspiration and injury to the lungs. It's a judgment call as to which is the greater risk: untreated dehydration or aspiration.

  Your forest ranger would likely have a canteen or some other water container. He would give the victim sips, splash some on his face and chest, and fan him with a shirt or similar object. He would move him into the shade of nearby trees and then transport him to civilization by whatever means he had available. He might call in a helicopter rescue team or make a litter and haul the victim down the mountain. Regardless, he would continue to rehydrate and cool the hiker as long as his water supply lasted.

  In the hospital the victim would receive IV fluids, usually D5W, which is 5 percent dextrose in water, or D5'/2 NS (normal saline,) which is 5 percent dextrose in salt water that has half the salt (NaCl) content of blood.

  Other electrolytes such as potassium and magnesium can be added to the IV as needed, depending on the results of blood tests for these minerals. Tests of kidney function are also important since dehydration and heat injury can damage them.

  How Long Ca
n Someone Survive in a Freezer?

  Q: Say I want to shove a character in a commercial freezer.

  How long would it take for the poor soul to die?

  A: The time required depends on so many factors that no definitive answer is possible. Here are some factors that would impact survival:

  Size and weight of the victim: This is a situation where a high percent of body fat would be welcome. Fat serves as insulation and a source of energy for heat production by the body.

  Age: The very young and the very old would tolerate the cold poorly and be at greater risk.

  Diseases the victim may have: The presence of heart or vascular disease, diabetes, or anemia would likely hasten the victim's demise.

  Food and beverage intake: When and what was the last meal? A high-carbohydrate meal might help somewhat. If the victim was well hydrated, he would be better off than if he was dehydrated. Alcohol consumption would definitely hasten loss of body heat and quicken the demise

  Medications or drugs: Alcohol, as mentioned, and some other medications can hasten heat loss from the body. Diuretics lead to dehydration, and certain blood pressure medications dilate the body's blood vessels and thus increase heat loss.

  Clothing: A ski parka would be better than a cotton Hawaiian shirt.

  Temperature within the freezer: Pray it's defective. If it is simply a cold locker for vegetable storage, the ambient temperature would be above freezing. If it was a meat or frozen food freezer, the temperature would be well below freezing and maybe below 0 degrees. A circulating fan in the freezer would definitely shorten the survival time. Think windchill.

  Protective materials present: Any cloth, canvas, or covering inside the freezer that could be used as a coat or to build an "ice cave" would be helpful. Either would help retain body heat.

  Perhaps you can use some of these to make the victim's survival longer or shorter as dictated by your story requirements. In general, two hours probably wouldn't be enough, and forty-eight would be plenty. I suggest leaving the victim in overnight if he is an average person and not dressed for the Antarctic. That'd probably do it.