Injury angst for writing dummies.
Hospitals and injury are always such a staple of angst fics, but 9 times out of 10 the author has clearly never been in an emergency situation and the scenes always come off as over-dramatized and completely unbelievable. So here’s a crash course on hospital life and emergencies for people who want authenticity. By someone who spends 85% of her time in a hospital.
Emergency Departments/Ambulances.
Lights and sirens are usually reserved for the actively dying. Unless the person is receiving CPR, having a prolonged seizure or has an obstructed airway, the ambulance is not going to have lights and sirens blaring. I have, however, seen an ambulance throw their lights on just so they can get back to the station faster once. Fuckers made me late for work.
Defibrillators don’t do that. You know, that. People don’t go flying off the bed when they get shocked. But we do scream “CLEAR!!” before we shock the patient. Makes it fun.
A broken limb, surprisingly, is not a high priority for emergency personnel. Not unless said break is open and displaced enough that blood isn’t reaching a limb. And usually when it’s that bad, the person will have other injuries to go with it.
Visitors are not generally allowed to visit a patient who is unstable. Not even family. It’s far more likely that the family will be stuck outside settling in for a good long wait until they get the bad news or the marginally better news. Unless it’s a child. But if you’re writing dying children in your fics for the angst factor, I question you sir.
Unstable means ‘not quite actively dying, but getting there’. A broken limb, again, is not unstable. Someone who came off their motorbike at 40mph and threw themselves across the bitumen is.
CPR is rarely successful if someone needs it outside of hospital. And it is hard fucking work. Unless someone nearby is certified in advanced life support, someone who needs CPR is probably halfway down the golden tunnel moving towards the light.
Emergency personnel ask questions. A lot of questions. So many fucking questions. They don’t just take their next victim and rush off behind the big white doors into the unknown with just a vague ‘WHAT HAPPENED? SHE HIT HER HEAD?? DON’T WORRY SIR!!!’ They’re going to get the sir and ask him so many questions about what happened that he’s going to go cross eyed. And then he’s going to have to repeat it to the doctor. And then the ICU consultant. And the police probably.
In a trauma situation (aka multiple injuries (aka car accident, motorbike accident, falling off a cliff, falling off a horse, having a piano land on their head idfk you get the idea)) there are a lot of people involved. A lot. I can’t be fucked to go through them all, but there’s at least four doctors, the paramedics, five or six nurses, radiographers, surgeons, ICU consultants, students, and any other specialities that might be needed (midwives, neonatal transport, critical retrieval teams etc etc etc). There ain’t gonna be room to breathe almost when it comes to keeping someone alive.
Emergency departments are a life of their own so you should probably do a bit of research into what might happen to your character if they present there with some kind of illness or injury before you go ahead and scribble it down.
Wards
Nurses run them. No seriously. The patient will see the doctor for five minutes in their day. The nurse will do the rest. Unless the patient codes.
There is never a defibrillator just sitting nearby if a patient codes.
And we don’t defibrillate every single code.
If the code does need a defibrillator, they need CPR.
And ICU.
They shouldn’t be on a ward.
There are other people who work there too. Physiotherapists will always see patients who need rehab after breaking a limb. Usually legs, because they need to be shown how to use crutches properly.
Wards are separated depending on what the patient’s needs are. Hospitals aren’t separated into ICU, ER and Ward. It’s usually orthopaedic, cardiac, neuro, paediatric, maternity, neonatal ICU, gen surg, short stay surg, geriatric, palliative…figure out where your patient is gonna be. The care they get is different depending on where they are.
ICU.
A patient is only in ICU if they’re at risk of active dying. I swear to god if I see one more broken limb going into ICU in a fic to rank up the angst factor I’m gonna shit. It doesn’t happen. Stop being lazy.
Tubed patients can be awake. True story. They can communicate too. Usually by writing, since having a dirty great tube down the windpipe tends to impede ones ability to talk.
The nursing care is 1:1 on an intubated patient. Awake or not, the nurse is not gonna leave that room. No, not even to give your stricken lover a chance to say goodbye in private. There is no privacy. Honestly, that nurse has probably seen it all before anyway.
ICU isn’t just reserved for intubated patients either. Major surgeries sometimes go here post-op to get intensive care before they’re stepped down. And by major I mean like, grandpa joe is getting his bladder removed because it’s full of cancer.
Palliative patients and patients who are terminal will not go to ICU. Not unless they became terminally ill after hitting ICU. Usually those ones are unexpected deaths. Someone suffering from a long, slow, gradually life draining illness will probably go to a general ward for end of life care. They don’t need the kind of intensive care an ICU provides because…well..they’re not going to get it??
Operations.
No one gets rushed to theatre for a broken limb. Please stop. They can wait for several days before they get surgery on it.
Honestly? No one gets ‘rushed’ to theatre at all. Not unless they are, again, actively dying, and surgery is needed to stop them from actively dying.
Except emergency caesarians. Them babies will always get priority over old mate with the broken hip. A kid stuck in a birth canal and at risk of death by pelvis is a tad more urgent than a gall stone. And the midwives will run. I’ve never seen anyone run as fast as a midwife with a labouring woman on the bed heading to theatres for an emergency caesar.
Surgery doesn’t take as long as you think it does. Repairing a broken limb? Two hours, maybe three tops. Including time spent in recovery. Burst appendix? Half an hour on the table max, maybe an hour in recovery. Caesarian? Forty minutes or so. Major surgeries (organs like kidneys, liver and heart transplants, and major bowel surgeries) take longer.
You’re never going to see the theatre nurses. Ever. They’re like their own little community of fabled myth who get to come to work in their sweatpants and only deal with unconscious people. It’s the ward nurse who does the pick up and drop offs.
Anyway there’s probably way, way more that I’m forgetting to add but this is getting too long to keep writing shit. The moral of the story is do some research so you don’t look like an idiot when you’re writing your characters getting injured or having to be in hospital. It’s not Greys Anatomy in the real world and the angst isn’t going to be any more intense just because you’re writing shit like it is.
Peace up.
Ya hear that, Buckley? Loss.jpeg ain’t realistic.
of all the additions and replies on this post so far this is by far my fave.
Thumbs up for this from your friendly neighbourhood physician. (Also, I did mostly emergency care for a few years before switching to radiology. I got the adrenaline junking out of my body before settling down.)
One correction from someone who spent almost a decade working in an ambulance across two states: it is required by law to have your lights on if there is a patient in your rig. Now, this might be a state-by-state law IDK, but in both states I worked in, it was the case. You reserve sirens for Serious Shit because, guess what, they stress out the patient, so unless your patient is crashing in the back of your rig, you don’t run a continuous siren. You are, however, once again required by law to turn on the siren briefly while approaching and driving through stop signs or red lights. (You will also use your siren briefly to get idiots in front of you to move over when you’re stuck in traffic and have a patient whose condition can escalate.)
Also, unrelated to the lights and sirens issue, lemme add a detail about us asking a lot of questions. If you want verisimilitude in your story, remember SAMPLE:
Signs and symptoms
Allergies
Medications
Past illness/injury/disease
Last food, drink, and medication taken
Events leading up to the injury or illness
These are the questions EMTs are trained to ask every patient, though they rarely end up coming out in that order. Also, you can totally add a W to that, which is inevitably “Why did you wait so long to call us?” *sighs forever*
And for some more basic on-scene emergency care, remember CABC: C-spine, Airway, Breathing, Circulation. This time, actually in that order (except for cardiac arrest, in which case remember CAB: Compressions, Airway, Breathing).
The long and short of CABC is: if the patient fell or was in a car accident or had any other potentially traumatic injury, start with stabilizing the C-spine (typically via cervical collar and head blocks and backboard), because if there is a fracture in the neck and you don’t manage it and end up severing the spinal cord that high up, your patient’s probably going to die, and if not, will probably be paralyzed from the neck down.
Once C-spine is stable, make sure the patient’s airway is clear (this includes both foreign obstruction and the patient’s own tongue). Yes sometimes this actually involves sticking your finger in their throat to clear shit out, and yes it’s gross. It also means positioning an unconscious patient’s head in a certain way (assuming there is no chance of C-spine damage) to keep the airway open. EMTs also carry little plastic hook things called oropharyngeal airways in a bunch of sizes that keep the patient’s tongue from blocking their airway. And of course if needs be you can intubate, although this is not a skill EMTs have (paramedics do, though, and in some states there’s a certification called EMT-I [the I for intermediate] that also teaches that skill). If someone’s just come across an unconscious person and doesn’t have an airway to use, and you’re sure their C-spine is fine, you can roll them onto their left side and gently curl them; that’ll help keep the airway clear and also helps the heart pump blood a little more efficiently than if you’d rolled them onto their right side.
Anyway, once the airway’s secure, you move on to making sure the patient is actually breathing. If they’re not, you do it for them with an ambu bag. If they are but are struggling, or aren’t struggling but may for any reason potentially go into shock or have compromised circulation (broken leg, high fever, etc.), you give them supplemental oxygen, typically through a nonrebreather mask, though the flow rate depends on their symptoms.
Okay so once we’ve secured the patient’s C-spine, airway, and breathing, only then do we worry about circulation (unless the patient’s in cardiac arrest, remember, in which case we secure circulation first). Which in the case of trauma is generally first aid for serious open wounds and preventing or treating shock, and in the case of medical issues may be getting an ECG reading or administering medication or, if the patient does go into cardiac arrest, chest compressions and defibrillation.
Okay, that’s the end of the CABCs, but you’ll note that in the last para I said treating serious open wounds. Because a minor open wound is going to wait until after the next step after the CABCs, which is a full-body assessment wherein we meticulously assess a trauma patient using palpation from, basically, head to toe, looking for broken bones, soft tissue damage, internal bleeding, etc. Some of those things can be pretty serious, so before we treat a shallow cut, we check for, like, broken ribs that might puncture a lung.
So obviously not all of these things happen all the time. A patient presenting with an asthma attack needs neither a full-body assessment nor C-spine and circulation management. So we just jump straight to airway and breathing and forego the rest. (And then ask anyone with them our SAMPLE questions if the patient is too distressed to speak, because we still need those answers, but also if the patient is too distressed to speak you can bet we’re asking their companion in the back of a moving ambulance.)
Sometimes you spend a Long Fucking Time at a scene, either because the patient is resisting transport (this happens a lot, especially with the uninsured; we stick around and do everything we can to help them while simultaneously trying to encourage them to go to the ER anyway), or because the patient’s trapped in a smashed car and we’ve got to cut the door off and peel the roof back and get a cervical collar and a backboard on the patient while they’re still in the damn driver’s seat and lemme tell you that is a goddamn game of Jenga and can take half an hour, or because the patient isn’t critical but you want to minimize discomfort and damage so you take the time to meticulously package them while also getting all your questions answered on scene to make sure you haven’t missed anything, or because … well, you get the point. Sometimes shit just takes forever.
Other times, we do what’s called a scoop-and-go, typically with patients in critical conditions that can’t really be managed without surgery or medications we don’t carry. Like, patient bleeding out while giving birth? Not a whole lot we can do about that, so we get them in the rig as fast as fucking possible and race to the hospital while trying to get the most critical questions answered. These kinds of situations are very rare, though; it’s much more common to be on scene for 15 or 30 minutes than 5 minutes.
OH AND, another thing. Listen. EMTs do not approach a scene that is not secured. If there’s an active shooter, or a hostage situation, or a raging fire, or a potential for something to explode (or for something that’s already exploded to collapse), or a flash flood, or a hazardous materials spill, or whatever else, we do not go in until the unstable situation has been resolved. It sucks waiting 100 yards away while a critical patient is maybe dying and you can’t get to them yet, but listen, the first thing they teach you is don’t make new patients. IOW, don’t become a victim yourself; you can’t help anyone if you get wounded in the crisis too, and in fact then you’ve just become an additional burden on the personnel remaining.
Okay, so, any questions?
ALL OF THIS. With one exception to what @rachelhaimowitz added, which is:
I’ve never heard of the lights-must-be-on rule. It’s gotta be one or a few specific states. Generally speaking, lights and sirens increase accident rates, and most states are actively trying to REDUCE their use, not increase them, but I don’t know where she lives, so that’s accurate in her part of the country (I’m assuming the US). But it’s inaccurate in most of the country.
xoxo, Aunt Scripty
So I love everything about this post and had to throw in my two cents!
So I work in a real crowded city and, luckily, I don’t need to go lights and sirens since I’m primarily non-emergency. But in the few times I’ve had to make that decision, I tend towards not using lights/sirens or at least not sirens.
Because once you turn those suckers on, drivers become unpredictable as fuck. They freeze, they slow, they swerve, at least one car is guaranteed to move to the left instead of the right.
I drive safer and get to a hospital faster when I go with the flow as much as possible and am able to predict what the cars around me will do.
Secondly, i used a scale called OPQRST which I use to quantify pain.
Onset (were you hit? Why pain?) Provocation (does it fade? Heighten?) Quality (dull or sharp?) Radiation (Where?Does it move?) Severity (pain scale) Time (how long has it been going on?)
If you ever want to heighten the drama and imply something is seriously wrong in your fic, try something like this:
EMT: so what happened? Where does it hurt? Bystander: X and X happened and got hit in the stomach really hard! Patient: ow! My right shoulder hurts! EMT: Fuck.
Referred pain is usually a sign of internal damage to an organ. In this case I’d be thinking there’s something bad with the liver, but I don’t really go further than the “fuck” before loading up and heading out.
