House Rules for Medical situations

by The Doc (Grant Kinsley)

From: Grant Kinsley To: Multiple recipients of list Subject: medical stuff

Bleeding

How much bleeding does a bleeder bleed

As you are all aware bleeding comes in a variety of severities. Minor bleeding is usually caused by bleeding from capillaries and venules. This type of bleeding will usually stop on it's own without the help of first aid or even a bandage. This would be things like paper cuts, minor nosebleeds, shaving cuts, abrasions(aka scrapes or road rash), catching a limb on something(like a nail sticking out of a fence, or a small tree branch.). Infection is rarely an issue in this type of injury although it is possible

Suggestion for Rolemaster. This type of bleeding is best represented as a single loss of hits or perhaps bleeding of 1 hit/rd to 1 hit/minute for a limited time, such as 1 hit/rd for 10 rds or 1 hit/min for 5 minutes. Wound infection could be prevented with a simple first-aid skill roll(applying alcohol/disinfectant and a bandage). If first-aid is not applied I would suggest a 5% chance of wound infection, or this could be a save vs. disease with the level of disease regarded as 1st level.

Moderate bleeding: Moderate bleeding would consist of bleeding from small arteries (arterioles) and small to medium sized veins. This would be caused by deeper slashing or puncturing wounds. Crushing injuries would also cause this in two ways. First, a crushing injury can cause splitting of the skin and subdermal structures by a pressure displacement phenomenon. If a vein or artery is in the way it may well split too. Although veins are more likely to do so as they are more fragile and less elastic (arteries have muscular walls). Secondly, a crushing injury can cause compound fractures, in some of these, the bone will puncture an artery or vein. The chance of wound infection is somewhat higher in these types of wounds as they are often deeper and may affect poorly vascularized structures such as tendons and bone.

In Rolemaster terms, I would consider thes types of wounds to bleed at 1-5 hits/round. They would be readily amenable to first aid and I would suggest a difficulty modifier be applied, depending on the amount of bleeding (as well as on collateral damage such as broken bones). My suggestions would be easy for 1 hit/rd and 1 step increase for each hit/rd after that, collateral damage may affect the first aid roll further (more on this later).Second aid would also be readily amenable in these cases to "suture the wound" or apply an appropriate pressure dressing following the first aid roll, My impression of first aid is that without immobilization for 12-24 hours in the case of bleeding wound, the wound will begin to bleed again. Wound infection would be perhaps 10% or save vs. level 2 or 3 disease. Collateral damage affecting poorly vascularized structures would vastly increase this (wounds to bone often require agressive irrigation and antibiotic prophylaxis with intravenous antibiotics in the present era to prevent osteomyelitis), again I will elaborate on types of collateral damage with future postings.

Severe bleeding: Bleeding of the severe nature occurs when a major vein (such as the subclavian, superior vena cava, inferior vena cava, or femoral veins) or anything larger than a small unnamed artery on the arterial side were to be compromised. Bleeding rates would of course be variable depending on the size of the vessel and on the pulse rate and blood pressure at the time and whether it is arterial or venous bleeding. The major factor of importance with these types of bleeding is the treatment. Pressure will slow or even stop the bleeding, but it must be very high pressure and needs to be applied perpendicular to flow direction. This usually requires a tourniquet. Suffice to say on cannot tourniquet torsos, necks or heads(while a neck can be tourniqueted but the results are less than spectacular). Tourniquets are good for only short periods of time (perhaps 20-45 minutes) beyond this irreversible ischemia to the limb results in limb loss. As well ischemia during the tourniqueted time results in loss or alteration odf sensory and motor function, therefore the limb is numb and then painful and will not move properly. The consequence is the patient is immobile and will have to be carried about. These type of wounds will not stop bleeding if you wait, removal of the pressure simply allows the vessel to again pour blood out again. Simple suturing will not help. It is a surgical procedure to reanastamose the vessel. These vessels cannot simply be clipped closed either as you will interrupt flow and produce irreversible ischemia to the target organs and the consequences of limb or organ loss. Wound infection is fairly high in these types of wounds because they usually involve ischemic down time (anaerobes love this) and there is usually a significant wound involved which means a greater surface area has been exposed to the offending fomite (device carrying the bacteria, aka sword/axe/dinner fork/unsterile surgical implements, etc.). Antibiotic therapy in these types of wounds usually involve prophylactic antibiotics in modern medicine and are an absolute requirement in wounds below the chest.

In RMSS terms I would interpret this as bleeding of 5+ hits/rd. In very large arteries it could be as high as 20 hits/rd. Treatment should require a first or second aid roll modified by the level of bleeding.( I would suggest a first aid roll with a penalty of 5/hit/rd of bleeding or a second aid roll of 2/hit/rd of bleeding). This would allow tourniqueting or direct obstruction of bleeding in a non-tourniquetable wound. Beyond this you would have 20-50 minutes depending on bleeding rate (perhaps 20 minutes for 20/rd bleeder and 50 minutes for that 5/rd bleeder and adjust the rest in between). I would suggest that a bleeder of greater than 10/rd involves such massive bleeding that if some form of intervention is not applied within 3 minutes the patient will need transfusion for exsanguination regardless of amount of hits lost. One might also consider the need for transfusion if one has bleeding damage of greater than 40% of their hits. Definitive of course requires surgery (again difficulty based on hits/rd) or magical intervention, possible transfusion, treatment of the likely infection (100% chance in an abdominal wound, perhaps 80% in chest, legs and arms, and 50% in head and neck). Wound contaminants would include tetanus, Staph spp. from our own skin, Strept spp. from our skin, enteric flora if the abdomen or esophagus is compromised, neisseria spp. and other naso-respiratory flora in wounds to the chest or nasal cavities and anaerobes of the worst kind with wounds involving the oral cavity, any area left devascularized for any significant period of time is also at high risk for infection with Clostridia Perfringens (gas gangrene). I will leave it up to you to come up with the fantasy variants of infection.) One other infective complication is very likely as well, asa major vessel has been perforated, bacteria may be introduced to the blood stream and as a consequence general sepsis and infection of internal organs (heart valves, liver abscess, meningitis) are all possible. I would suggest a save vs. disease (level based on DM's discretion and or type of bug infected with) to deal with this, general sepsis would be fairly common without antibiotic prophylaxis. The other would be significantly less likely.

Head Injuries

Skull Fractures: There are a variety of types of fractures involving the skull and facial bones. The skull can be divided into a variety of sections for purposes of these discussions. First is the cranial vault bones. These consist of the bones surrounding the brain, The basal skull consists of the thick bones at the base of the brain, the nasal bones are obvious, the zygomas are the arched bones colloquially known as cheekbones, the orbits are the bones surrounding the eyes, the maxilla is the area below the orbits to the upper teeth, and the mandible is the lower half of the mouth (the jawbone).

There are a variety of fractures that can occur in these areas. I will discuss each in turn.

The cranial cavity: There are really two types of fractures in this are: depressed and non-depressed. They are really exactly what they sound like. A non-depressed skull fracture is one in which the cranial cavity has been cracked, but there has been no displacement of the bones. On X-ray these are visible, but they are undetectable by palpation. Clinically a non-depressed skull fracture requires no treatment for the fracture, however treatment for the possible underlying closed head injury may be necessary (see the upcoming closed head injury posting. A depressed skull fracture is a fracture of the cranial cavity that has displacement of the bone. A segment of skull will be displaced in towards the brain. Possible complications in this type of fracture include compound fracture (the skin opens and communicates with the fracture), meningeal vessel tearing, cerebral edema, and direct damage to the brain. Clinically these patients present with symptoms of concussion and brain swelling (cerebral edema), they will often have a decreased level of consciousness, nausea, vomiting, and possible localizing signs of neurologic injury (altered sensory, motor, reflex or cranial nerve testing). These patients need operative care to elevate the fracture, relieve excessive pressure on the brain and to deal with any bleeding from meningeal or intra-cerebral bleeding.

I would suggest the following Rolemaster rulings in the cases of cranial cavity fractures: non-depressed skull fracture; penalties ranging from 0 to -25 depending on severity of hit (GM interpretation is required but could be built into crit tables in the future.) The peanalty would last 1-24 hours or sooner if analgesia is given (herbs/spells, etc.). Depressed skull fractures are more serious and the following considerations need to be accounted for in addition to the above suggested penalties (for non-depressed fractures). a) Was the fracture compound, if so the risk of infection is very high (meningitis or encephalitis). Treatment with antibiotic (or herbal/magical remedies) should happen at the outset. If not chance of infection would be 90% or greater (or a save vs. disease at level 10 or higher). b) Was there direct damage to the brain, If so the GM needs to determine the area of brain damaged and the effect, this could be potentially written into future crit tables. For the time being you would need to choose area of damage and then decide if the problem was in the motor or sensory paths or in the cranial nerves, or in central function. Example below:

sensory damage: loss of sensation in a limb or area of torso (anaesthesia)                
		increased sensation of pain in a limb or area of torso 
                (hyperaesthesia)
motor damage : loss of power in a limb or in an area of torso (paresis)
	       increased tone in a limb leading to permanent contracture 
               (spasticity)

cranial nerve damage: dependant on which CN: Olfactory: loss of scent, Optic: loss of sight (one eye), Ocular: loss of eye movement, etc (Others include loss of facial sensation, motor abilities in the face, control of vocal cords, tongue control, taste, hearing, balance, and more.) central damage: Many areas of the brain do not conform to a direct distal nerve but have more central functions: including the brains processing of our five senses, memory, balance, breathing, metabolic control of heart and blood pressure, coordination, speech abilities, recognition of speech, etc.

If people are interested I could generate some kind of table for this.

c) meningeal or intracranial bleeding requires surgical or magical intervention or the patient will die or be severely brain damaged. d) cerebral edema -mild cases can be treated by lowering the blood pressure and/or osmotically diuresing the patient (second aid and or herbs/magic). More severe cases require craniotomy, also known as trephination in the past, to relieve excess pressure on the brain, failure to do so results in severe brain damage and/or death in the patient. A surgiacal roll would be needed for this.

Basal skull fractures: Basal skull fractures occur along the inferior (lower) portion of the cranium. This is defined by the shelf that holds the brain up. The area that break most often are the ethmoid bone (at the top end of the nose) and the skull base in the area around the ears. Basal skull fractures are caused by blunt force to the mid face or to the sides of the head. The blunt force is typically over a small surface area (2X4, club, sword, mace, etc.) thus allowing the heavier bone of the skull base to fracture. Symptoms of basal skull fractures usually include local pain, bleeding or clear fluid (CSF) leaking from the nose and/or ears and most often bruising that occurs around the ears and eyes, referred to as a "Battle's Sign".

Complications of basal skull fractures include: concussion/loss of consciousness, meningeal artery tearing (with subsequent subarachnoid haemorrhage), intracranial bleeding, and localized brain damage. The most common complications are 1) anosmia. The loss of the ability to smell. This occurs in a fracture of the ethmoid plate. When this occurs, the olfactory nerve is disrupted and the ability to sense smell is lost. 2) infection(meningitis/encephalitis). These two infections occur as a basal skull fracture is usually compound due to the location of the injury. Since the wound coomunicates with the outside world, the brain an surrounding CSF are exposed to bacteria and infection is a likely result. Treatment in basal skull fractures is usually non-surgical and consists of prophylaxis of infection and observation.

Basal skull fractures in Rolemaster terms. Basal skull fractures could be applied in head criticals of a blunt force trauma variety the complications would really depend on the whim of the GM or to a table of his own devising (These will be done if a Medical Companion is done by myself and the members of this group.) The two important ones should be considered, however in each incidence of a skull fracture. Anosmia is relatively rare and would happen perhaps in 5% of cases. I would apply this as a % roll, GM's to apply modifiers as they see fit. Infection has a very high likelihood however and I would make this a saving throw vs. disease at a level of the DM's choice but I would suggest that it be high. Treatment would be with antibiotics, Disease healing magic/herbs, and or treatment with natural herb compounds (i.e. natural antibiotics. Treatment should be prophylactic and I would suggest the use of diagnostics and/or seciond aid. If treatment is left untoil encephalitis develops the patient still has a significant chance of dying or being left with permanent brain deficit. In the case of meningitis, brain damage is less likely, but the chance of dying is still significant.

I will consider the effects of meningitis/encephalitis further in diseases/infection.

Intracranial injuries will discuss the effects of subarachnoid heamorrage and intracranial bleeds further.

Injuries of the facial bones: There are 3 main areas in this topic, the nose, the zygomas(cheekbones), and the orbits.

Nose injuries are the most common of these and usually are simple in nature. The inferior end of the nasal bones breaks causing the nose to be crooked. Rarely this will cause the complication of serious bleeding. This can take the form of a persistent posterior nosebleed which needs posterior packing or surgical intervention. Bleeding may also cause a intranasal hematoma that will cause necrosis of the nasal cartilage in the middle of the nose. This usually requires simple drainage and packing. Setting a nose for cosmesis is fairly simple and can be done with little training.

Zygomatic fractures involve the tripod shaped bone that produces the cheek ridge. The major complications of this are pain and cosmetic loss of the cheek ridge. Setting them, however is a tricky open plastic surgical operation.

The orbits are difficult to fracture except in the case of what is termed a blowout fracture. This unique fracture is caused by a small round object such as a baseball hitting one in the eye. The resulting pressure causes the floor of the orbit to "blowout" trapping the inferior muscles of the eye. The eye will appear sunken and will not track properly. The result is double vision, particularly with upward gaze. These will heal themselves about 75% of the time and will need surgical elevation of the globe of the eye in the other cases.

Rolemaster interpretations: Nasal fractures, posterior bleed 2%, intranasal hematoma 2%. Posterior bleeds require a very hard or greater surgery roll. intranasal hematomas are amenable to moderate or greater second aid or surgical rolls. Simple bleeding associated with all other nasal fractures can be dealt with easy first aid rolls. Reducing and setting a nasal fracture could be done with moderate second aid or an easy surgery roll.

Zygomatic fractures: These requre no treatment other than for pain. Cosmetically they may decrease the victims appearance. Repair of these would require a difficult surgery roll in appropriate OR conditions with proper orthopedic equipment.

Blowout fractures: 75% of these require no treatment and will resolve with decreasing swelling over 2-10 days. The other 25% require a diddicult or harder surgical repair in an appropriate OR type setting.

Fractures

> (yup, a character in my campain has a compound fracture of the jawbone
>         Is this actually possible?  hmm.. should be.)
> Thanks
> SMOG - Newbee GM and New to the list.

So yes one can have a compound fracture of the mandible (or maxilla). A compound fracture's main problem is the very high rate of infection. a simple compound fracture (i.e. blunt trauma causing a fracture and the bone popping out secondarily) will be relatively clean and will get infected probably 50% of the time without irrigation, debridement and antibiotic therapy. On the other hand a compound fracture where the bone is exposed to a foreign body such as a club, sword, dinner fork, etc. causes skin and other types of bacteria to be forced into the wound and the bone. the consequence is nearly 100% infection in an untreated wound. The chance of infection is less on the face and scalp however. The real problem is it is the bone that gets infected (osteomyelitis) and bone is poorly vascularized meaning the antibiotic (or herb preparation) does not readily penetrate the infected area. treatment in a pre-infected compound fracture is on the order of ten days of oral antibiotics (or fantasy equivalent). In an osteomyelitis treatment is on the order of six weeks of IV antibiotics with possible need for surgical debridement and possible amputation and or bone removal.

> are any fracture that has bone interrupting the skin.
> >So yes one can have a compound fracture of the mandible (or maxilla). A
> >compound fracture's main problem is the very high rate of infection. a
> >simple compound fracture (i.e. blunt trauma causing a fracture and the
> >bone popping out secondarily) will be relatively clean and will get
> >infected probably 50% of the time without irrigation, debridement and
> >antibiotic therapy.
> ok, assuming the fracture is a simple compound fracture, what can be done,
> "In field" to help this person, setting of the bone ect...assuming that help
> is not
> comming any time soon (the Characters will be several weeks getting to the
> nearest town)
> I know that some herbs could help, but they have nothing really helpfull.
> Anything they do will be useing first aid, second aid, ect.
> one more thing, How much bleeding does a compound fracture involve?

Field treatment of compound fracture would include rigorous irrigation with a sterile, or even better, an antiseptic solution (perhaps an herbal concoction). then one should debride the skin, muscle and bone edges that are not clean or that have been contaminated by a sword or other fomite. the wound should once again be irrigated. the bone could then be splinted. Reducing the fracture in the field is usually not a good idea(i will discuss this further in my fractures post). The wound should not be sutured but left open to drain possible contamination. The wound would then close by secondary intention (in other words heal itself) or by third intention (suturing in sterile conditions after all likelihood of infection has passed) I would suggest that doing these procedures in the field would be second aid with difficulty modified by the equipment available to the person aiding the injured.

Joel Blair wrote:
> 
> On Mon, 17 Jun 1996, GKINSLEY wrote:
> >  Anyway here is the next medical stuff.
> 
>         """Holy s*#t! I'm never skip washing a paper cut ever again!
> Seriously doc, that was some great stuff. Only prob. is it makes me kinda
> sad for my players, none of them ever plays a healer (they wonder about
> high death rates. the fools). It also makes me wonder, if a tourniquet is
> applied could one losen and re-tighten again every few minutes and stop
> "ensehitic" (know I spelled that wrong, its that one prob. that goes
> along with tourniquets) from occuring? What about if the injuired person
> is given a lot of fluids??

Loosening and retightening would give you a small amount of extra time. The problem of course arises that the bleeding will restart at the same rate as it was initially. the tourniquet would nedd to be off for at least ten minutes in every hour to prevent irreversible ischaemia to the limb. In a serious bleed that ten minutes would probably be enough to exsanguinate the patient.

Giving fluids is ideal, but remember crystalloid fluid volume will only serve to replace volume and not oxygen carrying capacity. One can really only tolerate a loss of about one-third of the blood volume before oxygen capacity becomes an issue in the patients viability. Remember that the fluid needs to be administered quickly as the GI tract loses absorbtive ability if it has decreased blood flow. (Hence IV fluid delivery)

>         Here's another question. Could you post something on the list
> which states the "activation" time for different drugs/herbs. Mainly I
> ask this because there has been some questions about Herb stuff lately on
> the list and I've always had a prob. with people just "eating" something
> and then having the effect automatically "kick-in". Shouldn't there be a
> lapse time effect for certain herbs (paste vs. powder) and the amount of
> time it takes them to react in your body and inhibit/enhance reuptake??

Activation times for medications/herbs is dependant on route of administration. sublingual or rectal routes are quite fast (sublingual can take less than a minute, rectal absorption in perhaps 5 minutes. Nasal aerosols also work nearly immediatly. IV administation is immediate, subcutaneous and intramuscular injections are slow but allow a continuous delivery of the medication over several hours (or weeks in IM depot preparations). Transdermal administration will work within minutes and allows continuous delivery of medication if in a patch or paste form. I will try to elaborate better in the future,

Compound fractures are any fracture that has bone interrupting the skin. So yes one can have a compound fracture of the mandible (or maxilla). A compound fracture's main problem is the very high rate of infection. a simple compound fracture (i.e. blunt trauma causing a fracture and the bone popping out secondarily) will be relatively clean and will get infected probably 50% of the time without irrigation, debridement and antibiotic therapy. On the other hand a compound fracture where the bone is exposed to a foreign body such as a club, sword, dinner fork, etc. causes skin and other types of bacteria to be forced into the wound and the bone. the consequence is nearly 100% infection in an untreated wound. The chance of infection is less on the face and scalp however. The real problem is it is the bone that gets infected (osteomyelitis) and bone is poorly vascularized meaning the antibiotic (or herb preparation) does not readily penetrate the infected area. treatment in a pre-infected compound fracture is on the order of ten days of oral antibiotics (or fantasy equivalent). In an osteomyelitis treatment is on the order of six weeks of IV antibiotics with possible need for surgical debridement and possible amputation and or bone removal.

Hope this helps
The Doc


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