Author Question: Surgery for Shrapnel to the Abdomen

Naomi Asks:

My protagonist is a surgical resident at large hospital, and I want to write a scene where she is in the OR treating a piece of shrapnel entering the patient’s large intestine with no exit wound.

It took quite a long time to get the patient any sort of medical attention and he has multiple myeloma. I’ve read from my research that myeloma can cause increase inflammation and compression of blood vessels causing coagulation and lessening internal bleeding.

A few questions:

I want to know the chance of my character surviving the surgery. I’m aware since there was no exit wound, and the piece of shrapnel didn’t hit any vital organs, that it would be high chance. However, since he received medical attention rather late (perhaps between half an hour and an hour) I want to know the chance of him actually surviving.

What would be the role of the surgical resident in this scenario? I don’t necessarily just want her to be cleaning up, but I want this to be as accurate as possible.

How long will it take to recover from this surgery?

Are they any complications that could happen during the surgery? If so, please list the major ones.

Jordyn Says:

For this question, I went to one of the best OR types I know . . . my friend Kim Zweygardt who works as a Certified Nurse Anesthetist (CRNA).

Kim Says:

First of all, let’s talk about length of time.

If the shrapnel missed all vital organs and major blood vessels, the length of time to treatment is minor. Are you talking from time of injury? If so, it takes some time for EMS to get to the scene, stabilize the patient, and get to the ER. It takes time in the ER for the nurses to start IVs, for the ER doctor to assess the patient, and get lab and radiology studies to diagnose. It takes time for the surgery to be scheduled and the OR crew to set up for the case.

In a large teaching hospital, is there an OR open or do they have to wait? If the patient isn’t bleeding out, it’s urgent but not life and death. It’s unlikely for the patient to be in the OR from time of injury in half an hour or even an hour.  For instance, in a stat C-section with the patient and crew in house, it’s supposed to be decision to incision within thirty minutes and it’s sometimes difficult to hit that timeline. It takes time to transfer the patient and get the OR ready so I wouldn’t be concerned with that time affecting the outcome in this scenario.

Chances of surviving the operation? It’s kind of a misunderstanding that lots of people die in the OR! Your chances of surviving something is very good in the OR because everything and everybody is there to help you survive— all ways to stop bleeding, medications to resuscitate, etc.

The biggest risk is if the shrapnel was close to major blood vessels that could be nicked by the sharpness during removal.  Most likely scenario is if it’s embedded in the bowel then they would just resect the bowel. In other words, remove the piece of bowel damaged along with the shrapnel. That’s normally done using a special stapler and then reconnected.

It’s possible depending on damage that they’d do a temporary colostomy. Let the bowel heal and go back later to reconnect it.

Biggest worry is infection. Normally when you resect the bowel you do a bowel prep so the colon is empty of stool. The shrapnel itself is dirty but having to resect an unprepped colon— risk of infection is very high and serious enough to cause death. But it’s not an immediate thing. They’d put him on antibiotics but within 24-48 hours he’d have symptoms if infected.

Role of the resident— depends on how advanced they are in their training. If early in residency, assisting. Holding retractors. If more advanced they could do most of the case. In all cases, if an attending surgeon is there, the resident will be left to close the surgical wound, write the orders for post op, and follow up on the patient in the ICU or PACU (Post Anesthesia Care Unit). What they wouldn’t do is clean things up! That is left to the nurses and techs.

His recovery time? If no infection then three to five days if healthy and their bowels are moving to where they can eat, drink, go to the bathroom, etc. With infection recovery time could be weeks or even a month or more.

Hope this helped and best of luck with your story!


What Does a Nurse Do? Part 2/3

Let’s continue our discussion of what a nurse’s role really is and how you can use this to increase conflict in your manuscript.

You can find Part I here.

Last post we looked at the nurse as patient advocate. This post, we’ll look at the nurse german-shepherd-puppyas the patient’s safety net. Which dog would you rather have defending your house? The cute, furry puppy or the grown dog with the watchful eye? A strong nurse is the patient’s watchdog. I look out for my patient’s interests when they may not be able to do so.

I  am often the last line of defense between everything and the patient. Let’s delve into the medication arena. The nurse gives the patient’s medications. It’s my job to ensure that what the physician orders is the correct medication for the illness, for the right patient at the right dose given the right route (by mouth, intravenously, etc…). One of the challenges in pediatrics is there is no standard dose. Every drug dose is based on the patient’s weight. I’m not going to give the same amount of morphine to a 5kg infant vs. an 80kg teen. If the patient is not weighed or their weight is entered incorrectly, this can have disastrous effects when medications are given.

german-shepherd-578929_1920Medication errors do happen. I want to reassure you that there are a lot of safeguards in place to prevent such occurrences. Most departments are going to computer based medication ordering. This is beneficial in many ways. One, the order is typed and therefore easily read eliminating mistakes in reading handwriting. Second, most medication based ordering systems have built in safeguards that will check the prescribed dose against the patient’s weight to make sure the dose is not too high. In pediatrics specifically, all high risk medications are double checked by another nurse and co-signed on the chart. But as a good nurse functions as a safety net, so should the parent question what is being given to their child and why.

Let’s take a real life example. During my years in the pediatric ICU, I worked at a teaching hospital. At this particular institution, residents could rotate through the unit their second year. I had a second year resident order potassium, which is a potent electrolyte, at four times the recommended dose. Now, if too much potassium is given, it will cause the heart to stop beating. That’s how big this error could have been.

I approached the resident and questioned the order. He stated, “But the drug book says to give 4meq/kg/day.”  I explained that the “per/day” was the key term. That the drug should be divided into four doses given every six hours, no more than 1meq/kg at one time. I told him he could order it that way, but the pharmacy wouldn’t fill it and I certainly wouldn’t give it.

Needless to say he changed the order and the drug was given correctly.

Have you ever had a medication error happen to you? How do you think it could have been prevented?