Romeo: Courage, man; the hurt cannot be much.
Mercutio: No, 'tis not so deep as a well, nor so wide as a church-door; but 'tis enough, 'twil serve: ask for me to-morrow, and you shall find me a grave man.
- Romeo and Juliet, Act III

Going Deeper – Broken Bones and Mauled Viscera

Though not all wounds are "as wide as a church door" nor "as deep as a well", many will impact vital organs and may break bones.

Broken bones are actually far less of a big deal in themselves than movies make out. As any orthopaedic surgeon will tell you, it's not the bones themselves that are the worry, but the nerves and blood vessels that surround them. In dealing with a fracture, the first thing that a doctor will pay attention to is whether there is any "neurovascular injury". The next priority is tendons and muscles, and then last of all the bones themselves.

Similarly with organs, it's not so often direct damage to the organs themselves that is a concern (at least in the short term), but the bleeding around them. Once you introduce the possibility of internal bleeding from a torn liver or ruptured spleen, your players will never view "bashing damage" in quite the same way again!

But enough on general principles! Here are some crunchy injuries for you to inflict on your players…

Tension Pneumothorax

Seen Three Kings? There is a scene where Mark Wahlberg's character gets a bullet wound to the chest and finds he can’t breathe till George Clooney (obviously recalling his skills from his ER days) sticks a needle in his chest. That's a tension pneumothorax.

The injury is a hole into the outside world, which allows air into the pleural space around the lung. The air then can't escape because the infolded flaps of the chest wound act as a valve. With every breath that the wounded man tries to take more air is sucked into this cavity, which because it cannot escape then progressively pushes on and compresses the lungs.

Aesthetic notes:

Three Kings has this down pretty much perfectly. As the injury builds the individual will get more and more out of breath, eventually collapsing and turning blue. Letting the air out with a needle will produce an audible hiss, and instant relief. Of course lungs don't appreciate being squeezed and suddenly reinflated, so the individual will cough and gasp for a while, and may get all sorts of complicated physiological problems from re-inflation.

Mechanical considerations:

The movie has a great idea for using this in a story – Mark Wahlberg's character has the lifesaving plastic tube in place that will let the pressure out, but the valve is closed and his hands are tied behind his back.

Fractured Pelvis

A pelvic fracture is most likely to occur in game settings where you have the possibility of high energy collisions. Being in a car crash or a dragon slamming into you could equally cause a broken pelvis.

Aesthetic notes:

There's not much to see externally with this one, though of course the fracture victim isn’t going to be walking. An odd angle to the hips and the legs may be disturbing and visceral enough for most descriptions. Blood can also leak out through the end of the penis, so a GM might also want to describe a small blood stain over the crotch of clothes.

Mechanical considerations:

This is the fun bit. Bleeds from most fractures are self-limiting, because the flow of blood is restricted by the tamponading (squeezing) effect of the tissues around them. Once the dead space around the bone is full of blood, there's nowhere else for blood to go so you don’t bleed into it any more. A pelvic fracture is different, because the surrounding area is a big bowl with very little pushing on it. This means you can empty a good percentage of your blood volume into your pelvic bowl very easily, and can quickly die from blood loss.

Compartment Syndrome

If you break a limb bone, then the tissues around it can swell up. In turn this swelling can press on blood vessels, and as a result cut of circulation. You then get a vicious circle, as deprived of oxygen the limb can turn necrotic, and swells up even more. Compartment syndrome happens in about 1 in 8 open fractures (an open fracture is one where the bone is showing), and if a fracture is put in a plaster that is too tight for it, it can happen more often.

Aesthetic notes:

The limb will be extremely painful, even more so than a broken bone, with numbness further away from nerve compression.

Mechanical considerations:

Decompression is the key to this, and it's possible to have a scene where a chirugeon has to cut into the fascial compartments around the muscle to let the pressure out. Otherwise the limb can go ischaemic (damage from lack of oxygen supply), and can be lost.

Ruptured Liver

The liver is a big organ, and it has a lot of blood vessels going through it. It sits in the upper right corner of your abdomen, below your right lung. Any trauma to the liver could cause it to rupture.

Aesthetic notes:

Cramping abdominal pains, often spreading to the shoulders, plus signs of massive blood loss (pallor, fast heart rate, low blood pressure) would be typical.

Mechanical considerations:

A clean stab to the liver may actual cause very little damage, whereas a bullet may cause massive damage, even causing pieces of the liver to "shatter" away from the main body of the liver.

In a low tech setting a liver rupture could be fatal, as surgeons are unlikely to have the skill to open up and piece the liver back together again.

Head injuries

In the style of a Warner Brothers cartoon, player characters will hit a guard over the head with a heavy object, on the assumption that this will knock out the guard in a non-lethal and suitably clean way.

This is very silly. Policemen (in the UK at least) are trained never to strike someone over the head if they are aiming to merely incapacitate, as doing so is incredibly dangerous. Instead they'll strike at the collarbone, as the pain from a shattered clavicle is very disabling, and it’s a far less lethal injury than a skull fracture.

Hitting someone over the head with something hard is invariably messy.

This Aesthetic notes:

Scalps bleed a lot. The scalp is one of the best perfused tissues in the body, and it doesn't stop bleeding easily. Forget a thin trickle of blood running over a duellist's eye – when a scalp bleeds it torrents over a person’s head and shoulders.

Head injuries induce nausea. Too often in games I've heard GMs describe victims of head injuries as merely slumping to the ground. More likely they'll reel, grasp at the walls, and probably vomit. Even losing consciousness may not stop them throwing up, making choking a real risk.

Mechanical considerations:

Even in minor head injuries people will feel sick, dizzy and with a headache for the next few days.

Some head injuries will cause even more trouble. An intracranial haemorrhage could kill straight away, or more frighteningly hours or days after the event from small bleeds which continue to trickle slowly into the brain. A head injury victim could get up and walk away from the injury, and then forty-eight hours feel a pain like a kick to the back of the head, and suddenly collapse. An intracranial bleed is usually lethal, but in a high technology setting quick work with a bone-drill to create burr-holes will release the pressure.

Faking Injury – Telling Traumatic Stories

Hopefully over the last two articles I've helped convince you all that trauma ought to be traumatic, and that describing interesting injuries accurately can add to the storytelling experience. There’s a whole world of visceral injuries out there!

Short of taking an Advanced Trauma Life Support course, I suspect most GMs out there will have to improvise a bit when it comes to implementing these ideas. If you want to fake it – that is achieve a gritty and visceral style of storytelling without having to learn a lot of trauma medicine – then simply remember the following principles:

• Different types of injury deal different sorts of damage. A gunshot is best considered as a small internal explosion, rather than a piercing injury.
• Always consider bleeding, both internal and external.
• Think immediate effects, short term complications and long term consequences of any injury.
• If in doubt, add more blood!

Of course, the realistic approach to injury isn't for every game ("what do you mean my Toon has a subdural haematoma?"), but hopefully GMs out there have found this useful.

Have fun mutilating your players!

With this article, Medical Musings is moving to a semi-monthly publication schedule. Watch for the next article in just two weeks. -ed