A/N: I'm really excited about this one, y'all. This is a fic that I started writing an early version of when I was in high school. And now, a decade later, here it is! This is an alternate canon fic, set after 1x03.

xxx hidden injury

Ryan knows he got off easy. Helping Kirsten with stagings for a month is a far lighter punishment than he was expecting, given that an entire model home had burned to the ground. He'd rather help Kirsten with stagings for a year, ten, than spend any more time in juvie. The short time he'd spent there had been bad enough; any more time, and he knows it would've broken him, turning him into everything he's been trying so hard not to be. His ribs, which had already been sore after his run-in with Luke and his buddies, still ache from being worked over by Z. The sight of the bruising on his chest this morning had made his stomach turn.

So, yeah. Moving around furniture and vases and stuff really isn't bad.

Hi!

There's like... a lot to talk about in this movie. So instead of just talking about Benji's pneumothorax, I'm gonna go through as much of it as I can.

First, a shoutout to the injury Paris sustained in the previous movie- the fact that she actually has a realistic scar from the type of surgery they would have had to do for the stabbing injury.

The type of surgery is called a laparotomy. The reason it is done is because you can't just stitch up an abdominal wound and call it a day- there is damage to the intestines and potentially other organs in there from the stabbing, and you have to go in and repair all the damage. If you don't, the person can die of an infection from all the poop that leaks out of the intestine.

The next thing to talk about is the scuba diving situation. Here I feel we were promised a lot of problems Ethan would have to deal with, and then those problems were handled mostly off screen or just not dealt with at all. I would have liked to see some of the HPNS or decompression sickness, personally.

Scuba is a set of equipment that allows a person to breathe underwater. It usually consists of a set of tanks of compressed air, a regulator, and a buoyancy control device- a vest that can fill with air and help control where the person floats in the water.

Diving in relatively shallow water (up to about 60 feet) is a common recreational activity and is relatively safe as long as a person is appropriately trained, sticks to the rules, and dives with a buddy.

Going deeper requires additional training and sometimes different equipment. The deeper a person goes, the more complications they face and the more danger they are in, especially if diving in confined spaces, like Ethan does in the movie.

Some of the different equipment involves a different mix of gases in the tanks. For shallow water dives, regular air is fine. Regular air is about 78% nitrogen and 21% oxygen, with a few other gases making up that last 1%. As people go deeper, two problems occur with this mix of gases.

One is that nitrogen dissolves in body tissues under pressure, and as a person makes their way to the surface, that dissolved nitrogen expands into bubbles that cause severe pain and other problems. This is called decompression sickness, or "the bends". The way to prevent the bends is to ascend slowly, making multiple stops where you wait for the nitrogen to leave the tissues at different depths. Ethan couldn't do that (at significant depth you breathe a lot more air, which meant that the air he went down with wouldn't last long enough to allow him to do his decompression stops... conveniently).

The other problem is something called nitrogen narcosis. Nitrogen narcosis is a situation where high levels of nitrogen get in the brain at depth, causing confusion and euphoria (this is not the same as the HPNS discussed in the movie, we'll talk about that in a bit).

A way to prevent both of these problems is to replace the nitrogen with another gas. The main gases used for this are hydrogen and helium. Since hydrogen is not an "inert gas" as referenced in the movie, helium is really the only choice for that "classified" mixture.

Helium still dissolves in tissues, but it dissipates more quickly as the person ascends, meaning decompression stops can be fewer and quicker. Helium also doesn't cause narcosis at depth, making it safer for Ethan.

Another thing that points to helium is the High Pressure Neurological Syndrome (HPNS). HPNS only happens when breathing helium at depths below 500ft (which is like, serious depth for even commercial/technical diving). As far as I remember from the movie, we don't really know how deep Ethan has to go, but we can probably guess its greater than 500ft.

Now, I'm sure there are dive tables/calculators for helium/oxygen mixtures at that depth (commercial and technical divers do go this deep), but I was not able to find ones I could understand. FYI, the deepest regular recreational nitrogen/oxygen tables go is about 140ft, allowing only a bottom time (which is actually the total time under the water) of 8 minutes without decompression stops.

Again, I really wish we had gotten to see more than Ethan in the fetal position under the water for a few seconds and a not-sex-scene in the decompression chamber. Really feel like I would have enjoyed some HPNS symptoms or some actual symptoms of the bends once he was on the ice.

Anyway. Now onto Benji. Towards the end of the movie, Benji gets shot in the abdomen and then later inexplicably gets a pneumothorax. I say inexplicably because for a pneumothorax to happen something has to happen to a lung- you need either a hole in the chest (open pneumothorax/sucking chest wound) or a hole in the lung without a hole in the chest (tension pneumothorax).

Benji had neither- the entrance wound looked like it was in the lower left quadrant of his abdomen. After thinking about it, the only way he could have gotten a pneumothorax is that the bullet bounced around inside him a little and went up through his diaphragm, puncturing a lung and then stopping without creating an exit wound.

So for the purposes of this post, let's assume that's what happened.

So the bullet goes into his lung, and the lung starts leaking air into the chest cavity. Every time Benji takes a breath, more air gets into the chest cavity, which puts pressure on the rest of the lung, causing it to collapse. This can get bad enough that the amount of air trapped outside the lung in the chest cavity can actually start putting pressure on the heart and other lung, which can be even more life threatening.

The treatment is essentially to give the air trapped in the chest cavity a way to get out. Now, this might seem as simple as what they did in the movie- putting a tube in the chest and allowing the air to escape.

The problem with this is that air can go both ways through this tube. Because of the way air gets into the lungs (diaphragm moves down, increases space in the chest cavity, which then causes the lungs to expand to fill that space), air actually "prefers" to come into the chest cavity through the tube to the space outside the lungs because it is a path of least resistance. This makes things worse.

Here is a post about "chest darts" which is a procedure by which a large bore IV catheter is placed in the chest (about where they put the pen cover in the movie). This usually either has a one-way valve on it or the finger of a glove on it, acting as a one-way valve.

Original prompt submitted by @lancedoncrimsonwings.

“Character has broken ribs on one side, then fell from a horse (landing on the injured side and dislocating their shoulder by trying to brace to protect their ribs). Is it likely the fall would worsen the break, and if a rib punctured their lung, how would someone with them first aid that in the wilderness? (Medieval times, generally). They have access to water, a dagger, a form of herbal ish pain relief/sedative made from poppies, and reeds. Survivable or nay?”

This is a fun scenario!

Falling from a horse may seem fairly mundane, but many life threatening injuries can happen, especially if the horse steps on you. To end up with a dislocated shoulder, they would most likely land on their outstretched arm.

The instinct to fling out an arm when falling is stronger than the instinct to pull in and brace broken ribs. The shoulder would most likely dislocate anteriorly from this kind of injury. 

Source

Here’s a step by step guide on reducing a shoulder via the Hennepin technique: 

Lie down. Flat on their back with no pillow. 

The person who’s helping them should gently grab the injured arm by the wrist and bend the elbow to 90 degrees. Support the elbow with one hand, hold the wrist with the other. You can also hold their hand. 

Gently press the elbow to their side. 

Keeping the elbow near their side at all time, gently pull their wrist away from their body, externally rotating their shoulder away. This should go extremely slow, at least 10 minutes to allow muscles to relax. 

The shoulder will make an audible “pop” when it slides back into it’s socket. The pain goes away immediately, but is replaced with a dull throb a few hours later. You want to bind the arm to the chest to prevent movement of the joint as it heals. 

Source: Merck Manuals 

Now… it sounds like a dislocated shoulder isn’t the worst of their problems. Whoever is helping them may be more concerned about their obviously injured shoulder and focus on treating that first, while completely missing the fact that they’re showing symptoms of a pneumothorax, which is what happens if a rib punctures a lung. 

There are two ways you can play this. 

Option 1: Closed-Simple Pneumothorax

This can happpen when a broken rib pops a hole in the lung. This can be a tiny little nick, or a larger hole. Because it’s simple, that means that the air that’s coming into the pleural space (the area between the outside of the lungs and the inside of the chest, normall filled with slick fluid) is able to get back into the lungs again. There is a slight pressure build up, and the lung is slightly compressed, but you can have a simple pneumothorax and not notice it for literal months. The treatment is simple, let it heal on its own. There’s not much you can do, even with modern surgical practices. It’s better for everyone to leave it be. 

Option 2: Closed-Tension Pneumothorax 

Based on the supplies you’ve given me, this is probably what you’re thinking. A tension pneumothorax happens when that air coming into the pleural space isn’t able to get out. With each breath, more air is forced around the lung, collapsing it. The only way to relieve this pressure is to manually release the air by poking a hole in the chest wall. Before you do that however, we have to make sure they actually have a collapsed lung. Here’s the signs & symptoms: 

Decreased breath sounds on the bad side

Sharp pain in the chest

Panting

Fast heartbeat

Jugular Vein Distension (photo)

Tracheal deviation away from injured side (photo) 

Blue lips and fingernails

Jugular Vein Distention

Source

Tracheal Deviation

Source

While this is not a pneumothorax case, I could correctly diagnose a right-side tension pneumothoarx from this picture and listening to breath sounds. 

Alright, you’re sure it’s a pneumothorax? Fantastic. Now it’s time for the fun part. Here’s a step-by-step guide using the supplies (and time period) you’ve given me. 

Step 1: Identify the site you’re going to poke a hole. Refer to handy-dandy diagram for reference.

Source: PlumCast

Step 2: Clean as best you can. If you have strong alcohol, use that. If you have soap and water, use that next. Failing all else, use the cleanest cloth you have with some clean water to wipe off any dirt. The level you’re able to clean will determine the likelihood your character will survive. If you have alcohol, they’re more likely to pull through.  

You should be cleaning the chest, the daggar, and the tiny, hollow reed. 

Step 3: No time for pain medication, it’s not going to kick in anyways. DO NOT give them alcohol to drink for the pain. Use the smallest blade you have to make a small hole in the chest wall right between the 4th and 5th ribs. They only need to go about an inch if the patient is skinny. Most EMS units today use 3” needles, but not the whole needle is inserted. You probably won’t hear any air movement until you pull the dagger out, so it may take a few tries to get deep enough.

Step 4: Pull the blade out and insert the reed. Once the reed enters the pleural space, air and blood should come rushing out. Relief will be immediate, and the JVD and tracheal displacement should fix themselves in less than a hour. 

Step 5: Secure and prevent reoccurrence. That reed needs to stay in place. Use bandages or whatever you have to keep it there. You also need to create a one-way valve to prevent the air from just being sucked right back into the chest cavity through the convient hole you just made. Get a clean rag, soak it in lard, oil, or water if you have to and secure it loosely over the reed. The idea is that when they exhale, the free air in the chest is allowed to escape, but when they inhale, the cloth snaps shut over the reed and prevents air from entering. 

Step 6: And now it’s up to their body. The reed should be changed every 12 hours minimum to prevent infection, the one way valve as well. It’s important to note that if you’re using water on the cloth for your one-way valve, you’ll need to keep that wet. Now is the time for pain medication as well, boil the poppy seeds in clean water to make a tea. Poppy contains a similar chemical to morphine, so they will get some relief from this. It’s really hard to drink when lying flat on your back, so drip a washcloth in the tea and let them suck on it. 

Complications

Your biggest enemy is going to be infection obviously. There are several things you can do to prevent it. 

Clean the site. Alcohol or soap and water every 12 hours minimum (do it with the reed change). Make sure you’re cleaning the open wound, but don’t scrub into the chest wall, that’s going to push bacteria further into the wound. The signs of a local infection are: 

Red streaks coming from the wound

Pus

Warmth

Swelling

Green or yellow pus

Pain

If infection starts to develop, increase the cleaning to 4 hour rotations, and continue to replace the reed at that time. Signs of a developing system-wide infection: 

Fever

Nausea

Vomiting

Chills

Cold sweat

Fast heartbeat

Both honey and garlic have been clinically proven to have antibacterial properties . Apply crushed garlic and honey to the wound. Garlic also appears to be effective if consumed as well, honey is just topical. 

Sources:

Honey: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3609166/

Garlic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458355/

i can’t make this shit up

Pneumonia is a serious complication. Honestly, if they get pneumonia, they’re dead. They will have a high fever, start coughing, and die fairly quickly with a primitive chest tube in place. Sorry. :( 

Sepsis is also a death sentence. It’s a system-wide blood infection charterised by a high fever, low blood pressure, then sudden system shutdown and organ death. There’s not a lot you can do without real antibiotics, so avoid this if possible. 

Thankfully, the line between a bad local infection and sepsis is not easily identifiable without a hospital (a blood pressure cuff, really) so you can have quite a bit of angst around this and still have them pull through in the end. 

 What about the broken ribs? Leave them. There’s nothing you can do. Trying to manipulate them with your hands will only make it worse if you’re doing it blind (without X-Ray guidance.) 

It’s been awhile… now what? Normally, this patient would be rushed into the OR to repair the hole in the lung. Since you don’t have that, here are a few long-term options. 

The lung heals itself neatly. This is totally possible. You’re looking at at least two months though… and it’s a stretch. This character better have plot armor. Note: if you have pierced ears, you know that a hole in the body eventually seals itself off and doesn’t ever heal shut. Same with your makeshift chest tube. Once the lung has healed and it’s time to remove the reed, you may need to scrape the skin of the hole down a little to encourage healing. That’s another few weeks of healing. The lung can regain full capacity, and free air in the pleura will be absorbed into the bloodstream.

The lung heals poorly. As long at the hole in the lung is closed, the body will take care of the rest and absorb the free air. Same scraping for the chest tube site. They may lose use of the damaged lung- some people can learn to live without sections of their lungs but will never be able to do what they used to. It’s important to remember that the broken ribs may have healed in a place where they permanently damage lung function. 

The lung never heals. This means a permanent chest tube. The infection will eventually catch up to them, and they’ll die. 

Best case scenario survival odds: 60% 

Worst case scenario survival odds: 0%

Essentially, if you want them to survive, you can write it in a way it’s medically possible. But they have to fight hard, be strong, and have a healthy body with good fat stores before the accident. 

Disclaimer: Although I’m in school to become a medical professional, I’m not one yet. Please don’t sue. Can you even do that from a Tumblr post? I don’t know. All mistakes are mine, and I’m always open to discussion.

First, I would like to know if the person was hanging by the meat hook. If they weren't, all you have to contend with is the impalement, but if they were, you could be looking at a host of other problems. If all of the person's weight was on the hook, you would probably see the wound widening as the person is pulled down by gravity. You could also potentially see broken ribs, a broken collar bone and shoulder blade, or ruptured subclavian vessels. That's not to mention the damage to the lung.

I can't say exactly what a needle decompression feels like as I've thankfully never experienced one. Assuming the person is conscious when this occurs, my educated guess would be a mild stabbing sensation followed by a release of pressure. The needle is pretty huge (see the image below) so extrapolate as you will.

As far as survival odds go, I'm not confident that the patient is still alive before being taken off the hook, let alone after. But sometimes truth is stranger than fiction so I can't say it's completely impossible for them to survive. Their chances are far better the sooner they get advanced medical care.

I mean, there's so many to choose from but what about a bullet through the lungs? And what about an arrow too for the old fashioned types? Stuff to consider, what often gets portrayed wrong, etc.

That's something angsty people write about right

I really like this question, because I think lung injuries are just so dramatic. Coughing up blood (hemoptysis) is so cinematic. We'll go over basic lung injury, the treatment, and then the specifics for projectile/GSW injuries.

Alright so GSW to the chest, we're looking at some massive hemothorax (a fun word, imo). This is blood in the pleural space (lung cavity), which has a compressing effect on the lung. The lungs do have a high concentration of thromboplastin and low pulmonary artery pressure, which means that bleeding of the lung itself is limited. Mostly the issue is bleeding of intercostal arteries, internal mammary arteries (int. thoracic), and the pulmonary vessels being torn to shit.