Tuesday, June 4, 2013

Series Post: Ask Dr. Dina - Cuts and Punctures

DISCLAIMER: I am not a doctor, nor do I play one on TV. I do not hold a current medical license or certification (I let them lapse because I no longer work in the medical field and don't intend to ever again). What I do have is an extensive medical background in various fields. Everything you read here is the result of either education, training, research and interpretation, or personal experience. The information in this post is not to be taken as a substitute for professional medical advice or examination. Seriously, if you're having an immediate medical problem and you're reading this blog for help, get off the damned computer and call an ambulance! 

Hello Evil Readers! I have returned!

Welcome back to the Ask Dr. Dina series of posts covering medical issues in your writing.

For those just joining us for this series, so far we've covered:

Loss of Consciousness

Altered Levels of Consciousness

Broken bones

Sprains and strains



Today we're going to talk about more types of soft tissue injuries – lacerations and puncture wounds.

To clarify, a "laceration" is fancy medical speak for "cut." Cuts are open wounds (as opposed to closed wounds like contusions – "bruises"), and their depth is extremely important. They can be as shallow as a minor scrape (called an "abrasion," which can bleed or not depending on severity) to a wound that involves every layer of the skin and organs beneath it, like a gunshot.

Now, a laceration is different from an incision. Lacerations have jagged edges and are made by tearing/ripping rather than slicing. Razors, scalpels and even glass shards all make incisions – clean-edged cuts rather than torn. The difference is crucial when it comes to repairing/cleaning these wounds. Surgical cuts (incisions, NOT lacerations) are vastly different from cuts made by injury. Yes, they're damaging, but not nearly as much as traumatic ones. The clean edges of incisions are neater, leave less scarring and heal much faster than ragged ones. For the purposes of this post, we're going to talk about the former type of cut – lacerations.

Gunshot wounds (abbreviated in medical charting as "GSWs"), stabbings, car accidents, falls, trauma of any kind…all can involve lacerations. As I said above, the depth is the important thing. A cat scratch or a paper cut isn't likely to need stitches (though there are exceptions, I know), but then again, some gunshot wounds don't, either. It just depends on where the wound is and how it was made. (We'll talk about infection and wound care in another post.)

The injury itself is bad enough, but the repercussions of that wound is just as important to consider in your writing. If you have your hero shot, you'll need to take that into account. Where was he shot? In the abdomen? Well, there are lots of organs and some huge arteries and veins running through there. Depending on location, he could bleed out in a matter of minutes, or die from sepsis a week later if he doesn't get treatment for the bowel that got nicked. You have to take these things into consideration (I'm looking at you, Hollywood) when you injure your hero.

By the same token, shooting someone doesn't necessarily take them out. Again, it depends on where the wound is and how severe it is. There are things called "in and out" gunshot wounds, in which the bullet goes completely through the body. No bullet to extract (and for the record, you're not going to die from lead poisoning if you don't get the bullet out immediately). Just a hole and anything else it might have damaged passing through. Some bullets do serious damage, others just make the ER doc roll their eyes. (Trust me on this; I've been there.)

Another note about bullet extraction – sometimes it's best to leave the bullet where it is until you can get professional help. It's the same principle as a stab/puncture wound – LEAVE THE OBJECT WHERE IT IS. Why? Because it could be holding back hemorrhaging. Remember we talked about hemorrhage? Yeah, that's fancy medical speak for "bleeding," and if you pull that bullet or stake or piece of glass or metal or stabby object OUT of the wound, you could bleed out before help comes. LEAVE THE OBJECT. I know it's all macho and shit to have the hero pull the knife out of his stabbed wherever and use it on his assailant, but medically? Yeah, bad idea. Looks cool, though, so you're free to take a little creative license on this one. (See, this is why I write paranormal – I don't have to take this crap into account with immortals.)

Which leads us into puncture wounds. Here, have a graphic that shows you the difference between laceration and punctures.

Punctures are the worst possible wounds to deal with. They're messy, usually deeper than they look, nick things under them and are SERIOUSLY prone to infection. They're hard to repair, hard to heal…everything about puncture wounds sucks.

Punctures are caused by pointy objects – splinters, nails, knives, teeth, knitting needles…what have you. Sometimes they bleed, but sometimes (deceptively) don't, leading the person to believe they're not seriously injured when yeah, they really are.

Here's a trick about puncture wounds – if it's more than ¼" in depth, GO GET HELP. Home first aid isn't enough in these circumstances, because most home first aid is only superficial. That wound needs professional cleaning and possibly packing with antibiotic gauze or other type of repair. Just because you can't see any dirt or debris doesn't mean it's clean. This is especially true for facial/scalp wounds (which bleed a hell of a lot even when they're shallow).

Sometimes puncture wounds don't even hurt, because they're so fast and deep you don't know you're hurt until you realize you can't feel anything around the area. Also, just because you can't feel it hurting doesn't mean the puncture hasn't hit the bone.

Punctures are nasty, nasty things, especially stepping on a nail, hooking yourself with a fishhook or getting bitten by an animal (this includes humans, by the way). If you have your hero getting savaged by a wild beastie, there's going to be problems with those wounds later (besides the obvious lycanthropy, zombification, and whatnot), and you need to take that into account as a writer.

While regular tetanus shots have cut down on reported cases of tetanus by 95% (and cut deaths from tetanus down to almost zero), punctures remain the number one source of tetanus infections. (Or as the CDC puts it, "inadequate wound prophylaxis.")

Now, I'm not saying you have to give your hero's vaccination history in your writing. I'm just saying it's something to think about. If you have your hero in the ER with a puncture wound, they're going to ask if he has a current (in the last 10 years) tetanus shot, and if he doesn't, they'll give him one there.

Because that's adequate wound prophylaxis.

Also, if you, the writer, haven't updated your tetanus injection in the last 10 years, it wouldn't hurt you to do that. Because you never know when someone is going to stab you with a knitting needle. Or if you'll get bitten by a domestic or wild animal out on your run tomorrow.

That's it for this edition of Ask Dr. Dina. Next time we'll talk about burns. Or maybe wound care/infection prevention. We'll see. I'm open to suggestion.

Stay tuned!

Questions about medical issues with your writing? Leave them in the comments below and I'll get back to you as soon as I can. (THESE MUST APPLY TO FICTIONAL SITUATIONS ONLY. I AM NOT YOUR DOCTOR, NOR A SUBSTITUTE FOR ONE.)


  1. This series is amazingly helpful. I am at this moment about to shoot a character with an arrow. Are we talking puncture wound then? Or a combination of laceration and puncture? With the arrow head, it seems almost like a stabbing/poking combination.

    1. Arrows fall under punctures, generally. They're stabbing more than cutting. Piercing wounds fall under punctures. Knives for instance. Yes, they can cut, but most knife wounds are stab wounds, or punctures. Great question!

    2. I'd like to add to the gunshot thing - you said you won't die of lead poisoning if you don't get the bullet out immediately. Really, you won't die of lead poisoning if you don't get the bullet out ever - unless it's in your intestinal tract, the lead just sits in the bullet and does nothing but act as any other foreign body. Muscle tissue doesn't leach lead or other metal out. It kills me inside a little how many movies and stories make a huge deal out of digging bullets out, when in most cases you do more damage to the surrounding muscle, nerves, and vasculature than the bullet will ever do sitting there.
      The exception would be if you end up with a chronic inflammatory reaction and recurrent abscess formation around the bullet, but that's a matter of foreign body, not lead, and can happen with any object the body doesn't like (painted earrings for instance, or cheat grass/foxtail awns that get embedded in the tissue).


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