Knocked unconcious on a pirate ship

[sunsalute]

Can I pick a medical brain about how you'd care for someone that was knocked unconcious with a blow to the head? If there's experience with how it feels and how to describe waking up, that would also be super amazing. I know it's super dangerous and requires a hospital visit but this is fic-land and historical and they're on a pirate ship so we're ignoring that small tidbit.

Setting: I'm not going to lie, this is pretty vague. Whatever Pirates of the Carribbean is, ish? On a ship belonging to a relatively well-respected naval officer who's just picked up someone with an 'or alive' bounty. As little crew as they can get away with.

The Knockening: poor Character is headbutted into unconciousness. They stay unconcious long enough to be moved to another ship.

The questions:
-how long can they stay unconcious before breaking suspension of disbelief
-how would someone used to dragging unconcious bodies around check up on Character as they wake up
-how does it feel to wake up after such a blow
-assuming no lasting damage, what temporary damage can Character expect?

Thank you so much!

Comments

[pallas_rose]

MY TIME HAS COME! :D

In the real world and my personal experience, unless there is concurrent substance abuse (e.g. they're not roaring drunk), the loss of consciousness for a concussion is pretty short, on the order of minutes. However, after they wake up, concussion victims can be perseverative (asking same question over and over again) and with short term memory loss (don't remember asking that same question before, nor your previous response) for minutes to hours. However, I am constantly reading fiction with people knocked out for hours with no sequelae, so I think most people would be willing to suspend their disbelief for an hour or so.

With a more severe TBI (traumatic brain injury), where there is actual bleeding in the brain and the victim has a persistent depressed level of consciousness, they may never recover fully, and if they do, it may take weeks to months to years.

Someone used to people with concussions would be resigned but patient with the very annoying repetitive questions of the concussed, explaining what happened and where the patient was and what was happening over and over again. If they were also experienced with moderate-severe TBIs (even in old timey land!) the things they would likely check to see if the patient was deteriorating (e.g. bleeding getting worse, brain getting compressed) would be: symmetry, reactiveness to light and size of pupils, patient's ability to talk and be coherent, and ability to move all their extremities on command (raise your right arm; squeeze your left hand). Depending on the medical tradition you're using, a doctor might use trepanning (cutting into the skull; we would now use the term Burr hole in the modern era) to relieve pressure from bleeding on the brain if there are lateralizing signs (eg, an asymmetry in the physical exam). They would be planning to do this immediately and urgently if the exam changed, to prevent herniation of the brain and death. They'd do it with a hand drill after cutting an incision into the scalp.

As for how it feels: I have had patients with concussions who lost consciousness have no headache and others have terrible headaches, so both are possible. Concussion symptoms often include nausea, vomiting, dizziness, and photophobia (light hurts your eyes). If they don't remember the blow or the preceding events or immediate aftermath, they may never remember it in the future.

Similar answer for the cases with no lasting damage (meaning a minor concussion; mod-severe concussions can have the above symptoms and more for days to weeks).

Often people with concussions from being struck with an object have a laceration to their scalp where they were hit that bleeds like stink and needs washing out and sewing up. Even on the forehead, the scalp can split like that, and can bleed briskly! Even if no actual laceration, you can get a real goose-egg of a hematoma or a skull fracture. That said, the bone under the forehead is some of the strongest bone in the body, so not likely in your scenario, especially if they don't have any lasting symptoms.

Does that help? Anything I can clarify more? SO thrilled to be able to use my knowledge to help fic or fannish writers :)

[source: I am a trauma surgeon]

[armiphlage]

I agree from the patient side about repeatedly asking what happened and forgetting the answer, until people get annoyed and say they'll tell you later. Plus nausea and vomiting. And dizziness and being unsteady on your feet (especially with blood loss).

[celli]

This is great, from someone else writing about concussions. My guy is in a hospital, so I'm basing this all on my experience of two and a half concussions, but, you know, write what you know. :)

A followup question, if you don't mind - after my three injuries, they always did CAT scans. Is that standard for concussions, or depending on the result of other checks?

[pallas_rose]

Yes, it's standard for all injuries where the mechanism/history is consistent or reasonable risk for TBI, the spectrum of which includes concussion (no bleeding in brain, but loss of consciousness and/or symptoms) and the various kinds of brain bleeds: subdural, epidural, subarachnoid, and intraparenchymal hematomas/hemorrhages.

Basically, if you hit your head and pass out, or the mechanism of injury is with enough force (a car crash, for example), or you're older (brains shrink and rattle more in the skull, increasing risk of bleeding) or on blood thinners, we scan your brain. Plus other reasons I'm not remembering right now.

If it's negative for bleeding inside the skull, then you can be observed, either in the hospital if severe concussion or at home with people if less so.

But if there is bleeding, you often get serial scans or admitted for close observation and neuro checks. There are scales and such for treatment protocols depending on various factors, but that's the general case. Some kinds/extents of bleeding in the brain requires surgery. All traumatic bleeding in the brain (according to most US protocols, probably global as well) gets a week of seizure preventing medications, as well. Trauma centers will often check coagulation studies and correct any blood clotting problems to help prevent the bleeding from continuing.

[vriddy]

This is so helpful! My characters tend to live the kind of lives where they either get concussions or need to be unconscious for a bit, I'm adding this to my dw memories for later reference :D

[michelel72]

However, I am constantly reading fiction with people knocked out for hours with no sequelae, so I think most people would be willing to suspend their disbelief for an hour or so.

I am still salty about a fanfic in which a character was clonked over the head and was unconscious from that for half an hour but was confident he didn't have a concussion! (And that wasn't meant to be character confusion; the writer really did think a concussion was something separate from the half hour of unconsciousness caused by the blow to the head ....)

[pallas_rose]

Oof. Yeah. But if I back-buttoned from every medical improbability I wouldn't read much! I suspend my disbelief liberally!

[dreadlordmrson]

Thank you so much for this information!
I just had a character run over by a car, but because of magical protections, he only had the "minor" effects of a concussion and copious bruising over most of his body.
I had written him as waking up in his own family's hospital a few hours later, but this information makes me think that maybe I should edit the fic to give him a choppy memory of the time in between where he was being moved around.

Right now I have him -- right after waking up at home -- storming around his house in his normal manner, grumpy and with a headache, some balance issues, and sound sensitivity. Then he goes to bed normally.

You mention moderate-severe concussions having symptoms lasting for days-weeks, does that mean a light concussion only lasts hours to days?
Is there a strong or light correlation between severity/number of symptoms and length of concussion?

How unlikely would it be to have him waking up feeling mostly fine in the head after a night's sleep? It feels a little like I'm letting him off too easy after having him run over, but I know from family history just how rough severe bruises alone can be.
Less for medical reasons and more for narrative feel, it would feel better to have his head injury slowly ease off over the course of 2-3 days. That seems a decent timing from what I can understand of your post?

I've also heard that the brain is extra vulnerable for a while after a concussion, as it recovers in ways that aren't made obvious through symptoms. That people need to be extra careful of impact or possible whiplash-like effects or anything else that could jolt the brain in ways that normally would be sub-concussive in effect.
Should his doctor* father be giving him advice to be very careful with physical activities for... days? weeks? a month or two? after the accident?
I already had the character thinking about that as he had to go upstairs to get to his bedroom, while slightly off balance.
(* I think his father is a GP but I haven't double-checked)

Thank you in advance if you answer any of my questions.
And thanks either way for reading this somewhat train of thought post.

[pallas_rose]

Hi hi!

His grumbling around with a headache sounds within-normal-limits to me for the day after a mild concussion, but I will say that often times being covered in bruises is SIGNIFICANTLY worse the next day. Plus, young men are the WORST patients. Unless they've done a contact sport for a while, they've never really been in pain, and are absolutely shocked and unable to cope with it. So unless he's a football or rugby player, he should notice the bruises feel worse! He might even be surprised and horrified at how much pain and how stiff he is upon waking the next morning.

Having a choppy memory or some amnesia of the event and immediate aftermath is perfect. Yes, a minor concussion is probably an hours-to-days phenomenon. When you get into repeated concussions you've lost me, that's a neurologist's or Physical Medicine & Rehab person's bailiwick.

In terms of correlation between severity/number of symptoms and length of concussion: I don't THINK so? TBIs in general are unfortunately a lot of "well, let's see what we end up with" and sometimes people do a ton better than we expect and sometimes a lot worse. We don't know how to predict outcomes very well!

Hmm, in terms of brain being more vulnerable: well, it is for sure after a real brain bleed or stroke to things like hypoxia, low blood pressure, etc, which is why a patient with a true TBI goes to the ICU for monitoring usually. Out of the acute phase for a concussion (days?) I don't know that we have much in terms of re-injury counseling, except for the fact that repeated concussions lead to CTE (the thing football players are rightly suing the NFL for these days). If he's covered in bruises, and dizzy, he probably won't WANT to do physical activities for days to weeks! Usually we say things like: listen to your body, don't push through pain, but be lightly active as you can tolerate.

And wear a g-d helmet!

[dreadlordmrson]

Thank you so much for taking the time to answer!

re: contact sports
Canonically, he's been a martial artist since he was around 6, and he gets into tussles with school bullies regularly, so he's at least used to getting into fights and sometimes roughed up.

I'll definitely be going back and editing to add some fractured memories of him getting moved around between the accident and getting home, then! No more X hours of full unconsciousness for my boy.

He probably should wear a helmet. :p
Though in this case he was on foot and got hit by a car that veered off the road, so he didn't exactly expect to be in a dangerous situation at the time. And he had his fic-magic to keep him from going home in a body bag.

What I know about concussions has been, y'know, what I could scrap together from the internet that wasn't too contradictory. Plus the time when I was young that I only partly remember, when my mother had a very severe concussion that left her emotionally regressed to childhood for... months. And even after recovering she had some permanent cognitive-behavioral effects. Just being a little bit more volatile, a little less emotionally regulated...
And that was just from falling out of her chair at work! ...admittedly, onto a concrete floor.
But I know my personal concussion experience is not super typical and not a great measuring stick for how to handle more minor or moderate cases...

So thanks again for all this information!

[acelightning73]

When I was a kid, I'd see all these movie and TV adventures where someone got punched in the head and fell down, and by the next commercial break he was on his feet and chasing after whoever punched him. I knew from my own experiences that being hit in the head isn't like that.Every time it happened to me, it left me dazed and disoriented, with a lot of pain where I was hit and, I'd eventually throw up. Not like Heroic Private Detective who just got whammed in the medulla oblongata with a large revolver.

[cnoocy]

I'm sorry you had that much experience with it at a young age.

[acelightning73]

I was bullied for being a weirdo. At one point an adult said, "Why are you hitting her? You're bigger than she is?" "She's a weirdo, so we have to beat the weirdness out of her." "What do you mean she's a weirdo?" "She does weird things, like read books for FUN. We only read books when we have to for school." Childhood in the suburbs.

[full_metal_ox]

And somehow I just bet you read ahead of your grade level! And even committed that most grievous of offenses, reading ahead of the assigned chapter!

[acelightning73]

I was actually skipped ahead a grade - instead of going from 5th grade to 6th, I went directly into 7th grade. And I read and did book reports outside of class assignments, for extra credit. "You did schoolwork you didn't HAVE to do? Why?" (It increased my average, and I was on the Honor Roll. My parent bought me an expensive toy as a reward for making the Honor Roll. And I usually read the entire textbook once I received it. Once I had the bright idea of answering all the chapter questions in advance, but the teacher considered that cheating.

And because I got put into junior high ahead of time, I wasn't old enough to take driver education (you had to be 16) when I was in 12th grade. And I looke awfully silly in my prom dress.

[full_metal_ox]

Wow—that’s one hell of a way to accrue research, isn’t it! I hope that by now you’re safe from whomever did that to you.

[acelightning73]

Well, I'm 75 years old, not 11. And I've had a lot more practice being weird.

[lyorn]

Not a medical brain, but the scariest thing I ever experienced:

I had a motorbike accident when I was 17 and must have hit my head badly when some car (not going fast) drove into my right side (probably) while I was not going fast (quite sure). I was wearing a helmet.

That was around half past five in the evening, in December, so it was dark.

I remember an endless night chopped into pieces, a strange place I could make no sense of, people around me I did not recognize, me always asking "what happened", "where am I", yet never receiving an answer.

Later I learned that one of the people had been my mother, and that my questions must have been answered dozens of times. Another was my best friend who I did recognize and who could calm me down a bit. I remember nothing of that.

I awoke around nine in the morning and recognized that I was in the local hospital which I knew well enough, and that it was winter outside. Someone had said something about an accident, and after I had checked that I was physically OK, I mostly worried about my motorbike. When I tried to remember anything, I found that in my last easily accessed memories it was summer. I had some skin scraped off my knuckles, a bruise on my chin, and was otherwise OK enough. I took me about three days to piece my memory back together, but I happened on forgotten details for weeks, and I never remembered the accident.

So:

To my best guess, I was up (and agitated as hell) probably shortly after they got me into the hospital which was 500 metres from the accident site. Maybe even in the ambulance? Consciousness is not either/or. It has degrees.

But I was completely out of it for more than 12 hours. Even if you allow for most of them to have been sleep, it took the staff at least 30 minutes to find my mother and get her there, and my best friend arrived later than her.

I did not even have much of a headache, and my eyes were just fine. (I had a concussion when I was eight and I had trouble reading for about half a day because the letters seemed broken.) I was confused and worried but very relieved that I was physically OK.

I might have been nauseous and lost my supper. That had also happened the first time I had a concussion, where I did not lose consciousness, awareness or memory.

Five days after the accident they let me out of the hospital. Two weeks after I was still easily exhausted and fatigued. One month after I was quite well again, also mentally: I was preparing for final exams (in math, chemistry and geography) and passed the exams two months after the accident.

No lasting damage, except for some months in my life which have always been a bit vague in my memory.

[pallas_rose]

THANK YOU for WEARING A HELMET. Truly, honestly. I am so glad you did.

Also, everyone always asks about their bike! It's a classic.

[acelightning73]

I agreee about the helmet

I dated a guy who had a motorcycle, and who was teaching me how to drive it. There was a highway cloverleaf which wrapped around a very low hill, and people used to drive up it on motorcyles and bicicles to get a little bit of a "jump", and my boyfriend did that, and the bike landed on its side. I was wearing a helmet, which prevented me from having my face scraped off in a patch of gravel, and my ankle landed on the exhaust pipe which gave me a nasty-looking burn. But I kept trying to drive that bike, which was too tall for me - my feet didn't touch the ground when I straddled the seat.

And my son worked in a hospital as a volunteer, and also as an EMT, and motorcyles are referred to by ER personnel as "donorcyles".

[abracanabra]

From personal experience in being a dumb-ass, if they get a hard hit to the front of the head, one likely medium-term damage effect is raccoon eyes bruising and swelling that will take a couple of weeks to go down (but takes about 24 hours to fully develop). Painful and VERY noticeable.

Welfare check might include checking to see if the pupils dilate appropriately, if they match in size, if they remember what happened, if there are any squishy spots in the skull, if there's clear fluid or blood coming from the nose or ears.


Wakeup might be--hey, I'm awake! ...why does everything hurt and why are things sort of blurry? Why can't I remember what happened? (A few minutes to an hour of memory loss prior is likely.)