A Medical Opinion – A State of Shock

Hi everybody! I’m Stella, a medical student with a passion for writing who’s tired of authors getting things wrong. In this column I hope to answer medical queries of YWS members so that they can write more convincing injuries and illnesses in their novels. If you have a query, you can leave it at http://www.youngwriterssociety.com/viewtopic.php?f=12&t=99843 and I’ll try and get around to it.

A disclaimer before we get started – I don’t want to replace the need for research, I hope to give you some basic information to get you started but Google is still your best friend. Secondly, I am still just a student, I’m bound to get things wrong so don’t take my word for granted. Lastly, it goes without saying, don’t take any of the information here as actual medical advice, this is all for the sake of fiction!

So today’s question is one that I’m really happy got asked, and it comes from the lovely Lauren2010. Lauren asks,

“I’m really interested in what happens when someone goes into shock. Or what level of injury/incident would send someone into shock. What are the dangers if being in shock, is there a higher risk of further injury if you don’t take a rest and recover.

I put my characters through so much, I’m pretty sure they should be taking it harder than they do!”

First things first, there are two very different processes that go under the term ‘shock’. The first is not called shock by the medical profession, it’s called an ‘acute stress reaction’.  This is what we get when we get bad news, or go through a traumatic experience. If your character is bereaved or has a particularly bad confrontation, they may have an acute stress reaction. This does start with a bodily response (acute stress response). To understand this, I’m going to give you a quick rundown of the human nervous system. Essentially your nervous system is split into two – your somatic nervous system that does all your thinking and moving that you want it to do, and your autonomic nervous system that does its own thing. The autonomic nervous system is split into two again. Usually, the parasympathetic nervous system is in charge, and its functions are best explained by the term ‘rest and digest’. It digests your food and keeps your body ticking over at a steady rate. Its job is basically just housekeeping (or ‘maintaining homeostasis’ if that’s what you want to call it).

But then every once in a while, you’re faced with a werewolf or a madman with a sacrificial blade and your sympathetic nervous system takes over. This is the famous ‘fight or flight’ response. Blood supply is redirected to where you need it most, your heart and muscles and brain. A surge of adrenalie/epinephrine is released from your adrenal glands (just above your kidneys) and is helped out by your hormone system – the HPA axis.

Maybe you don’t get over this trauma. Maybe you’re just sick and tired of watching friends die or having maniacs hunting you. But after the initial fright, the feelings of anxiety, isolation, fear, stress all persist. This is the acute stress reaction of which I was talking. It’s defined as lasting between two days and four weeks, and if it lasts past four weeks then it’s deemed to be post-traumatic stress disorder, on the subject of which I am not an expert, and you may be better off looking elsewhere for answers.

But wait! Didn’t I say there were TWO types of shock? Yes, that’s right! And while everybody thinks about emotional/psychological shock, I’m afraid I’m sort of hijacking Lauren’s initial question to answer the question I want to address the most – why is physiological or circulatory shock so underutilised in literature?

The medical term ‘shock’ describes a state where blood isn’t being pumped around the body the right way. This causes multiple organ failure and eventually death. And there’s three main categories:

1.     Hypovolemic shock: this describes shock due to a state of not having enough blood to pump around. This is a good one for writers to keep in mind, as it can be due to bleeding, such as from a wound or internally, or from dehydration. Remember that dehydration doesn’t just happen from not drinking water, it can also happen from having extended bouts of vomiting and diarrhoea, or from burns.
2.     Cardiogenic shock: this is the type of shock probably least useful to writers, but it bears mentioning – cardiogenic shock results from insufficiency on the part of the heart. For one reason or another – generally a heart attack or some other injury to the heart.
3.      Distributive shock: this is another that I think writers should really take advantage of. The most common cause of distributive shock is sepsis – a bloodstream infection that sends you into septic shock. The body undergoes an inflammatory response, with all the blood vessels dilating. This causes low blood pressure, and blood can’t be pumped around the body, eventually resulting in organ failure and – yup, you guessed it, death. Sepsis can come from a wound that isn’t properly cleaned out, and if you’re writing a world before antiseptics – or even modern day as sepsis is still devilishly hard to handle – you should really think about the possibility of your character being in a very serious, life-threatening condition. Other types of distributive shock include anaphylaxis and a few hormonal things which I won’t bother you with… right now.

There are four stages to shock, which I’m not going to go into now, but they are called ‘initial, compensatory, progressive and refractory’. Most of the differences between them lie at a cellular level, and you won’t see any change in your character’s general health, except that they’re steadily getting more sick. If they get to the progressive stage without any help, they’re well on their way to death unless you do something quick. Usually this something involves reversing  the original cause – so if they’re hypovolemic, get them some fluids as quick as you can or stop the bleeding. If it’s cardiogenic – fix their heart. And if it’s distributive, constrict the blood vessels and fight off the infection. The most important treatment is always fluids though, to keep as much blood flow as you can going while you deal with everything else.

Provided you have someone who knows what they’re doing, you can come back from hypovolemic, anaphylactic or neurogenic (caused by spinal injuries) shock. Septic shock though has a mortality rate as high as one in two, which is food for thought next time you decide to give a warrior a festering wound.