Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Wrist Lacerations as a form of suicide attempt. Because this is a sensitive topic for many readers, I’ve omitted some visuals for this post on Tumblr, and you should feel free to skip it if you feel it might upset you.
For the rest of the Mangled Mondays series, [click here].
1 or 5 (depending on whether the artery was lacerated)
What Is It?
Sometimes, characters want to end their own lives. It’s tragic, and it’s heartbreaking. And if you’re reading this and considering ending your own life, please don’t.
However, this is one of the most common questions that crops up on the ScriptMedic blog: What happens when my character slashes their own wrists?
The answer is entirely along the lines of it depends.
First, we need to consider the anatomy of the wrist. The wrist itself is a collection of ten bones (which compose one of the most flexible joints in the body). There is also a complex set of muscles and tendons that control the motions of the hands, and two arteries that ensure that the hand gets excellent blood flow.
Yes, two. The radial artery is the more commonly known of the pair, and healthcare workers long ago discovered that if they compress the wrist over the radial artery they can feel a patient’s pulse. But there’s also the lesser-known cousin, the ulnar artery, which passes over the pinky side of the wrist. If one artery is damaged or lost, the other is able to keep blood flow to the hand. (This is why we can put arterial IV lines into the radial artery; the hand has the ulnar artery to ensure we don’t stop blood flow to the hand.)
Typically, it’s the radial artery…
that is the target of suicide attempts; I’ve never heard of a patient deliberately trying to cut the ulnar artery, though it’s certainly possible.
The effectiveness of a suicide attempt by wrist laceration is going to depend on two things: the direction of the laceration, and the depth of the cut. The artery is deeper than many people think, and it takes some effort to cut down and pierce it.
The most effective lacerations in this scenario are going to be deep cuts that begin at the pulse point on the wrist and extend up the long axis of the arm (toward the crook of the elbow). This makes clotting extremely difficult.
The least effective lacerations will run along the short axis of the arm, at least 2cm / 1 inch further up from the site of the pulse point. This is because the radial artery is close to the surface of the skin at the wrist but dips fairly deep a few centimeters above that point; shallow cuts will not nick the artery.
Generally speaking, the laceration’s ability to threaten life is dependent entirely upon whether or not the artery is lacerated. If it’s left intact, these wounds are not life threatening, though they may affect function or appearance of the arm; if it’s injured, the character may bleed to death, though it’s possible that they won’t.
“Cry for help” cuts
Many people consider shallow, horizontal lacerations that are ineffective in reaching the artery to be “cry for help” cuts. The idea is that the character “didn’t want to die badly enough” to actually pierce the artery. While this is true in some cases, it is not true in all; the instinct against self-harm in humans is strong, and fear of pain is a large part of human survival. Two characters can have the same level of intent to die, but one may succeed and one may fail, due either to lack of understanding of anatomy or to unwillingness to face pain along with their death.
Radial and ulnar arteries. Gray’s Anatomy, 1918. Public Domain.
In short: just because a character’s cuts are shallow doesn’t mean their intent wasn’t “real.”
We can then categorize these attempts into two groups: nonlethal and potentially lethal. They have very different outcomes and consequences, so while they share a mechanism in common, they’ll be treated separately.
Nonlethal – Clinical Signs
- Bleeding from damaged skin (oozing).
- Venous bleeding (flowing) is possible, especially for short-axis lacerations.
- Potential difficulty moving the hand due to nerve damage or tendon damage.
- Multiple cuts may be apparent.
Potentially Lethal – Clinical Signs
- Arterial hemorrhage: spurts of bright red blood, in time with the pulse.
- As the character enters hypovolemic (decreasing volume of circulating blood) shock, their heart rate will climb, blood pressure will fall, skin will become pale and cool and sweaty, and they may lose consciousness.
- As blood pressure falls, the character may become confused and disoriented.
- If the hemorrhage isn’t stopped in time, the character will die.
Nonlethal – Symptoms
- Pain; worse with the blunter instruments such as scissors or broken glass, less with sharper instruments such as scalpels or razor blades.
- If nerve damage: numbness in the hand.
Potentially Lethal – Symptoms
- Pain, same as for nonlethal.
Feelings of anxiety or nervousness. Character may become certain that they are going to die (feeling of impending doom).
How Does It Happen?
A character attempts to slash their own wrist as a suicide attempt.
Alternatively, someone may attempt to murder a character and have it appear to be a suicide. This is seen more often in fiction than in real life.
The immediate treatment of a suicide attempt in this manner is threefold.
First, hemorrhage control – stopping the bleeding – is critical for survival; the exact methods will be discussed below, as they vary based on the extent of the hemorrhage.
Second, it must be ascertained that the character has not attempted any other form of suicide. Many suicidal characters want to be “sure,” so they will ingest large quantities of alcohol and pills in addition to the attempt by knife.
Third, the character must be removed to a situation in which they are not a danger to themselves. A hospital is ideal, if available.
Hemorrhage can usually be controlled with some form of dressing and pressure on the wound(s). Bleeding will also stop on its own, eventually, but it’s far better for the character to have their wounds dressed.
Stopping arterial hemorrhage is of the utmost important; it is what will determine whether a character lives or dies.
A pressure dressing – a piece of dressing tied in place in such a way that the dressing itself puts pressure on the wound – will likely not be enough to stop the bleeding.
Instead, the treatment of choice is a tourniquet. Belts make poor tourniquets, because it’s very difficult to apply the correct amount of force over the skin. Instead, something like a wide strip of cloth or a scarf, tied using a stick, pair of scissors, or ruler as a windlass, will do well. Generally speaking, the wider the material, the safer it is on the skin.
EMS will likely use a commercially available tourniquet that is fast, effective, and safe.
Characters in shock will need to be kept warm with blankets (even on hot days). EMS may put in IVs but will likely not have blood products to administer, opting instead for IV fluids (Lactated Ringer’s, or LR, for preference).
One particularly vivid detail about tourniquets: it has long been the custom that when a tourniquet has been applied to a character, the one applying it writes the letters TK and the time – for example, “TK 1415” – in blood on the forehead. This is to alert all caregivers that the limb has been tourniquetted; limbs can survive tourniquets for a few hours, but start to die after 4–6 hours. (The time is always written in military time).
Surgery / Hospitalization
For nonlethal injuries, the character will be treated in the emergency department, and will likely admitted to a psychiatric unit on an involuntary basis. The character is clearly a threat to themselves, which makes the admission not just reasonable but imperative in keeping them alive. Characters with complex medical needs will be admitted to a medical floor with a 1-to-1 monitor to keep them safe, since psychiatric units typically cannot meet complex medical needs of their patients. Characters in medical units will be visited by psychiatry staff.
In the emergency department they will get a physical evaluation of their wounds and of the hand to determine if there’s damage to the nerves. Wounds that are deep enough to require sutures will be sutured; see Part 0.3 regarding different suture types.
Characters who have lacerated their arteries, however, are in deeper trouble and will require a great deal more care from the medical team.
First is a full trauma evaluation, including mental status, breathing, circulation, and neurological function. The character may not wish to comply with these things, but they must.
The character will get IVs, likely more than one. Blood will also be drawn; the workup will include CBC (complete blood count), BMP (basic metabolic panel), a tox screen (for toxicology; characters may lie about what they’ve ingested or haven’t), and type-and-cross (blood typing and cross-matching with units of blood).
Characters in shock will be given a massive transfusion; that is, an infusion of blood products including red blood cells, plasma, and platelets. The specific amounts of each blood component given will be determined by the character’s lab values.
Some locations, including the US military, simply use whole blood for their transfusions; this is equivalent to using a ratio of components.
They will also require surgery to repair the damaged blood vessel. This is a relatively simple vascular surgery, but it’s critical to their survival. The sooner they can get into the OR for surgery, the better, since the tourniquet will limit the amount of time they have before limb damage occurs.
Surprisingly, the surgeon may opt not to actually repair the damaged artery. Since the ulnar artery actually provides most of the blood flow to the hand, they may simply opt to ligate (tie off) the damaged radial artery.
That said, the procedure is relatively short, it just needs to be done in a sterile environment.
The overlying skin will be sutured, likely with thread (where some ER providers may prefer a liquid suture, surgeons prefer thread; this choice is almost entirely down to a provider’s individual style.) If needed and available, vascular or hand surgeons may be consulted.
The character will likely be sent to the ICU for monitoring, and from there transferred to a step-down unit before being transferred to a psychiatric unit.
It’s worth noting that the character’s emotional state will also determine, in part, how they’re treated; characters who are calm or depressed will be comforted, but characters who are agitated or who attempt to rip out their stitches or harm themselves will be sedated. Characters who are anxious may be offered medication to help them calm down.
In the Austere Environment
Field sutures are the order of the day. Ligation, or tying-off, of the artery will have to be done by someone who knows what they’re doing.
Field transfusions are extremely rare, but are possible, especially if characters know their blood types ahead of time.
The Rocky Road to Recovery
Characters will retain neurocognitive abilities (unless prolonged shock caused brain damage).
Characters will retain the ability to walk and use their arms.
Characters may or may not have full function in the affected hand.
Some, but not all, characters may have some numbness or weakness in the affected hand, but these effects should be fairly minor and will usually get better over time.
Some characters will have numbness or difficulty moving the distal parts of the hand, but this experience is not universal; many characters will have no lasting disabilities.
Features of Recovery: Hospital Stay
Emergency departments and ICU care have been noted above.
Characters with arterial injuries are at risk of complications from their surgery, including infection, arteriovenous (AV) fistulas (where the two blood vessels are directly connected and bypass the capillaries), and other vascular complications. They may need to return to the OR emergently at some point while in hospital.
Psychiatric units are locked-door units and are typically part of the hospital that originally received the patient, but the character may be transferred to a separate hospital for this portion of their recovery. (If so, they are always transferred by ambulance, not by car.)
Care inside psychiatric units is outside the scope of this book.
Features of Recovery: PT/OT
If the hand and wrist have ongoing numbness or weakness, exercises will be performed to help strengthen the affected hand.
The New Normal
Characters will typically form scars at the site of the injuries; these are publicly visible. Because of the location, they may hide them beneath a tattoo, a watch, or long sleeves. If visible, these scars are common enough that they may or may not be points of conversation or question, and characters may even bond over having similar scars.
Characters who have undergone a psychiatric admission may recover, or may reject what they’ve been taught and learned; this is character dependent and outside the scope of this book.
Characters who have made a single suicide attempt are at risk of trying it again, but this is not a curse; they are not doomed to repeat their attempts.
Total Recovery Time (Typical)
Wound healing: 4–6 weeks
Psychiatric recovery: variable
Broken skin oozes dark red blood.
Lacerated veins emit a steady flow of dark red blood.
Lacerated arteries spurt bright red blood.
Characters may see stars if they are on the verge of losing consciousness. They may also see black spots or get tunnel vision immediately before passing out.
Blood will pool on flat surfaces, but also form clumps (clots) within a few minutes. Characters may trail blood when they walk, and may leave bloody handprints on everything they touch.
Blood has a pungent, sweet, coppery smell to it. It can cause nausea in those who smell it, especially in quantity.
Characters may hear their pulse in their ears as their body begins to compensate for their blood loss. Blood from an artery might splatter against a surface; blood from a vein might make a plunking sound as it drips. Blood on carpet might produce a squish when walked over.
An extremely sharp instrument like a scalpel or razor blade is reported as being very unpainful when used, almost surprisingly so. However, blunter tools, such as glass, screwdrivers, and pizza-cutting wheels, are extremely painful.
“Up the road, not across the street.” – the “proper” way to commit suicide. Yes, healthcare workers are morbid humans.
- The severity of the injury is largely dependent on the damage, if any, to the radial artery.
- Characters are guaranteed a psychiatric admission and will be placed on 1-to-1 care until they are in a locked inpatient psychiatric unit.
- Characters who do not lacerate the artery can be admitted to psychiatry directly from the ER.
- Characters who do lacerate the artery will likely need vascular surgery.
- If the surgeon opts to ligate the damaged artery, the character will not have a palpable pulse in that wrist anymore.
- Characters who lacerate the artery can enter shock and will likely require blood transfusions; this may require an ICU stay.
- Characters may have some numbness or weakness in the affected hand; this will improve somewhat with time and physical therapy but may not disappear totally.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.
will be out 10/23 COMES OUT TODAY!!!, just in time for NaNoWriMo!