Scrapes and bruises -- more medical (mal)practice

[narc0tiq]

As suggested by Dragoonseal in IRC, there should be more opportunities for scrapes, bruises, minor cuts, etc., which could show up as status effects and would provide targets for the first aid system (bandage your finger, whatever).

• Critically failing a craft might result in you cutting your hand or a finger.
• SHARP terrain's cuts might show up as status effects for this.
• Getting knocked down might bruise and/or scrape.
• Getting thrown around by a hulk or brute should be obvious.
• Combat, in general, should have a high chance of leading to these.

Untreated cuts/scrapes could open the way to infection (as zombie bites do), or tetanus, or might just heal on their own even if they're not minded (but decrease the hidden health stat in the process). Not sure if there's much you can do about bruises other than applying ice.

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[Zireael07]

Cool idea!

[KA101]

Cleaning wounds is already a resource-sink. I'm not sold on the need to add more drains on medical supplies/health.

[narc0tiq]

So use different supplies. A simple cut needs to be cleaned and might need a little band-aid (not a full bandage). A scrape likewise just needs some clean water applied. I wouldn't even drain a single point of HP for these -- superficial wounds only.

The idea here would be to give a survivor that first one or two points of first aid skill without requiring grinding recipes or reading a possibly unavailable book.

[KA101]

OK, if you're asking for a use for soap, sure.

[narc0tiq]

Hey, yeah, that's a good one. Didn't even think of that.

On Sat, Dec 13, 2014 at 1:26 AM, KA101 notifications@github.com wrote:

OK, if you're asking for a use for soap, sure.

— Reply to this email directly or view it on GitHub https://github.com/CleverRaven/Cataclysm-DDA/issues/10444#issuecomment-66851145 .

[kevingranade]

This is actually the way I want to go in the future, replacing hp with individual wounds.

[Rivet-the-Zombie]

This is actually the way I want to go in the future, replacing hp with individual wounds.

[DavidKeaton]

@Rivet-the-Zombie you won my heart with that image.

[Dragoonseal]

Apologies if I bring up the game NEO Scavenger too much, but the wound/infection system in it is probably my favorite part about the game.

You get cuts and bruises far more often in NEO, both from combat and also from just scavenging locations and choices in events. You bleed a lot more often because of it, and potentially get more infections because of it as well. However medical supplies like drugs, disinfectant (alcohol), and sterile bandages are very rare and very expensive, so even if you have some you're always having to make the hard choices of using them, saving them for potentially more dire circumstances, or selling them for a lot of money.

However you have other options available, that being dirty rags, boiled sterile water, and boiled sterile bandages. Dirty rags are almost always an option, you can tear clothing into them or just find them pretty much all over the place. While they give you the ability to stop bleeding they introduce a higher chance of infection. Sterile water and bandages are not always an option, if you don't have the equipment to boil your own, but are among the more common finds when scavenging. Clean water makes for a weaker disinfectant and clean bandages lets you stop bleeding without the additional infection risk, and potentially stops the bleeding faster.

So various points about the system for context: You're never told/shown if a wound is infected or disinfected. The name of the game in NEO is risk management, you determine how much precious time/resources you wish to sink into lowering the risk. Wounds could easily heal up on their own and never get infection. See last point. There's an overall immune system stat (and UI bar if you have Medic trait). Low immune system gives penalties, and eventually death. Makes contracting infections easier as it goes down. Antibiotics helps your immune system stat and can help fight off some (but not all) infection types. Very rare, worth a small fortune at traders. Bark/tanin tea gives smaller immune system bonus. Clean water has about a 50% chance of disinfecting. You also need clean water for drinking. Clean water has more importance in NEO than CDDA, as it's almost your only source of hydration, and often only source of disinfecting. Clean water has much bigger weight and volume costs than in CDDA, it's heavy and takes up a lot of precious space. Dirty/unidentified water is readily available, but boiling water is a lot more time consuming in NEO, and boiling containers take up a lot of precious weight/space. Boiling bandages is even more time consuming. Dirty rag plus disinfectant is a quick and easy, but expensive, option for making sterile bandages. Bandages have hefty weight/volume costs as well. Bleeding can stop on its own, but the worse the bleeder the longer it takes. There's a blood stat (and UI bar if you have Medic trait). Low blood gives penalties, and eventually death. Making fires to boil things can draw unwanted attention. Alcohol has about a 95% chance of disinfecting. Very rare, worth a small fortune at traders. Disinfecting with alcohol gives a bit of pain. There's a pain tolerance stat and UI bar. The lower it gets the more penalties you get, easier it is to get stunned from attacks, and eventually you are rendered unconscious if it runs out. Water purification tablets exist, but are uncommon and worth a decent amount at traders.

Personally I'd like to just ape the whole system for CDDA, it would be a great fit and could be expanded on, but I think even just parts of it could do a ton to help the boring first aid aspects we currently have.

My suggestions for a CDDA style of this: Don't tell/show if wounds are infected/disinfected or not. Unless they're actually showing symptoms. Clean water by itself as a low end disinfectant. Less effective than in NEO because of its availability. Low to mid range disinfectant options. Soap and clean water, bleach/water solutions, acid/water solutions, saline solution, choice alcoholic drinks, etc. High end disinfectants, like we have already. Certain chemicals, specialized alcohol, iodine and hydrogen peroxide solutions, etc The sky is the limit really, there are an incredible amount of disinfectant and antiseptic options, many of which are already items in the game, others that could easily be added. Some disinfectants could give pain. Recipes for clean/sterile bandages. Low/no skill requirement, auto learn. More of a time/tool concern. Low/no skill requirement auto learn disinfectant recipes as well, if they need recipes. Option to use rags as non-sterile bandages. Immune system stat (or the health stat expanded on), blood stat. Saline injection to help with blood regen, or help counteract the penalties of low blood. Failing that, plenty of food and rest.

[Okiemurse]

See also: UnReal World, Dwarf Fortress

I love the ideas! Adding in the need to make a decision to staunch bleeding NOW on a bad cut with whatever is at hand and risk infection or to wait until you can get back to your home base where you can use proper clean supplies but risk bleeding out before you get there sounds like it adds meaningful gameplay decisions into the mix. In other words, fun!

[KA101]

I've bled on a few occasions, and one major point is to keep pressure on the wound. Currently the only mechanic we have for that is that you're presumed to be applying pressure, and therefore don't bleed, during long actions that are trying to stop bleeding.

If we're going to permit wound conditions to (sometimes) passively resolve, I'd like to be able to hunker down and use the long-wait action to just apply pressure and see if that stops it.

[Okiemurse]

To add my opinions on health and injury in general as a healthcare worker:

You have several stats. Some hidden, some not. Medical knowledge should make some hidden stats visible or give you some hints on how well things are working or what might work to fix a problem.

Keep current immune stat. Add a hidden blood stat (although if it gets low you should start feeling noticably weak and faint). Maybe adapt the existing limb HP stats into "limb function" that can impose greater penalties the more the structure (muscle,bone) is damaged. Limb function should probably be visible since how well your arm works is pretty obvious to a layman.

Individual wounds. Easily abstractable to head, torso, arms, and legs but could be expanded all the way down to eyes, fingers, major vital organs if you really want to do all that. It would be super cool to see a Dwarf Fortress style crit system where some hits, especially from piercing weapons, can puncture a lung but that might require a significant overhaul and could be set aside until the basics are in place and has the potential to be heavily cumbersome.

Deep/serious wounds should significantly impair the limb they're on in some way. Moderate wounds may not on their own but should add up to a penalty if you get too many.

If you really wanted to get grim add in broken bones and splints/wheelchairs. Maybe even a survivor game start that starts in a hospital or something with a broken leg. You could also add in the major vital organs hidden so that major injuries could affect the brain, lungs, or heart but that opens up the possibilities of one-hit kills if an attack does significant damage to one of these so it depends how gritty you want this system to get. I personally like a pulp feel and would avoid this but to each his own.

The type of damage you receive should affect what happens to you. The damage numbers should indicate severity of the wound.

• Slashing/Tearing: Deep localized wounds that can sever arteries and completely sever large muscle groups and nerves. Dangers are blood loss, loss of limb function, permanent loss of limb?, infection.
• Crushing: Blunt force trauma. Can cause internal bleeding, compartment syndrome in a limb, broken bones, punctured lungs from ribs, and all sorts of other nasty torso injuries. Very little to no risk of infection due to skin staying intact. Dangers should primarily be loss of limb function unless you want to get into modelling hemopneumothoraxes and flail chest.
• Piercing: Very deep very localized wound that tends to pass in a straight line through the body. Dangers from this are to the vital organs, and bleeding risk is lower in the extremities. You don't want your torso pierced through as the list of nasty things that happen to your organs and major vessels with a hole through them is quite long. Dangers should be bleeding, vital organ damage, infection.
• Fire/Acid/Electricity: For sake of simplicity I encourage keeping these the same category. All of these damage modes attack the biggest organ in your body - the skin. Highest danger from these is by far infection, and if the burns are big enough dehydration is a huge worry as well. A strong enough electrical shock could disrupt the heart but this might be viewed as a one-hit kill without an implant to defibrillate the heart once it goes into ventricular fibrillation so you might want to leave that out. You don't want fire or acid burns on the head as you have a very good chance to damage your senses. In real life fire to the head generally means very hot smoke in the lungs which means you will be breathing fluid very soon instead of air but that can be left out I think.
• Smoke/Fumes: Smoke inhalation is pretty bad for you as well without a good respirator but not a huge need to revamp things here I don't think.
• Radiation: While radiation does do genetic damage which in real life causes cancer and in game causes tentacles, rapidly absorbed high doses of radiation can damage the skin so badly that the vascular system collapses and the skin sloughs off in full thickness, much like a very deep burn and if this type of damage is included, should be treated as a "radiation burn" and have all the same effects as an acid or fire burn.
• Poison: Really depends on what type of poison you want to model. There are several types of poison. Toxins, or poisons from nature, are the only ones that are really applicable to this game (unless you do something stupid and ingest a gallon of a highly corrosive substance like bleach or lye). Some of the nastiest poisons are actually a mixture of most of the below. --Cyanotoxin. From Cyanobacteria, or blue-green algae. These can vary and cause respiratory failure, liver failure, and skin rash. --Hemotoxins. Most commonly from pit vipers. These attack the red blood cells and cause very rapid anemia. --Necrotoxins. Common sources are brown recluse, puff adder, necrotizing fasciitis (flesh eating bacteria). These destroy all tissue they come in contact with in a fairly localized but spreading manner. --Neurotoxins. These attack the nervous system. Common sources are black widow, scorpions, box jellyfish, sea snakes, cobras, cone snail, blue ringed octopus, and many venomous fish. These will threaten local limb function in lower severity and central nervous function in higher severity. --Cytotoxins. These are pretty nasty and disrupt basic cell function. Pretty deadly. A common cytotoxin is ricin which interrupts basic cell metabolism in a major way. --Apitoxins. Bee venom. These operate by stimulating your inflammatory system and in rare cases deadly allergic response. Generally harmless but in high doses (like from a giant bee) the site will become extremely inflamed and the immune response can go into overdrive systemically and you can get so puffy you can't breathe.

Treatment of poisons is primarily supportive care, i.e. treatment of symptoms rather than the poison itself. Some specific poisons have very specific antidotes. Injected poisons can be slowed or stopped from spreading systemically by binding the limb in a pressure bandage proximal to the injury to stop the spread and immersing the limb in hot water (50 celsius) to break down the proteins of the poison. This only works on protein-based poisons which I believe most animal toxins are. You can further decontaminate the body if the poison was ingested into the stomach with activated charcoal, gastric lavage, bowel irrigation, and nasogastric suction. Vomiting is not effective at getting the swallowed poison back out.

As far as treatment of wounds, you're absolutely right that a survivor should with even a boy scout manual be able to make some pretty clean dressings and do some basic doctoring of moderate to mild wounds with no difficulty. Mild wounds take no longer than 5-10 minutes to stop bleeding in a dangerous way. Moderate perhaps 30 minutes of pressure would be more than adequate. Larger gashes may require stitches/staples/butterfly bandages/superglue. (Did you know that superglue, or cyanoacrylate, was used as a spray in 1966 in the Vietnam War to stabilize soldiers in the field and that it, under the trade name Dermabond, is a highly effective tissue bonder that has been shown to be safer and more effective than sutures and has been in wide use since 1998?)

Dressings have 2 purposes: One is to hold pressure for you constantly. Wrapped around an arm tightly or taped down to the torso with enough very tight tape, these can hold pressure for you while you use your hands for other things. Compressing the severed blood vessels is the best way to stop bleeding. The second purpose is to create a "lid" on the wound to keep dirt out until your body is done healing over the wound. A dressing itself will not fix a dirty or infected wound but will keep a recently cleaned wound from getting dirty again. The pressure part can be done with any ol' handy item that can be wrapped around the area. The "clean lid" part is a bit harder to do in the woods but some scavenged antibiotic cream and boiled rags could do very well in a pinch. Many Dermabonded wounds I've treated don't even need dressings as the glue acts as its own waterproof seal.

Saline is tricky and should probably only be used with a disposable IV set just like how the syringe works and the saline itself should probably only be scavenged, not easily craftable. Sterility is HIGHLY important when injecting things directly into the bloodstream intraveneously if you want to prevent infection. The saline will help keep blood pressure up in the case of acute blood loss. The blood will dilute and cause anemia but hypovolemia will kill you way faster than having low red blood cells. Most people without a chronic illness that inhibits production can regenerate their red blood cells fast enough for anemia to not be a problem except in cases of ridiculous amounts of lost blood. Maybe recent consumption of red meat can give a 1 day buff to blood regeneration rate?

(all of the above information is just for fun and having all of it added to the game would take forever and make first aid a chore - I just am a medical geek. Use it to inspire you to make an awesome first aid system that is FUN!)

[DavidKeaton]

Honestly these are all great points. I do plan on coming back to my medical additions, and help how I want to start. I, a healthcare duder myself, want to stick closely to a good system for this stuff, and you got some gears going with ways to do this.

[Okiemurse]

I forgot to add a note on cauterization!

Thermal cautery (i.e. hot knife on wounds) is actually very very effective at stopping bleeding, even on full amputations, and is still used today in the form of electro- and chemical cautery on with very fine instruments to close individual blood vessels during surgery. It also kills virtually any microbe that might be in the area at the time (even zombie spit!)

The form in game has a very big drawback however - INFECTION. By giving yourself 2nd and 3rd degree burns, you're setting up a 5-star germ buffet for anything that wanders by after the cauterization. I think the form in game is pretty good actually. Self cauterization should be used as a last resort emergency measure ONLY and should be very effective at stopping bleeding and risk of zombie bite problems in exchange for a very heavy penalty of the worst pain imaginable plus a very high risk of gangrene/infection in the future with environmental microbes. This could be modeled by stopping the blood loss but adding a "burn" injury to the area with all the inherent penalties.

Another idea while I'm typing this - premedication with lidocaine and a syringe could be done to an individual wound before treatment to negate some of the pain penalties of treating it! It also comes in a spray form but injectable is more effective.

[deathnutts]

also some thing that could be added is "quikclot" witch is a powderd cloting agent that is used out hunting and in sports a lot

[Okiemurse]

Yeah, QuikClot gauze and WoundSeal powder and alginate pads are all really cool items that could probably be abstracted into a consumable non-craftable item that gives you a much higher chance to succeed at the "holding pressure" skill and could outright just stop minor cuts. You could just call it "hemostatic powder".

[KA101]

"quikclot"

Already in, under that id. Named haemostatic powder, IIRC. ;-)

[Okiemurse]

LOL well then. You could use a charge of the existing item to just knock an active bleed down one category? Severe to moderate, moderate to mild, mild to none. Only useable once per wound?

(there is an inherent problem with me vomiting ideas all over the place but never having gotten my own character past mid-game or so. Never had a bionic superman or anything. Or encountered Haemostatic powder)

[illi-kun]

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