Tuesday, July 29, 2014

Author Question: Treatment of Burns circa 1807


Michelle G asks
:


I'm working on a historical (surprise, surprise) 1807, to be exact, in England, and wondered if you could give me a little medical advice? I've burnt the leg of one of my characters, a little boy, like 9, and I want him up and about in 3 weeks or so, but he can use a crutch. What would that leg look like? How much pain? How would he react that first week? I don't want to overdo it, nor do I want to gloss over it either. What's your .02?

Here's what happened to him...

“Thomas leaned over the hearth to scoop a ladle of stew from the pot. He moved too fast, with too much force. The hook broke. The pot fell into the flames. Coals shot out, catching the fabric of his trousers. He tried to whack it out, brave boy, but ended up fanning it larger. He ran. I stopped him. I thought he was…” She gulped back the lump in her throat. “I thought he was dead.”

Jordyn Says:

This sounds like a pretty significant burn-- his pants catching on fire. Easily partial thickness and could even be full thickness in some places. Have you considered just having the pot of stew fall on him-- maybe with bare legs? This would be more partial thickness and could more likely heal in your time frame.

Full thickness burns are problematic because they usually require grafting so back then treatment was likely very limited. We also do fluid resuscitation for significant burns and if both of his legs were this severely burned-- he'd need quite a bit of fluid, and again, I'm not sure this would be available during your time period.

So, I might try to back down the injury to second degree burns. Those should heal up pretty nicely in your three week time frame. Second degree or partial thickness would include skin blistering and peeling, big concern for infection (intact skin is your largest protector against infection) and dehydration initially because burns also leak a lot of fluid. He could probably walk with crutches. It's not really a muscle injury (it would be if you go with full thickness burns-- like his pants catching of fire) so he should be able to walk.
Pain is going to be a big issue. Burns are very painful. So, he's going to need something.

Here is a very interesting link that has tons of information on the evolution of burn surgery. It will give you some treatment options for your time period. 

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Keep up with the exploits of Michelle Griep at Writer Off the LeashFacebookTwitter, and Pinterest. You can check out her latest novel,  A Heart Deceived, at David C. Cook as well as AmazonBarnes & Noble, and ChristianBook.  


Sunday, July 27, 2014

Up and Coming

Hello Redwood's Fans!

How has your week been? Mine? STRESSFUL! I've been planning a surprise birthday party for my husband. It's a BIG one but I won't divulge the number here. As of this writing, the party is tomorrow but when this posts the party will be DONE and I'll likely be drinking some of the leftover liquor to celebrate.

Do you like surprises? I do. Maybe that's why I'm a suspense author. It's been interesting, weaving these lies to keep him in the dark until the big reveal. It's actually been kind of hard because, even though I am a suspense author, I don't find it easy lying to people in real life-- particularly a loved one. I don't know how people lead multiple lives and lie to SO many. I've had trouble with one birthday party and not letting something slip.

What's been your most favorite surprise ever?

For you this week.

Tuesday: Michelle Griep stops by (who is awesome!) with an author question about historical treatment of burns.

Thursday: Author Martha Ramirez stops by to share her personal experience of discovering she had a congenital heart defect as an adult and how this inspired her to write a children's book.

Have a great week!

Thursday, July 24, 2014

Author Question: Hockey and Head Injuries


Elaine asks
:

A hockey player gets knocked down in a fight and hits his head (with his helmet in place) on the ice. Could he be unconscious? I know the trainer would come out on the ice and possibly a doctor, but if he is unconscious, I’m assuming they’d call for the stretcher and put him in the ambulance as a precaution.

I was going to have him regain consciousness in the ambulance on the way to the hospital, but wonder what would the paramedics/EMT (which/who would it be) be doing in the ambulance? What would they do if he “came to”? And what would happen when they reached the hospital?

Jordyn Says:

Yes, it would be possible for a hockey player to be knocked unconscious with a fall on the ice even with his helmet on. If he stays unconscious, then he's going to need to be transported to a hospital. Baseline treatment would be C-spine precautions (C-collar, back board), supplemental oxygen even if he is breathing adequately on his own, and likely an IV.

If he wakes up in the ambulance, they'll first orient him to what happened. "Hey Mike, my name's Roy and I'm a paramedic taking care of you. You took quite a hit on the ice and you were knocked out. To be safe, we put a c-collar on you and put you on a backboard to protect your back. We're on the way to Swedish Medical Center to get you checked out."

Then they'll assess him. Can he move everything? Can he feel everything? Does he know his middle name? Does he know the month? Does he remember any part of the accident? Does he know what city he's in?

At the hosptial in the adult world-- you're more likely to get a CT of the head for this type of injury. So upon arrival to the ER-- the nurse would check his vital signs, do a neuro exam (as described above), and make sure the IV is patent.

The doctor will likely order plain x-rays of his neck and spine and a CT of his head. If all that checks out-- he would probably be discharged home.

Tuesday, July 22, 2014

Author Question: Doctor's Training


T.E. Asks:

Hello, I realize this may sound quite bizarre, but another author recommended you to me because I have a question about medical school.

One of my characters is currently doing an internship to become a doctor. I imagine he's about 8-10 years in with his studies, and he's at a small hospital in a fictional town right now. I know he's not a certified doctor just yet . . . but I have no idea what people refer to him as? I've heard he should be called "Fellow Xiong", but I want to make sure I've got this right. Can you help me?

Thank you so much for your time.

Jordyn Says:

Thanks for sending me your question! First, my answer is based on this being a US medical school. Not sure where you're from.

Medical school is four years. After a person completes medical school-- they take an exam and if they pass-- they are then referred to as "Doctor" and then last name. After medical school they pick what type of residency program they want to do such as adult surgical, adult medical, pediatrics, etc. A doctor's first year of residency is called their intern year but they are still referred to as Dr. such and such. After residency, they can further specialize into a discipline like cardiology, transplant surgery, etc and this would be referred to as their fellowship program.

But-- after they pass the exam after medical school they are always "doctor" and then last name regardless of where they are at in their residency or fellowship program. We might further clarify among ourselves as medical people (he's a first year resident or first year fellow) because this will give us an idea of how much training they have had.
If writing a book, though, as staff we usually call each other by first names. In front of families we'll usually say "doctor".

One thing I want to caution you on is that "small" hospitals typically don't have these types of residency programs. Just larger hospitals and those associated with universities are the most likely so you may need to rethink your setting or rethink where the doctor is at in his training-- maybe make him an attending. A small community hospital is not going to have this type of program.
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T.E. Ridener lives in a small community in Southeastern Kentucky.  She is an author paranormal romance and urban fantasy, including but not limited to; vampires, werewolves, werebears, elementals, and ghosts. When she isn't stuck in her writing cave, she loves being an awesome aunt to her niece and nephew and catching up on all of her favorite TV shows.   She is the co-founder and co-creator of an online Christmas charity that gives presents to children in need.  In 2013, over $69,000 worth of toys was given to children who otherwise would not have had a present to open.

Sunday, July 20, 2014

Up and Coming

Hello Redwood's Fans!

How has your week been? Mine-- lovely. As you know, I'm not a fan of summer but we've been having quite a few summer thunderstorms and it has been positively marvelous. I love hearing the rain and seeing the lightning flash in dark bedrooms at night. Definitely gets my suspense author's mind working.

For you this week!

This week is my favorite activity for this blog-- answering author questions.

Tuesday: Just when do you call a doctor a doctor?

Thursday: Hockey and head injuries. Just what would the ER treatment be?

Have a safe and cool week.

Jordyn

Thursday, July 17, 2014

Author Question: Drug Testing

My super good friend and author Mark Young is stopping by to challenge me with a medical question. Mark writes great novels and recently won the 2014 National Indie Excellence Awards panel in the Mystery category for his novel Broken Allegiance. Congratulations!

Welcome back to The Edge, Mark.

Mark asks:

I was hoping you could help with a little medical drug testing problem I have in my latest novel.

Here is the situation: My main character, Tom Kagan, is knocked out using the drug Ketamine. Later, when an internal affairs investigator orders blood and  urine samples taken, Kagan also has the hospital take a second sample for himself. 

When the drug test comes back for the cops, it shows nothing in his system. But when Kagan gets his sample back, it show Ketamine in his system.

Here is my question: Can someone provide a sample of a clean blood type that is the same as Kagan’s but is someone else's, destroy the test sample containing Ketamine, and make it appear that Kagan’s blood is clean? And urine tests, how specific are they tied to an individual? Can anyone provide a sample and make it appear as if it is Tom’s?

Jordyn Says:

It is not routine to "type" someone's blood unless they need blood. In general, when blood is sent to the lab, we have no idea what type it is. These days, there is a push at many hospitals to label specimens at the bedside to avoid patient ID errors. Many hospitals are also having the patient or family member initial the lab label (that has the patient's name, DOB, and medical record number) as a double check. The nurse (or collecting provider) then notes a collection time, the date and initials the specimen as well.

Most specimens are sent to the lab via a tube system. Specimens that are collected for legal reasons, I imagine, would also have to maintain the chain of custody.

So, it is possible for a blood specimen to be switched out for someone's who doesn't have the ketamine in their system but these are the problems you'll have to overcome. Switching out the tube but still having the label appear as it normally would. 

You could do a handwritten label. This would be rare but not unusual as long as it had all the identifying characteristics the lab would require. At a minimum, this would be the patient's name and DOB. Something like the computer system going down could cause something like this to happen. The lab may call to investigate why it was labeled in such a manner which could increase tension/conflict in your scene.

Also, in some situations, specimens are hand-carried to the lab on occasion to ensure delivery. This might well be the case here because there is legal concern and this is when a switch could take place as well.
  
Generally, what is tested for drugs is urine. Here is a post I did on the common, illicit (depending on the state) drugs we look for. You can test for Ketamine but it is going to be a "special order" test. Here is some great info on Ketamine drug testing.

You will have the same issue with a urine sample. Urine isn't "typed"-- it's not tied to a particular individual except by the label on the cup. Also, if it's a legal manner, the individual might have to be monitored as they pee to ensure the specimen wasn't altered or substituted out.

An intriguing scenario you have here. Good luck with your novel!

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Mark Young is an award-winning author of three previous bestsellers, Revenge (A Travis Mays Novel) and two Gerrit O’Rourke novels, Off the Grid and Fatal eMpulse. Prior to his full-time writing career, Young served as a police officer with the Santa Rosa Police Department in California for twenty-six years. Additionally, he was an award-winning journalist and a Vietnam combat veteran. He served with several law enforcement task force operations, including the presidential Organized Crime and Drug Enforcement Task Force targeting major drug traffickers, and the federal Organized Crime Task Force charged with identifying and prosecuting prison gang leaders. He lives in the Pacific Northwest with his family. Visit www.MarkYoungBooks.com to find out more about Young and his writing.

Tuesday, July 15, 2014

Trauma Call/Domestic Violence: Dianna T. Benson, EMT



I am pleased to welcome back award-winning novelist Dianna T. Benson. I love how she writes these scenes fictionally but conveys a host of medical details along with it. 

Welcome back, Dianna!

EMS 6, Stabbing, TAC Channel 12”

     Responding to a domestic disturbance call, my partner and I park our ambulance in front of an upscale home over a million dollars. Not atypical – EMS is too often called out to the rich on domestic violence.

     “Did you know the power company turns off this zip code for lack of pay more than any other in the state?” I ask my new partner.

     “Yep. Idiots living beyond their means. No wonder they’re so stressed out and hurt each other.”

     At the front door, we join a fire crew, as three cops enter the house, all three with weapons drawn.

     “Scene isn’t safe?” I ask.

     “Not sure,” the last cop answers then trails his two buddies.

     The fire crew of four hangs back with me and my partner.  

     “Was the door unlocked?”

     “Yup,” one of the firefighters answers me.

     After five long and boring minutes of standing around on the lawn in the dark of night, I radio in to dispatch. “EMS 6. Standing by outside residence. Any updates from PD on scene?”

     “Yes. Scene is secure. PD is with victim.”

     “Copy that.” I roll the front of our loaded stretcher into the house.

     In the family room, I find one officer bent over a body, the other two talking with an agitated man.

     I kneel at the woman’s other side. She’s supine on the carpet, her lapped hands pressed to her lower abdomen and covered in blood.

     “Ma’am?” I touch her shoulder in comfort.

     My patient blinks at me then flutters her eyes closed.

     “Can you tell me your name?”

     “Judy,” she whispered in a pained voice.

     I brush my hand over hers. “Judy, are you hurt anywhere other than here?”

     “Don’t know,” she mumbles.

     “Judy?” I stare into her eyes, mascara smudged underneath them. “Can you move your arms down at your sides?”

     She does.

     My partner hands me trauma scissors, a stack of 5X9 sterile gauze pads, and an occlusive dressing. As I rip open the gauze packages, my partner hooks up the patient to our cardiac monitor and focuses on assessing and monitoring vital signs.  

     “How can I help?” one of the firefighters asks me.

     “Perform a rapid trauma assessment.”

     “You got it.” He starts at the head.

     With the trauma scissors, I cut Judy’s shirt, exposing the wound. Noting no debris other than blood, I cover the gushing horizontal wound—thin but long—with one sterile gauze pad after another, and apply direct pressure with my palms. “Did a knife do this, Judy?”

     “He did.”

     “With a knife?”

     “Steak knife.”

     “I see nothing else,” the firefighter informs me at the patient’s feet.

     I nod. “Thanks.”

     I glance at the monitor screen for Judy’s vital signs. Her heart rhythm is normal, but her blood pressure is too low, pulse too high, indicating she’s headed to shock due to blood loss. My guess is she’s bleeding internally, the knife blade sliced an organ or two, maybe the abdominal aorta. Regardless of what’s injury, she needs a surgical team.

     I look at my partner. “We gotta go. Now.” 
       
     “Give me the switchblade,” one of the cops says, alarm in his tone. “Sir, you’re just making things worse for yourself.”  

     “Past time to go,” I whisper to my partner, a rush of panic clogging my throat.

     “No kidding,” he whispers back, wide-eyed.

     “Get out of here,” one of the cops says to us.

     “What’d you say to them?” the agitated man shouts.

     “You don’t want a murder charge, do you? The EMS crew needs to get her to the hospital.”

     The cops deal with the perpetrator, as my partner readies the stretcher. I blanket the dozen or so bloody gauze pads with a towel.

     Inside the moving ambulance, I raise the foot of the stretcher to treat for shock. I cover Judy’s mouth and nose with a non-rebreather oxygen mask and turn on the O2 to 15 lpm. Since none of her organs eviscerated, I do not apply an occlusive dressing. Instead, I add additional 5X9s and a fresh towel and instruct the one firefighter who joined us en route to press his hands over it for direct pressure. I insert an IV saline bolus and consider administering morphine or fentanyl for pain.
  
     “More cops dispatched to scene,” my partner yells back from the driver’s seat. “Guy stabbed one of the cops and fled the scene on foot.”

     I look down at my patient. She doesn’t indicate she heard those disturbing words.
  
     “We’re ten minutes out,” my partner yells back at me.

     I pick up the radio. “Wake Med ED, this is EMS 6.”

     “Go ahead EMS 6.”

     “We are enroute with a thirty-eight year old female. Left lower quadrant adnominal stab wound. No evisceration. BP 82 over 56. Heart rate 173. Non-rebreather at 15 liters per minute. Legs elevated for shock treatment. Place OR on stand by. ETA 10 minutes.”

     “See you in 10. Wake Med out.”

     “EMS 6 out.”  

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Dianna Torscher Benson is a 2014 Selah Award Winner, a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne de Maurier Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. She’s the author of The Hidden Son, her debut novel. Final Trimester is her second release. After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMS degree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need. Dianna lives in North Carolina with her husband and their three children. You can connect with Dianna via her website.
 
   

          

Sunday, July 13, 2014

Up and Coming

Hello Redwood's Fans!

How IS everyone doing? Surviving the summer heat? As I'm sure I've said before-- summer is my least favorite season. It's just too hot and too bright! Anyone else with me on this? I think, truly, I have reverse seasonal affective disorder. I think the sun makes me depressed. But then again, who ever said suspense authors are normal.

For you this week:

Tuesday: I always love it when award-winning author Dianna T. Benson stops by. This week, she writes an engaging scene that deals with a stabbing victim. It's a great way to convey the medical information in a creative way.

Thursday: Friend, law enforcement guru, and award-winning author Mark Young stops by to see if he can stump me with a medical question about lab testing. Hmmm--- can the cop stump the nurse? You'll have to stop in and find out.

Have a great week and stay cool.

Thursday, July 10, 2014

What are EXIT Procedures?

Some might say the only procedure where there is potential for 200% fatality, of both the mother and the baby, are EXIT procedures. 

Wikipedia
EXIT procedure stands for Ex Utero Intrapartum Procedure and I will tell you-- it is amazing what they are doing to save babies lives these days.

Some babies, if they were born with their congenital malformation, would not survive birth. These might include conditions where the infant's airway is obstructed, where the abdominal contents are in the chest cavity (congenital diaphragmatic hernia), or they have a high risk tumor like a cervical teratoma.

This is really not a C-section as the surgeon does not want the uterus contracting. In fact, the mother is placed under a very deep level of anesthesia so her uterus does not contract (which is risky for the mother) until they are ready to deliver the baby after the surgery on the baby is complete. 

Once the baby is partially delivered, it's desired for them to still have placental support for oxygen and nutrients. But in case this doesn't happen the baby is always intubated prior to the procedure. Also, the infant is given an IV and pain medication and is monitored via echo and sonogram because it's hard to monitor them with conventional technology like ECG pads. 

Once the procedure is complete, the baby is then delivered. These procedures generally take place between 28 and 34 weeks. EXIT procedures shouldn't be confused with fetal surgery which could take place at 24 weeks but then the child is placed back into the womb to continue to grow. Fetal surgery might be done for something like spina bifida. 

An interesting question becomes-- can the mother consent to a procedure when she has so much invested in emotionally saving her child?

What do you think? Worthy of a fiction novel?

Tuesday, July 8, 2014

What is Hypoplastic Left Heart Syndrome?

What is Hypoplastic Left Heart Syndrome (HLHS)? It is the most deadly type of cardiac congenital anomaly an infant can have.  It wasn't more than 60 years ago when nothing could be done for these babies. It has a 100% mortality rate without intervention. Even as recently as the 90s the mortality was 40-50%. Now, over 90% of children are living and one year survival rates are around 68%.

The easiest way to think of HLHS is that the infant's left ventricle is severely underdeveloped and blood isn't oxygenated the normal way it should be. The left ventricle is the portion of your heart that is most responsible for propelling blood forward to the rest of your body. If that isn't working well-- you can see how this can prove difficult for the infant. 

Now, there are only two options for treatment of this rare but fatal heart condition and that is a three staged surgical repair (A BT shunt, a bi-directional Glenn, and a Fontan repair) done over the first couple of years of life or a heart transplant. Even if the infant goes to transplant they will likely need one lifesaving surgery after birth because their life depends on certain holes in the heart staying open. This is where the term "ductal dependant" lesion comes from. The obvious difficulty with offering transplant for these patients is the scarce number of infant hearts available for transplant.

What's interesting and new in medicine is that they're trying to predict, based on some blood testing, which infants will do better getting surgery and which will do better going to transplant. What they're looking at is a micro RNA marker which is a biomarker that could predict the success of surgery for these patients. 

What might be some signs of a congenital heart defect (not necessarily this one) in an infant? Even with today's ultrasound technologies-- not ALL cardiac anomalies are detected prior to birth though a large majority are.

Look for:

1. Increased breathing rate above what would be normal for that age. A normal respiratory rate for an infant is between 40-60. Anything consistently over 60 breaths/minute is concerning. 
2. Increased heart rate.
3. Hepatomegaly. This means the liver is large. The liver sits on the right side of your abdomen housed just under the right rib cage. You should be able to feel the lower edge (maybe 1/2-1 finger breadth) but anything over that should be checked. The reason the liver will become palpable is due to blood congestion from a poor functioning heart.
4. Difference in blood pressure between the upper and lower extremities. As a screening test, blood pressure may be done on all extremities.
5. Difference in oxygen level between upper and lower extremities. 

Another way to pick up on a heart defect in a child is to give them oxygen and see if it changes their oxygen levels. If an infant's heart is "shunting" where oxygen may not go directly to the lungs then giving oxygen will not change the patient's oxygen levels or it will change them very little. 

Below are some steps we would use to stabilize the infant in the ED setting for a "ductal dependant" heart lesion: 

1. Give medication to keep the holes in the heart open. This would be a prostaglandin drip.
2. Prevent shock but don't overload the heart. This is typically done through fluid boluses but we would give half the normal dose over a longer time period.
3. Use a vasopressor (this is a medication to keep the BP up) like Dopamine if needed.
4. If continued blood pressure support is required then add a medication like Milrinone which will decrease SVR (the resistance in the body the heart has to beat against) and increase circulation.
 
So, if you need a tough diagnosis for your fictional pregnant family to deal with--Hypoplastic Left Heart Syndrome might be the choice for you.

Sunday, July 6, 2014

Up and Coming

Hello Redwood's Fans!

How has your week been? Hopefully, none of you had to visit the ER for anything scary like blown off fingers. I am praying all of you were safe.

This week is all about the kids. I LOVE being a pediatric ER nurse. There are so many interesting things medically that can and do happen to kids that you just don't see a lot of in the adult population. One is congenital heart defects. Though, through improved surgical techniques and medical care, children who have had congenital heart repair surgery are living much longer than they ever have so my adult ER counterparts are dealing with this more and more.

Tuesday: Just what is Hypoplastic Left Heart Syndrome (HLHS) and why has it been such a devastating diagnosis worthy of investigating in any fiction novel?

Thursday: What are EXIT procedures and why do they put both mother and baby and risk?

Have a great week!

Thursday, July 3, 2014

Author Question: Treating Injuries Related to Torture 2/2



Today, we're wrapping up Taylor's questions about treating injuries related to torture. You can find Part I here.

Question #2: She was whipped/flogged, and has wounds from that across her back. Her shirt is torn, and dried blood makes the fabric stick to the wounds, which is (obviously) painful. How long does it take for mild infection to set in? (Nothing major – no blood infection, sepsis, etc. Just the beginning signs – redness, swelling, warmth, etc.)  How would the wounds be treated? Antibiotics? Cleaning the wounds – how is that done? Can they be stitched?

Jordyn Says: These wounds will need to be cleaned for sure. To get stuck material from wounds we generally saturate them with saline to dissolve the blood and peel away the fabric. I did a recent post specifically about wound infections but on the short side is 12 hours. More commonly is 48 hours and considering her condition, wound infection is going to be a big concern. They cannot be stitched up.

Here is another post I did on stitches but outside time frame for stitching someone up is 24 hours and that is only if the wound is super clean which these would not be. Taking her to the OR for wound cleaning, debridement and dressing placement might be an option if they are extensive. They could do a better job with better pain control. The reason they can't be stitched is concern for infection-- we don't want to trap pus/germs in a wound. Better to let it drain out. They'll want to be sure she's had a tetanus shot within the last five years. If not, she'll get a booster. Antibiotics are probably warranted in her case-- something for skin infections like Keflex. 

Question #3: When the soldiers rescue her from the hospital, how do they move her? She doesn’t have a spinal injury; she’s able to sit up and move in bed. Lying on her back on a stretcher wouldn’t be very comfortable. I guess she would have to lie on her side (the one that isn’t bruised and battered). Are there any other precautions they would need to take?
Jordyn Says: If they aren't concerned about spinal cord injury than transporting her in a "position of comfort" is reasonable but she'd still have to be secured in seat belts some way.   

Question #4: How long do cracked ribs typically take to heal? She was kicked and/or stepped on by her captors, and has 1 or 2 cracked or broken ribs. If they are only cracked and bruised, if she was given some sort of wrap/brace, is it plausible that she would be able to go “out in the field” again after 2 weeks or so? She won’t be jumping out of helicopters, leaping tall buildings in a single bound, or anything like that – she’ll be interrogating suspects, maybe running for a bit in a foot pursuit, and will have some involvement (to be determined) in the take down of a very bad guy near the end of the book.
Jordyn Says: Cracked ribs usually take six weeks to heal. Here is some information on treatment of cracked ribs. Wrapping cracked ribs is not recommended anymore. We want the patient to be taking deep breaths so they don't develop pneumonia. Wraps inhibit this. Cracked ribs are painful but not an unstable fracture so she can interrogate suspects and run but it will be quite painful and she'll have decreased stamina for sure. A take down will be quite painful too because it will be hard to protect the area. 

Hope this helps and thanks so much for your questions! Best of luck with your book.