Implement basic saline infusion to help with blood loss

[GuardianDll]

Summary

Features "Implement basic saline infusion to help with blood loss"

Purpose of change

FMS pointed out it is possible, Venera explained how exactly implementation should look like

Describe the solution

Do the basic version by Venera's suggestion
Also fix few prosthesis stuff that annoyed me

Describe alternatives you've considered

None

Testing

Additional context

Very basic implementation, so infusion effect applied only in the very end, tho with suggested rate of infusion (2L per hour) even the big 2L bag of solution is gone in an hour
Because there is no way to read player's activity via, EoC, my cool idea with giving you vitamin slowly was doomed to fail
Only blood vitamin is affected, issues with redcells player should survive on their own

Issues with prosthetics i fixed

@Venera3 suggestions? is firstaid lvl 3 4 is enough to use it or not? any additional thoughts?

TODO: document the flag no flag, nothing to document

[worm-girl]

This is great! I was planning to take care of this via activity_actor but if it's doable via EOC that's way better.

I think we should go with at least 4 firstaid though. Most people aren't even aware of what specifically is wrong during hypovolemia and people who administer IVs IRL are skilled professionals. Balance.md says a trained professional has 6 skill, so even 4 feels generous.

[GuardianDll]

oh, it's actually 4, i got confused by my own json

[ANickelN]

1. What is required to do this? From looking through the files you just need the bag? You should need your IV start kit, or their separate components to do this procedure.

A disinfectant, could be alcohol or chlorohexidine for the site, an IV needle (would probably be a 20g or 18g if you're looking to run this thing quick), the line to connect the bag to the hub, dressing, tape and a tourniquet to find the vein easier (veins will be crap if you're running this for hypovolemia). Since you're running it by gravity having a stand or something to hang it on would be useful but that could be abstracted.

You could get away with just the IV needle w/ hub, line and bag but you really shouldn't be doing that without cleaning the site first.

2. I'm not sure if this is a typo or if I'm completely misunderstanding what is being proposed, but the part "put a small nail in your vein" doesn't make any sense to me.

3. I would second that first aid 4 seems appropriate for starting the infusion properly without infiltrating or blowing your veins.

[GuardianDll]

What is required to do this?

saline bags are assumed to have rubber tube and cannula, and Venera convinced me to not make an iv pole requirement

disinfectant

nice idea, i think it is doable (tho it would be a bit odd it is the only place that require disinfecant for injection)
not sure character, that got shot in the torso and dies from consequences of heavy bleeding will go "i don't have any disinfecant, i guess i'll rather die", but we can try to emulate consequences of it

put a small nail in your vein

it is one of this things where i need to consult someone, because i implement it because i can, not because i know anything about intravenous therapy and how it is performed

first aid 4

done

[worm-girl]

I agree that we probably shouldn't be asking the player to have anything other than the basics, and it makes sense that'd all be bundled with the IV bag. Most of the other stuff isn't strictly necessary for the process.

As for sterilization, pretty much all of our antiseptics should work, and I don't think we should be terribly picky about which one in this PR. Maybe in future PRs we could allow for risky IVs using makeshift antiseptic or even no antiseptic (hey, it's an emergency!)

You don't need disinfectant for regular syringe injections because they're only stuck in you for a split second. There's a lot of debate IRL about this: https://hospitalnews.com/the-alcohol-swab-before-the-needle-a-point-of-debate/ - but there is no such debate for IV bags. With IVs, the needle is stuck in you for several minutes so the chance of infection is dramatically higher, thus the swab.

OP, if you want help with writing:
You prepare a saline solution, put a small nail in your vein, and patiently wait until all the liquid goes into your bloodstream.
could read more clearly as:
You prepare the tubing, insert the needle into a vein, and patiently wait for the saline solution to flow into your bloodstream.

Your other writing all reads very clearly to me. :)

[ANickelN]

I don't want to rag on this too much because I do really like filling this gap in treatment in the game, but if it is done I just want to make sure it is done properly so it (hopefully) doesn't have to be redone 1, 2, 3 years in the future.

I agree that a character at risk of dying of hypovolemic shock probably isn't worried about the infection, but it isn't nearly the same as a muscle injection. The reason infection is so problematic using an IV is that your bloodstream connects to your whole body. Infection WILL kill you very easily if bacteria slips into your bloodstream.

If you want to have the whole process only involve one item instead of two (bag and IV kit), it would make more sense to rename the item so that it makes it clear it includes both the bag and the equipment, something like "1L Saline Infusion Kit" If I was a player looking at it I would immediately assume it was just the bag itself, void of any equipment.

The wording I would use for the infusion would be something more like, "You insert the needle, connect it to the bag and start to feel the saline flowing into your body"

I would also rewrite the description of the bag to say:
"A sealed bag of saline solution, commonly used in IV therapy to treat fluid loss. The kit it comes with includes all of the necessary equipment to start an infusion if you know how. This bag reads "XYZ"mL.

[worm-girl]

It being an EOC means that anyone can edit it at any time with no coding knowledge. That's no reason not to hold it to a high standard, but you also don't need to worry about bad code holding the system hostage.

It might also make sense to package IV kits separately. Looking at how they tend to come in hospitals, it's usually a sterile envelope with the tube, cannula, and needle inside, and the bag is just kind of sitting out by itself. This would have the advantage of possibly letting players autoclave their own IV kits, and would make medical looting a bit more dynamic.

[ANickelN]

It being an EOC means that anyone can edit it at any time with no coding knowledge.

It might also make sense to package IV kits separately. Looking at how they tend to come in hospitals, it's usually a sterile envelope with the tube, cannula, and needle inside, and the bag is just kind of sitting out by itself. This would have the advantage of possibly letting players autoclave their own IV kits, and would make medical looting a bit more dynamic.

I agree that splitting it into the two components makes the most sense. The needle and hub used also works effectively as a blood draw kit, so it has more than just one use in a pinch. They can spawn in the same locations as they would typically be placed near each other.

[GuardianDll]

The very reason i made it like this, as a kit, and not just a bag with saline inside, is specifically to ensure saline itself is not contaminated and still sterile - it is fine to use such saline to wash your eyes, but to put it in your veins is death sentence
I really like the idea of disinfection, and it is not actually hard to make it. question would be: how not using disinfectant can affect character? what consequences would be in this case?

[ANickelN]

The very reason i made it like this, as a kit, and not just a bag with saline inside, is specifically to ensure saline itself is not contaminated and still sterile - it is fine to use such saline to wash your eyes, but to put it in your veins is death sentence I really like the idea of disinfection, and it is not actually hard to make it. question would be: how not using disinfectant can affect character? what consequences would be in this case?

A bag of saline would come enclosed in a plastic wrapping to ensure it hasn't been tampered with. See the following image for an example. When I grab a saline bag from storage this is literally what I'm grabbing.

The consequence of using contaminated equipment or not properly cleaning the site could lead to a couple different issues but the only one that would probably be modeled here would be sepsis and death. The bloodstream connects to the entire body, and by putting a needle into it you have given bacteria a direct line into your entire body.

To put it simply, it is a serious error to not use proper IV cleaning procedures in the hospital setting, having this happen in a setting where you're exposed to bacteria from rotting corpses is magnitudes worse.

[GuardianDll]

could lead to sepsis and death

well eeh, we don't really have a sepsis in the game, and i assume it's one of this things that, if given to character, would be just "you will die in X hours" without a way to deal with it. I am fine with it actually, what are the odds of this happening should be?

A bag of saline would come enclosed in a plastic wrapping to ensure it hasn't been tampered with. See the following image for an example.

yeah, i meant from game perspective i could just make bag as a container, where player can easily add and remove saline - but i didn't, to show that the bag is sealed, and you can't just dump few bottles of saline to wash your eyes into said bag and inject it right into your body

[worm-girl]

Could we just reskin the existing blood draw kit item to be the IV kit? So you'd need a sterile bag of solution and a sterile blood draw kit, plus one dose of any antiseptic? We could make blood draw kits autoclaveable (but not the bags) and lose their sterile flag on use.

We'd want to turn their spawn rate up, as they're pretty common pieces of medical hardware, to the point where hospitals probably just throw the whole thing away after each use.

[GuardianDll]

it can be done, and it won't be difficult to do

[ANickelN]

Could we just reskin the existing blood draw kit item to be the IV kit? So you'd need a sterile bag of solution and a sterile blood draw kit, plus one dose of any antiseptic? We could make blood draw kits autoclaveable (but not the bags) and lose their sterile flag on use.

We'd want to turn their spawn rate up, as they're pretty common pieces of medical hardware, to the point where hospitals probably just throw the whole thing away after each use.

Renaming the "blood draw kit" to "IV kit", bumping their spawn rate way up and changing their description to match what they contain (needle, tubing, vacutainer for blood draw) would probably do the trick. Yes, IV needles are single use and can't be re-used once they're set due to the design. The metal needle itself is garbage after you've stuck with it, because you pull it out after feeding the little plastic tubing (catheter) into the vein.

[worm-girl]

Could we just reskin the existing blood draw kit item to be the IV kit? So you'd need a sterile bag of solution and a sterile blood draw kit, plus one dose of any antiseptic? We could make blood draw kits autoclaveable (but not the bags) and lose their sterile flag on use.
We'd want to turn their spawn rate up, as they're pretty common pieces of medical hardware, to the point where hospitals probably just throw the whole thing away after each use.

Renaming the "blood draw kit" to "IV kit", bumping their spawn rate way up and changing their description to match what they contain (needle, tubing, vacutainer for blood draw) would probably do the trick. Yes, IV needles are single use and can't be re-used once they're set due to the design. The metal needle itself is garbage after you've stuck with it, because you pull it out after feeding the little plastic tubing (catheter) into the vein.

So even in an emergency, you wouldn't be able to autoclave it and use it later?

[GuardianDll]

tho i'll be honest, making blood draw kit one time use item goes beyond my competence level, probably, but i'll see what i can do

[ANickelN]

So even in an emergency, you wouldn't be able to autoclave it and use it later?

It isn't that you couldn't throw it into the autoclave (although I have doubt regarding if it would be able to completely sterilize it), it is that once the needle is removed from the IV, it can't (and shouldn't be) put back.

See the below video for an example of what I mean. The needle is inserted, she advances the plastic catheter into the vein, then presses the safety button (wow that one is fancy!) to snap the needle back into the device for disposal.

https://youtu.be/ue96cuS-lNs?si=6YuLgSRUFQKKES2B&t=152

Reusing these should never be a concern because even a small community hospital likely has thousands or tens of thousands of these. That should be reflected in their spawn rates in-game.

@GuardianDll
To answer your earlier question what the chance of infection should be, I don't have anything to reference but my gut (and inclination for gameplay balancing) would tell me it would be better off at something like 50/50 for gameplay purposes.
If there is any system of overall cleanliness of the character it would be nice to scale it with that, but as far as I'm aware there isn't so 50/50 seems to provide a good enough incentive for the player to find even a basic disinfectant.

[worm-girl]

i feel "emergency" and "autoclave" are pretty incompatible :D

It's actually very relevant in the third world and in war-torn countries. There are major studies about doing things like sterilizing hypodermic needles and surgical implements in multi-cookers, which apparently works as well as doing it in a professional setting. It's not advisable outside of an emergency partly because needles dull pretty quickly, but if it's possible and reasonable, there's no reason not to include it.

However if the part is rendered physically inoperable after one use, as with the IV kits, then it shouldn't be autoclaveable.

tho i'll be honest, making blood draw kit one time use item goes beyond my competence level, probably, but i'll see what i can do

You can have the EOC delete the item and give you a new one, which is like "used blood draw kit" and is just trash.

[harakka]

This would have the advantage of possibly letting players autoclave their own IV kits

It's not advisable outside of an emergency partly because needles dull pretty quickly, but if it's possible and reasonable, there's no reason not to include it.

We've workshopped this a lot over the years on devcord, this PR is informed of those discussions, and there is a strong intention for this stuff not to be something player can craft or tamper with, because we don't want to get into the weeds of what can and can't be represented with our extremely limited health and skill system. You find and use sterile equipment, we know that's sterile. Anything beyond that is just too much of a minefield.

[Venera3]

As mentioned, you're not packing anything sterile in the postapocalypse. Hooking up Point of Care sterility for medical stuff in general is a worthy goal but it's not something we can track at this stage.
Involving blood draw kits has the same problem - you can't reuse one for anything you need sterility for, but you don't care about that if you're just bloodletting from a zombie for Science or whatever. The whole iv mutagen/heroin permanent syringes thing is its own problem, but that's a tangent for now.

description

I'd just go with something generic like together with the necessary supplies for a one-time infusion. They are not packaged together, but if we can accept not having shoe sizes we can accept your crafty survivor grabbing some line sets while rooting around the hospital.

skill req

Unless you want to go the extra mile and add a proficiency I'd go with healthcare 3 (or healthcare / first aid 3/3). Skills are the worst, medical skills are the worstestest of them all, but that's not on you to fix.

no disinfectant leading to 50/50 sepsis

Man, it must be hard being a heroin dealer, what with half your clientele dropping dead every shot. On a less cheeky note it's not something I'd gate aggressively, since these are single infusions (no permanent plastic) into notionally different veins and the chance of a complication that's gameplay-relevant is extremely low.

This is a completely reasonable first pass at iv fluids as it stands, and closes a useful capability gap wrt blood loss. There are of course miles of depth you can get out of this stuff if you're so inclined, but that's the same as with everything.

[ANickelN]

As mentioned, you're not packing anything sterile in the postapocalypse. Hooking up Point of Care sterility for medical stuff in general is a worthy goal but it's not something we can track at this stage. Involving blood draw kits has the same problem - you can't reuse one for anything you need sterility for, but you don't care about that if you're just bloodletting from a zombie for Science or whatever. The whole iv mutagen/heroin permanent syringes thing is its own problem, but that's a tangent for now.

description

I'd just go with something generic like together with the necessary supplies for a one-time infusion. They are not packaged together, but if we can accept not having shoe sizes we can accept your crafty survivor grabbing some line sets while rooting around the hospital.

skill req

Unless you want to go the extra mile and add a proficiency I'd go with healthcare 3 (or healthcare / first aid 3/3). Skills are the worst, medical skills are the worstestest of them all, but that's not on you to fix.

no disinfectant leading to 50/50 sepsis

Man, it must be hard being a heroin dealer, what with half your clientele dropping dead every shot. On a less cheeky note it's not something I'd gate aggressively, since these are single infusions (no permanent plastic) into notionally different veins and the chance of a complication that's gameplay-relevant is extremely low.

This is a completely reasonable first pass at iv fluids as it stands, and closes a useful capability gap wrt blood loss. There are of course miles of depth you can get out of this stuff if you're so inclined, but that's the same as with everything.

I'm going to disagree with a majority of what you've said here.

1. Medical loot is already pretty straightforward and to the point, there isn't many miscellaneous use items like an IV kit would be. Looking through the loot tables for the hospital there is a lot of items you see on a day to day basis that are missing. I already agree regarding re-use, there should be enough of these laying around that it shouldn't be a concern anyways. Having the bag and equipment separate would flesh out the loot tables a little bit and add a bit more verisimilitude to the setting.
2. Adding a proficiency would probably be the best course of action, but otherwise it really should be healthcare 4 minimum. The medical skill being difficult to increase is a separate issue (although I'm not sure I agree with that either considering the prevalence of medical books). An EMT (somebody proficient with basics of pre-hospital care and who in most states does not touch anything intravenous) starts with healthcare 5 for reference. A paramedic (who deal with advanced prehospital care) starts with healthcare 6.
3. Putting aside the fact that injecting intravenously with a needle and setting up an infusion to run for an hour or longer are entire different levels of risk, I also think it is safe to assume that a player smashing brains and fighting in filth for much of their day is likely dirtier than the average IV drug user in the first world.

I don't think this is a bad first pass at the subject at all. I just know that as with a lot of other things first passes often become ONLY passes for years, so if it is being done it should be done correctly the first time while things are still in motion.

[worm-girl]

Autoclaving is also not difficult nor does it require special facilities. A pressure cooker or even a multicooker are sufficient, you don't even need an autoclave.

https://pubmed.ncbi.nlm.nih.gov/12267939/

A 3-day training course covering sterilization principles was conducted for 5 community health workers. This experience suggested that pressure cooker sterilization can be easily carried out at rural health facilities or even in homes.

You just throw the stuff in an autoclave pouch beforehand: https://youtu.be/r3r8G8CbOzM?si=HYiEZ8JDBA-IlZEN

We should eventually have a hygiene score, but I don't think the present state of our game suggests everyone is filthy. Our systems allow survivors to live in extreme comfort.

Man, it must be hard being a heroin dealer, what with half your clientele dropping dead every shot.

There is a lot of debate over whether needle injections need skin swabs done beforehand. No such debate exists for sticking an IV in your arm for half an hour because the risk of infection is many times higher. I don't think 50/50 sounds right, but it's not something they play around with in the medical industry.

[MNG-cataclysm]

What does the addition of the "MUNDANE" flag do to prosthetics?

[GuardianDll]

What does the addition of the "MUNDANE" flag do to prosthetics?

• MUNDANE This item uses magic-related features, but is not magic itself - for enchantments it means the item's color won't be changed to pink, and for spells the item description would be changed from "This item casts spell_name at level spell_level" to "This item when activated: spell_name". use_action of "type": "cast_spell" can use this feature separately, using boolean "mundane": true

[Venera3]

3. Putting aside the fact that injecting intravenously with a needle and setting up an infusion to run for an hour are entire different levels of risk, I also think it is safe to assume that a player smashing brains and fighting in filth for much of their day is likely dirtier than the average IV drug user in the first world.

This is about the time I point out that this kind of stuff is quite literally my day job as a crit care anesthesiologist. Can you get an infection from a dirty iv insertion site? Sure. Is the chance of a relevant infection above a tenth of a percent? Not even close. People can and do shoot up in austere environments for decades without much in the way of asepsis and enough live to tell the tale.

I don't think this is a bad first pass at the subject at all. I just know that as with a lot of other things first passes often become ONLY passes for years, so if it is being done it should be done correctly the first time while things are still in motion.

The bar to hit is "is this good enough", not "is this perfect". If the missing bits inspire somebody to work on this in the future, great, if not - we're still farther ahead than we would be without.

Autoclaving is also not difficult nor does it require special facilities. A pressure cooker or even a multicooker are sufficient, you don't even need an autoclave.

Yeah, you do that to line tubing and see what you can use it for afterwards. Again, point of care sterility would be the best you can aim for as a loner, magic bionic storage notwithstanding.

There is a lot of debate over whether needle injections need skin swabs done beforehand. No such debate exists for sticking an IV in your arm for half an hour because the risk of infection is many times higher. I don't think 50/50 sounds right, but it's not something they play around with in the medical industry.

See above. Plastic-associated sepsis is a major thing in my line of work, but we're not laying a stable line here.

[GuardianDll]

something cursed going on with this bags, for some reason it activates eight-nine times instead of doing it only once

[ANickelN]

Venera's Text Cut

I think that we're seeing eye-to-eye for the most part, but that I'm more in favor of a more gameplay/verisimilitude-oriented (you can do this without it, but you'll have a higher risk) approach and that you're favoring a more realism-based (the chance is so small it isn't worth including) approach. Going with your claim that chance of an infection from running a peripheral line for around an hour isn't even a tenth of a percent, it would hardly even make sense to have any disinfecting agent be an optional use item at all.

I didn't see a reply to the skill level/proficiency question so I'm not sure what your thoughts are regarding that.

I would understand the hesitancy towards changing other elements of the PR (splitting solution and tubing) if it involved substantial code work such as adding new systems, but I don't see the point in handwaving particular elements as "good enough" if the work to change something from "good enough" to "near perfect" can be done within the first PR?

If GuardianDLL doesn't want to add to the PR, then it makes sense for someone to pick it up later (I've been personally guilty of doing this in previous pull requests). However, if he's actively gathering feedback for the PR why push to keep things "good enough"?

[worm-girl]

Given that the relevant systems are all json, I see no reason to heap the responsibility of a perfect implementation on GuardianDLL if a "good enough" implementation doesn't have any glaring flaws. More smaller PRs are better than fewer big ones, especially if we're not dealing with confusing C++ that would be difficult for someone else to work on.

[ANickelN]

Given that the relevant systems are all json, I see no reason to heap the responsibility of a perfect implementation on GuardianDLL if a "good enough" implementation doesn't have any glaring flaws. More smaller PRs are better than fewer big ones, especially if we're not dealing with confusing C++ that would be difficult for someone else to work on.

It's probably just a difference in how I perceive it then, the PR is in draft form and Guardian was asking for suggestions. If he doesn't want to add anything more that's perfectly fine. I'm overall just happy we get some options for treating hypovolemia. I can open a PR further down the line to add other requirements at a later date.

[Venera3]

Proficiency is the right way, lowish/mixed medical skills are an acceptable solution barring that. The problem with the medical skill is that they encompass vastly different skill sets that don't map onto a linear learning spectrum, from practical stuff to biochemistry to kinda biology I guess.

I think that we're seeing eye-to-eye for the most part, but that I'm more in favor of a more gameplay/verisimilitude-oriented (you can do this without it, but you'll have a higher risk) approach and that you're favoring a more realism-based (the chance is so small it isn't worth including) approach.

Real things should work like real things work. Fake realism that "feels" right is worse than not having anything ingame - look at oh I don't know, about half of our current medical systems.

I would understand the hesitancy towards changing other elements of the PR (splitting solution and tubing) if it involved substantial code work such as adding new systems, but I don't see the point in handwaving particular elements as "good enough" if the work to change something from "good enough" to "near perfect" can be done within the first PR?

Adding clutter items A) doesn't change anything on the base functionality and B) opens up the whole ummm I mean a rubber hose should be a reasonable substitute right line of questioning which is not somewhere we want to land. You don't need to track tubes, line dressing and all that crap as long as you don't get to reuse a line, and you don't get to do that without a lot of extra work.

[GuardianDll]

After further investigation, it seems #70566 (comment), instead of running inventory EoC once, runs it as much as you have items in your inventory, which causes lot of duplications
@Ramza13 sorry to bother, but may i ask you is there a problem in u_run_inv_eocs EoC somewhere (or maybe search_data?), or in my current EoC?

[I-am-Erk]

I was asked to comment but at a glance can't see anything venera has missed. The only way we should bother modeling infection risk here is by eg. allowing an injection item to gain a filthy tag when used on someone else, in which case, sure. I deal on the daily with people injecting god knows what into veins right through a raging cellulitis infection while sitting three feet away from their makeshift outdoor bathroom on a street corner in the industrial area, and I still only see bad cases of sepsis in a couple of them a year.

Eventually we should look into a fluid overload effect, so that we can have a consequence to trying to replete yourself with saline when under-trained. For most survivors that's gonna be a little tough though, they're more likely to just pee it out than get puffy.

[GuardianDll]

It should be ready now, per Venera sanitizing the skin is meaningless, at least with the medicine we have now, and since some odd bug made it not work anyway, i scrapped it

[DeciusBrutus]

Would a staph infection even be able to compete with the various things that are rewriting DNA and fully healing serious wounds within days?