Can you give an example of how the narrative of a serious wound, that is not fatal, has been used in your game?
Several examples the first two being the most interesting but also most atypical:
- Primary one is my Kingmaker campaign where there is no PC cleric, with the only source of healing a Druid that will not choose all healing spells (and usually chooses none by playing his character in a "particular" way - that annoys one my players to no end because they think this character should be playing the healer when such a thing is just NOT what this PC does). There have been various situations where the primary fighter in the group went into the negatives or close to it without immediate magical healing available. Due to the expansive non-rushed nature of this sandbox campaign (and the fact that no one is that great at healing), the group has on several occasions chosen to "spend a week or so recuperating" before heading back out to the frontier. At low levels, those DC 15 heal checks are not that easy. Funnily enough, the narrative in this campaign has a real "wild west" feel to it with the lack of magical healing combined with low level really adding something special.
- I remember in a previous 3e campaign where the cleric died leaving a big gaping healing hole in an adventure where the group had to stop a very nasty ritual within a day. With several characters seriously injured, the rather significant decision to not continue and effectively "fail" was a crucial narrative tipping point and decision. While it made stopping the "bad guys" and their plans much more difficult, I think that particular one was actually really rewarding because of the struggle to eventually gain victory after a significant defeat. Certainly a case of a victory earned rather than a victory given.
- There is then of course the large number of times when a PC goes into the negatives and a very serious wound is described (that is usually quickly dealt with via magical healing). Despite the fact that magic is typically used and thus the "effect" of a serious wound is not felt; the description of a serious wound is still given (and would have been felt if no magical healing was available).
In practice though, I get your point that having a group stay on hold due to injury is far less likely than due to researching something or crafting MIs or general downtime. The fact that in 4e you can't go to that "serious wound" description however is significant (at least for some groups).
See, in my experience, the game presumes that the group has access to healing magic of some sort. So, in all the years I've played, serious wound has never really played much of an issue. Probably because we never worried too much about the healing times in 1e (heh

). But, even beyond 1e, since you almost always had a cleric in the group, "serious, potentially fatal wound" was never a narrative element.
Back in the day playing AD&D when I was a teenager at school, I think it fair to say that we too only used an "approximation" of the rules as written; and that our descriptions of such things were usually bizarre, impossible, psychotic or a mix of all three.
See, I think your "gaping hole" is a very, very small corner case that almost never comes up in games.
Playing 3e/Pathfinder, our group
regularly describes serious wounding
whenever a PC goes into the negatives. Going into the negatives equates to the "serious wound situation". I also think this is true for a lot of groups based on various posts on these boards over the years. Even if such narratives are quickly undone by magical healing, the descriptive "threat factor" is still there where as when playing 4e, we are generally more cautious just sticking to the numbers and the excitement they can generate (rolling that healing save on 2 strikes is always thrilling). Going into the negatives in 4e is not the cue required. Going into the negatives with "save strikes" and no surges left is. As you say though, in 4e this situation rarely occurs (mainly because it is usually easy to not get yourself into a low surge/low hp situation). Where as in 3.x/Pathfinder, going into the negatives (and thus describing a serious wound) is much more common.
So far, we've seen exactly one example of narrative that is diffiucult to do in 4e - a bleeding head wound. If it was a "gaping hole" why aren't I getting buried in narratives?
Because I don't think people care that much (except for imbeciles like me who have an axe to grind regarding damage and healing in D&D and who really want to see it fixed in 5e

). In addition, I would say for those that agree with my view, I have provided an un-countered specific example and an un-countered general situation explaining why the difference occurs (and perhaps because I play 3e/Pathfinder/4e and find fault with all of them in regards to damage and healing as well as mentioning incredibly easy fixes for it, my analysis is viewed as fair). As such, it is kind of like premise disproved, case closed, let's move on. Specific examples while interesting are never going to match the debating power of analysing the general situation and why the specifics occur rather than examination of just a handful of particulars.
Then again, "4e prevents me from using a small, corner case example of narrative" just doesn't have the same ring does it? Doesn't quite roll off the tongue.

(and yes, that was meant as tongue in cheek, not snark)
Obviously no snark taken.

As I have shown, for groups with a similar style to mine, 4e forces you to pull back/change how we do things in terms of damage description producing a slightly unpalatable overall narrative lacking in a certain verisimilitude.
Best Regards
Herremann the Wise