The Coma 2: Vicious Sisters

There are 4 times throughout the game that you can build devices. When you complete a major sections of the game, you automatically use the device and prevent damage. If DO NOT build the devices, you will permanently lose a health state. Losing the health state 4x is what is required for this achievement. In short, do not build any of the devices.

School-taser
Police Station/Shops-Caltrops
Subway-Gas Mask
Hospital-Mobile Decoy

You CAN do both of the options while only doing one playthrough.

-Create a save file just before building the device.
-Build the device and complete the section
-Reload the save file and DO NOT create the device
-Finish the section of the game

Every time you do this, you will lose a health bar for the rest of the game. For the Hospital section, I would suggest doing the opposite; finish the chapter WITHOUT building the Decoy first. Your achievement for having lost 4 permanent health states will unlock.

Then reload your save file and complete the chapter AFTER building the decoy. This way you will have 2 health bars instead of 1 to finish the rest of the game.

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The rest of the game is not incredibly tough with only 2 bars of health. You can also get both ending A and B in the same playthrough too. Create a separate save file just before getting the ruby [revisiting the guy with the sword].