Muse Medicine

Advice here is for the purposes of fiction writing ONLY and is at best an educated guess. With a solid understanding of the human body and a bit of research, I can probably help you make a guess that won't turn off readers. Do not attempt to enact this advice on real human beings, pets, plants, or imaginary friends. I'm not a doctor and as such I do not diagnose, treat, dispense advise, or prescribe for real problems or real people. Email questions to muse@nursewriter.com.

Name: Arizela
Location: United States

I write dark fantasy. I use my nursing knowledge to help out fellow writers with medical, infant, child, and women's health issues. I am blunt and occasionally foul-mouthed. If you knew me in person, you'd never guess any of that stuff.

Friday, September 4, 2009

Unfortunate News

Hello everybody out there who reads this blog. As you can see, I've been very hit or miss with posting lately. I've got a boat load of good excuses, most of which revolve around my health or my husband's, but none of them are going to post for me. Unfortunately, I just don't have time right now to deal with the sort of highly-researched general posts that this blog was created to share.

So after a year and a half of trying to keep it up, I'm afraid I'll be calling it quits for a while.

Hopefully, this is a temporary closure, and I'll leave the site up so that the older articles can still be accessed. Feel free to continue to shoot me emails with writing questions, as most of those I can answer informally on a fairly quick basis. I'd be more than happy to continue to share my expertise with all of you as my time and health permit. Again, you can reach me at muse @ nursewriter.com (take out the spaces).

Keeping this blog and answering general questions that hit my email have been a lot of fun for me. Some of the questions led me to consider things I had never studied and others kept my adult nursing knowledge fresh. Unfortunately, life sometimes intervenes in the best of plans. Good luck to you all in writing and for the future.

Arizela

Thursday, June 18, 2009

Cut-Throat Old Ladies

How much strength dose it take to cut a throat? Can an old lady do it?

I'll be honest. When I got this question in my inbox, I thought to myself, 'how should I know'? And then I thought 'how do I find out'? Questions like this, which seem to be so specific that the knowledge would really only help the questioner sometimes turn into real gems. In this case, my second-thought led me to a wonderful resource that I feel compelled to share with all of you who read this modest little effort of mine.


It took me three tries and strong Google-fu to find anything even close to what I was looking for, but of all the research I've done over the many years I've been doing this, both formally here and informally at Forward Motion and NaNoWriMo forums, this excites me more than any of the rest of it.
The resource I've found details, with step-by-step illustrations, nine methods for silently taking out a sentry by stealth, several of which would allow even someone with minimal physical strength to effectively kill a much stronger individual, both quickly and silently.

Again, just for the sake of my conscience, PLEASE, PLEASE, do not try this at home (or anywhere else but your fiction-verse). Don't even try it in demo mode with a willing partner and a blunt instrument. You can do SERIOUS damage to the structures of the neck and even cause death just from some of the initial steps prior to the actual cutting of the throat.

The full story, with illustrations - Sentry Removal

From what I know about physiology, these techniques look like they would be pretty effective, some more quiet and requiring less physical strength than others. For the sake of brevity, I'll focus on the first (illustration below). The idea here is to stun the sentry or victim using a blow to the neck/shoulder junction with the handle of the knife, then pull that person back against the attacker's body and let the weight of the victim slide down toward the floor. The weight of the victim would provide all the force required to actually cut the neck.
One of the first things you get taught in nursing school is if a patient is falling, slide them down your own body. It's possible to control the "fall" of a much larger/heavier person without injuring yourself if you use this technique. Using this technique while allowing the victim's weight to pull the knife through the tough, fibrous structures of the neck would allow even a very under-powered person to kill any opponent whose neck they could reach.

I could see this information applying to my own fiction and I can certainly see a wide-spread appeal for this type of information among the folks with stomachs strong enough to read this blog. Great question!

*****This blog is written for fiction writings, for the purpose of writing fiction. Information herein is not intended for use by real people, pets, trees, or imaginary friends. Arizela is not responsible for information used for purposes other than those expressly intended*****

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Wednesday, June 17, 2009

Food Poisoning 101

My character ate some fish that's gone more than a little bad. Now what?

As with almost everything in writing, the answer is - that depends. Food poisoning can be caused by any of over 250 substances (bacteria, parasites, fungi, etc), and symptoms range in severity from very mild to life-threatening or fatal. Therefore, as long as you get the basics right, you, the author, can play with the outcome and severity to your hearts content. The most common symptoms of food poisoning include:

  • Diarrhea
  • Abdominal pain or cramps
  • Bloody diarrhea
  • Nausea
  • Vomiting
  • Fever
  • Headache
  • Weakness
  • General malaise (feeling "ill")
Symptoms usually start 2-6 hours after consuming the bad food, though this timeframe can be shorter or much longer (up to several days) depending on the agent of infection (bacteria, toxin, etc). Most food poisoning will clear up on its own without specific medical treatment within a week, depending on the agent, but most people will recover completely within 12-48 hours.

Youngsters and elderly folks tend to get symptoms more easily, and also tend to have more severe complications.

Complications of food poisoning are rare, but can include:
  • Significant dehydration and shock
  • Kidney failure
  • Significant blood loss and shock
  • Arthritis or joint pain that doesn't go away with the symptoms
  • Nervous system disorders (paralysis, tingling sensations)
  • Respiratory failure
  • Inflammation of the tissue that surrounds the heart
In all of these cases, seeking medical help is important, but if your character lives in an era or region of the world that doesn't have the technology or knowledge to help, many of these complications can be fatal. A few of the organisms that most often cause fatal food poisoning and the foods they are found on are listed below.
  • Salmonella - a bacteria commonly found on birds and reptiles, this little germ (see photo) is transmitted to humans through contact with these or by eating undercooked poultry (bird meat or eggs), consuming unpasturized milk, or eating food that's come into contact with surfaces that have been contaminated by salmonella (ie that old cutting board where he cut up the chicken first and then diced the tomatoes for the salad)
  • Chlostridium botulinum - an anaerobic bacteria (non-oxygen environment required for growth) that multiplies in canned foods where the can or jar is damaged, the seal is broken, or the food was not properly sterilized prior to sealing. Even cooking the food thoroughly won't save the fellow who chows down on a can of this, because the bug that makes botulism produces a neurotoxin (nerve poison) that carries on after the germs themselves are dead. Botulism also lives in very low, mild forms in honey, but this is safe for all but the youngest or most immune compromised people. Babies should never be fed honey prior to age 1.
  • Shigella - this little bug is passed heavily in the feces (pooh) of people with the infection. So how did it get on your cheeseburger? Somebody didn't wash hands before putting on that bun, more than likely. Ick. Symptoms last up to a week and can include pus in the diarrhea as well as all the usual symptoms. Kids who get severe shigella can develop seizures and brain damage.
  • E. coli - unlike media reports would lead you to believe, E. coli is usually a mild infection. Even the most virulent (deadly) form of the infection, a strain called O157:H7 is rarely fatal. Most cases clear up within a few days, but this infection can spread into the rest of the body, causing severe bleeding problems and kidney failure. The most common way to get this little sucker is to eat undercooked ground beef. Why? Because modern food processing machines aren't always the most careful and meat can be contaminated with cow shit. Oops. Cooking ground beef or needle-punch tenderized meat thoroughly can save your characters a lot of problems later.
  • Cholera - this type of food poisoning usually isn't passed in food. It's caused by dirty drinking water. Drinking untreated water, particularly in areas of high population, poor sanitation, war, or famine is just asking for it. Cholera outbreaks in pre-modern eras were devastating to populations, and continues to be a major problem in Africa, parts of Asia, India, Mexico and South and Central America. Vaccines are currently in development to prevent this infection but are still in human testing phase
A few other things to consider when poisoning your characters via dinner are the parasites that can be picked up through food. These include but are certainly not limited to:

  • Fish tapeworms (giant tapeworms that can reach up to 30ft in length - see photo, yeah, that's not a shoe lace) can be contracted from undercooked or raw fish. In the US, sashimi and sushi-grade fish is flash-frozen at very precise temperatures to kill off these potential pests prior to serving.

  • Trichinella (worms that invade the muscles of animals and humans and cause severe pain) are primarily gotten by eating undercooked pork.
  • Giardia are one-celled parasites that spread from infected animals or people. If your character's dog gets bloody diarrhea, plan to fork over some $$ to test for and treat this before it spreads to the people.


As with any medical situation in fiction, consider what your reader needs to know, and what it's reasonable for your character to know. You, the author, might know that the character's symptoms are caused by that nasty waiter not washing his hands after using the toilet, but unless the character has gone to the doctor and been tested, or is prescient, she won't, and if the specific bug isn't important to the story, the reader won't care either.

*****This blog is written for fiction writings, for the purpose of writing fiction. Information herein is not intended for use by real people, pets, trees, or imaginary friends. Arizela is not responsible for information used for purposes other than those expressly intended*****

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Monday, June 8, 2009

Animal Attacks

So your character is wandering along, minding his own business when out of nowhere a vicious creature leaps on him intent on lunch. The intrepid hero manages to fight the beast off, or perhaps the plucky heroine rescues him for a change, but he's not without battle wounds. Now what?

What kind of creature was it?

  • Small animals like rabbits, rats, and squirrels tend to cause small, painful bites and marks, but unless your character is a hemophiliac, chances are he'll survive.
  • Camels, horses, and other large grazing animals can do some major damage with bites, particularly if they occur on the head or face. Another concern with these animals is crushing injuries from hoofed kicks which can be serious or fatal depending on the force of the blows.
  • Domestic cats and dogs come in all shapes and sizes, and their damage capacity varies just as much. The ferocious neighborhood chihuahua isn't likely to cause nearly the trauma that crazy old Bill's trio of abused pit bull guard dogs could. Likewise and ancient rolly-polly tabby cat is less likely to eat your face than a muscular tom in his prime.
  • Large predator animals, be they tigers, lions or bears (or wolves, coyotes, primates, etc) are the biggest risk. Harder to fight off and with much more advanced weaponry than the average racoon, these big carnivores and omnivores mean business. Their survival depends on their ability to turn the next guy into ground chuck rather than being served up themselves. Big cats in particular come along with an increased risk of infection because they routinely lick their claws, dragging mouth germs all over these 5cm to more than 8cm long weapons.
  • Humans (yep, we're animals too, folks) typically only bite during altercations of some sort (and in undead movies). Our teeth can do a lot of damage to hands and faces, but like the grazing animals above, the damage is usually limited to the cosmetic rather than the life-threatening (vampires and zombies aside). The big risk here is that human bites are much more likely to become infected than most animal bites. Yes, your mouth is dirtier than your dog's.

First things first - stop the bleeding

In an emergency situation, the ABC's of triage apply - Airway, Breathing, and Circulation. Most survivable animal attacks are going to endanger the third category, circulation. No blood means no circulation means bye-bye birdie, so the goal of first aid is to keep the blood where it belongs, on the inside. If the blood isn't gushing out, washing the wound in clean running water is recommended to prevent infection, but stopping the bleeding is more important and more immediate a need.

All but the deepest and deadliest injuries in a normal, healthy person are going to respond to pressure. Obviously if the animal has ripped into the abdominal cavity or neck or sliced through an artery, your character had better hope there's a rescue chopper on standby. But for flesh wounds, pressure is your friend. To stop most bleeding, apply direct pressure to minor wounds for 5-10 minutes without peeking. Even for deeper gashes, direct pressure will often stop or slow bleeding until further help can be organized.

Minor scratches can be cleaned with soap and water and covered with a clean bandage. Puncture wounds, deep scratches or wounds on the face should be attended to by a medical professional if at all possible. If your character is enjoying the good life in 1810, however, cleaning the wound with clean water and using stitches to close the wound is about the best you can hope for.

Special cases: Facial and scalp wounds

Face and scalp wounds bleed. A lot. Bleeding from scalp or facial wounds, even small cut
s, can be pretty significant. Get pressure on it as soon as possible and seal the wound with stitches or surgical-grade bonding liquid (aka medical grade super glue).

Second step - Preventing Bugs


Infection is the most significant risk associated with wounds that are not immediately life-threatening (these include uncontrollable bleeding, penetrating abdominal, head, or chest wounds, neck injuries, head injuries). Keeping wounds clean and covered helps in any setting. In the modern world, small cuts can be covered with a thin layer of antibiotic ointment like Neosporin, Polysporin, or Bacitracin. Large, penetrating wounds may require surgery and/or prophylactic (preventive) antibiotics via either oral or IV methods.

If an infection occurs, symptoms usually start 2-5 days from the initial injury or sometime during the healing process for major wounds (which can take months). Symptoms include redness of the skin around the wounds (see photo, child with infected dog bites to face), increased pain, heat or warmth at the site and on the surrounding skin, foul-smelling drainage or pus (creamy or chunky textured drainage in any of several common colors including yellow, rust-brown, green, pink, blood-tinged, or white), and delayed healing. If the symptoms don't get any worse, minor wounds usually clear up on their own after a few days or a week in healthy individuals. However, folks who are very old, very young, immune-compromised (prone to getting infected), diabetic, or who have circulation issues, or folks who have deep or large wounds, or whose infections are caused by "super bugs" (antibiotic-resistant germs) can get very sick, very quickly and even die from skin infections.

Signs your character needs a doctor, shaman, or undertaker - fever, chills, generalized feelings of weakness, ill ease, fatigue, red-streaks along the skin starting at the wound and tracing lines outward, irregular heartbeat, or difficulty breathing. These symptoms may indicate a life-threatening spread of infection into the blood stream or other body organs. Some few people recover without aid from this sort of infection, but there is a high risk of death.

Third, consider the source

Bites from your fellow humans typically occur during a fight of some sort. In those situations where there is a likelihood of blood from another person entering an open wound, special tests for HIV and hepatitis are recommended.

Small animals, particularly rodents, can be carriers of Yersinia plague (aka The Black Death, see also Rare Diseases: Yersinia Plague). Yes, even in modern times, Yersinia plague can cause deadly disease, but modern antibiotics can cure the plague if given within a very narrow time frame. Seeking medical attention can be life-saving, particularly in regions where animal carriers of the plague are more common, like the US west.

Wild dogs, stray pets, raccoons, and large predator animals are considered to have rabies unless proven otherwise. Rabies is a disease which, if left untreated, leads invariably to madness and death. Treatment consists of giving a series of vaccine injections after exposure but before symptoms develop. Once symptoms show up, best start digging the grave.

Domestic dogs and cats are considered free of rabies if they have been vaccinated or if they could not possibly have come into contact with wild or unvaccinated animals.

Special Case: Bats in the Attic

Though bats are small mammals not birds, these tiny bug-eaters can harbor rabies virus. Bats are responsible for most of the cases of human rabies that occur in the US. According to the Centers for Disease Control,
Rabies can be confirmed only in a laboratory. However, any bat that is active by day, is found in a place where bats are not usually seen (for example, in a room in your home or on the lawn), or is unable to fly, is far more likely than others to be rabid. Such bats are often the most easily approached. Therefore, it is best never to handle any bat. Bats have tiny, needle-sharp teeth that can penetrate the skin and infect a human without even leaving a mark, so if a Sunny Susie awakes to a bat flying around the ceiling, she'd best get the bat tested for rabies, or she could end up looking like this:
Just kidding!

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Monday, June 1, 2009

Excuses, excuses... And a list of what's to come

My apologies, guys, for the little Muse Med hiatus. I've been dealing with some real life health problems over the last couple of months and it sort of got away from me.

But!

I've gotten a little back-log of questions from very patient writers that will be addressed over the coming weeks. Stay tuned for everything you ever wanted to know (or maybe didn't want to know) about:

animal bites and scratches
food poisoning
parasitic worms
hemorrhagic fever

Keep those questions coming, folks.

Tuesday, March 10, 2009

Famine - the look and feel

Famine, it has been argued, is one of the most devastating of the preventable disasters in human culture and history. Despite the tireless work of relief agencies, individuals, and governments to end world hunger, many regions continue to face famine regularly. Military instability, political unrest, climate changes, natural disaster, and other factors can lead to food shortages, failure of distribution systems, and hunger.

A question recently hit my in-box regarding the effects of famine. What does it look like? What health effects occur?

Those are very difficult questions because famine doesn't come in one shape. The faces of famine are many, as are the causes.


There are victims of famine who would not look substantially different from Nicole Richie (pictured on the left) -- a little bony, head a little too big for the body, but otherwise without outward signs of dysfunction. Now, I'm not saying how Nicole got her body to look like that, because I don't know, but during famine, this shape will often appear after months of mild calorie deficiency. The amount of food taken in is reasonably close to what is needed, but misses the mark. Energy levels tend to fall off, as the body attempts to conserve calories, which in many pre-industrial countries means less food is produced and thus less food is available, making the situation increasingly worse. That said, there are certainly people whose natural body type fits this profile, and that doesn't mean they are starving. Those people may have just as much energy as anybody else and eat diets comparable or even higher in calories than the average, but their bodies naturally do not store the same amount of fat or muscle as someone with a different build.

A familysuffering from malnutrition in India.

More prolonged or more drastic starvation results in an even bonier appearance. Health problems of extreme starvation include hair loss, loss of or decay of teeth, brittle bones, thin skin, mouth and skin sores, bleeding gums, lack of energy, weakness, lethargy (extreme drowsiness or inability to engage in normal activities due to weakness or tiredness), increased susceptibility to infections of all sorts, and death.


A Sudanese boy suffering from extreme malnutrition.
Children who experience famine are many times more likely to die before reaching adulthood, are shorter of statue, and can have learning disabilities, developmental delays, and reduced IQ because normal brain development requires a good deal of fat and nutrients. See also my post on infants during famine.

There are also photographs that show up on impassioned TV infomercials attempting to solicit aid for regions of the world under famine that depict bony children with large bellies. There are two reasons for this distinctive appearance. First, in many cases, the large bellies are a result of parasites. Worms contracted from dirty drinking water, undercooked meats, or unclean or partially spoiled food breed and multiply in the abdomen, feeding off what food the person is able to take in. The worms grow while the person starves for lack of calories. The second reason is ascites (pronounce ass-site-ees), which is caused by severe malnutrition that leads to low protein levels in the blood. Protein is what holds fluid in your bloodstream, so without it, the fluid tends to leak into the abdominal cavity (belly) and make it appear swollen.

Famine can occur in populations where average intake of calories exceeds the American Dietetic Association's recommendations of an average of 2,000 calories per day if the people must expend significantly more calories than the average American on whom those recommendations are based, such as in farming communities without modern farming equipment or technology, in areas where the environment temperature is extremely cold or hot, etc..

There could also be adequate calories in a person's diet, but insufficient vitamins and minerals to support life. Diseases associated with malnutrition (the condition of not being properly nourished) are many and are specific to the nutrients being missed. Examples of nutrients include vitamin B, iron, protein, calcium, vitamin C, etc.. Any component that humans must get via diet which is missing or deficient in the diet can cause disease associated with malnutrition. Malnutrition can be a "silent" disorder - occurring in people who "look" average weight or even extremely obese. Symptoms vary by the nutritional component(s) the body is missing.

*****This blog is written for fiction writers, for the purpose of writing fiction. Information herein is not intended for use by real people, pets, trees, or imaginary friends. Arizela is not responsible for information used for purposes other than those expressly intended*****

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Cuts on the inner forearm

A question recently hit my in-box from an author who has a character being tortured for information. In the scenario, the author intended to have the protagonist "stabbed on the inside of his forearm and the knife gets dragged through the flesh towards the wrist a couple of inches." The protagonist needs to be worried, but able to walk a good distance and not pass out or die from shock.

The trouble with using a knife as a torture device is that unless the torturer is very skilled at what he does and knows anatomy very well, he's as likely to kill as extract information. In this particular case, there are two decent sized arteries running along the inside of the forearm, the radial and ulnar arteries (see photo). Stabbing down into the flesh and dragging the blade toward the wrist is almost sure to hit at least one of them.

Slashed wrists is a common method of attempted suicide which is widely known to not be terribly effective because by the time the artery gets to the wrist, it's pretty small. It can take hours to bleed to death from a slashed wrist, but cut the artery higher up the arm and you've got bigger problems. Shock can set in pretty quickly - my best guess being within ten minutes. And after that, you've got some time to stabilize the victim, but he's not going to be doing much to help you as he will likely be unconscious or too confused to function.

If your victim gets away within minutes of the cut and applies pressure directly to the wound and then gets help, chances are good with surgery and perhaps blood transfusions that the victim will live.

If you want a lot of pain, an alarming amount of blood but not truly immediately dangerous, you could go with any major muscle group that isn't near a major artery. Muscle bleeds a lot. Some locations that are pretty choice, the calf muscle, the muscles of the outer forearm, the top of the thigh or outer thigh area, the shoulder. Think meaty parts that aren't near pulse-points. The muscle will likely stop working for a while, but with some stitches will generally heal up pretty well.

Alternately, cuts that bleed an alarming amount, hurt a lot, and are generally unlikely to cause death are cuts to the ears, scalp or forehead. Try not freaking out when someone slashes you across the forehead and there's blood running into your eyes.

*****This blog is written for fiction writers, for the purpose of writing fiction. Information herein is not intended for use by real people, pets, trees, or imaginary friends. Arizela is not responsible for information used for purposes other than those expressly intended*****

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Monday, January 26, 2009

Rib Injuries

Question: What are the differences, symptoms, severity, and complications of rib injuries, and how much do they hurt?

Ah, ribs. Those grand old things that protect all your most vital organs. What lay-people generally think of as a ribcage aren't just bones though. They are actually composed of twelve bones on either side of the chest, plus thick, tough cartilage (like in your nose, only stronger), and the sternum (breastbone). All 24 long, curved rib bones attach to the spinal column in the back (backbone), but in the front, only some of them are attached at all. The top seven on either side are attached to costal cartilage which attaches directly to the sternum. The next three pair are attached to costal cartilage which attaches to another cartilage rather than the breastbone, and the bottom two pairs, called "floating ribs" don't attach in the front at all.

In the above computer modeled ribcage photo, the white areas indicate bone and the golden-yellow areas are costal cartilage. The area circled in pink is a small tip of bone called the xyphoid process, which can be broken off pretty easily. In a living body, there would also be muscles called intercostal muscles in between each long rib bone to connect each bone to the one above or below it.

Types of Injuries

There are three basic types of injuries that can happen to the ribs: Fractured or broken bones, bruised bones, and torn cartilage. "Cracked" ribs are broken ribs - there is NO difference between cracked and broken ribs, however breaks can have varying severity - anything from a little "crack" to a complete break across the entire thickness of the bone. The symptoms for all three are going to be pretty much identical.
  • Pain, especially when taking deep breaths, coughing, laughing, bending, twisting, lifting weight, or pressing over the injured area.
  • Possibly bruising over the injured area
  • Crunching or grinding noises or sensations with movement
  • Actual deformities in the shape of the chest over the injured area (a dent, basically)
  • Difficulty breathing (either from the pain or as a complication of a fracture - see below)
How do rib injuries occur?

Anything that causes a trauma to the chest can injure the ribs. Contact sports, fighting, car crashes, and CPR are some of the most common causes of damaged ribs. I once had a doc tell me that if you're doing CPR chest compressions and you DON'T feel ribs breaking, you aren't doing it right. While not a really good rule of thumb, it is true that CPR chest compressions often result in broken ribs, especially in the elderly and small children. It is important not to be afraid of breaking ribs though, when doing CPR. Most people would rather be alive to complain about the rib pain later.

How are they treated?

In modern medicine, all three injuries are basically treated the same way:
  • Rest - avoid anything that makes the area hurt, except breathing.
  • Ice, on for 10-20 minute and off for 20-30 minutes. Rinse and repeat.
  • Over the counter pain medications - preferably in the NSAID (non-steroidal anti-inflammatory drug) class such as aspirin or ibuprofen because these drugs treat inflammation/swelling as well as pain, unlike tylenol(acetaminophen)
  • Deep breathing exercises to prevent pneumonia if breathing is troublesome.
In days past, docs used to apply rib splints or compression dressings (think ace wrap) to help "support" the ribs and prevent them from moving around too much. This decreased the amount of pain associated with breathing and coughing and whatnot, but in turn significantly increased the risk of pneumonia and death as complications. Oops.

We don't do that so much anymore, although applying some firm, consistent pressure with a hand over the injured area only when coughing or sneezing, or doing something else short term that causes increased pain can be effective at decreasing pain. These days compression dressings and splints are only used in cases that are VERY severe.

What nasty little surprises can my characters expect me to spring on them down the road?


Ah, complications. They do make a story interesting. The complications of rib injuries are going to vary by the injury a bit.

  • Pneumonia - All three types of injury can cause significant pain with breathing, encouraging the person to take very shallow breaths. If the person keeps this up for a few days or a couple of weeks, chances are good that the person is going to regret it later, in the form of a solid case of pneumonia. The lungs produce mucous constantly. Kind of ichy, but there's a good reason for it. Germs, dust, and other nasty things that shouldn't find a home inside your lungs get trapped in the mucous and coughed up. If you don't take breaths that fill your whole lungs up with air, over time the mucous can thicken up and "collapse" the air sacs inside the lungs, along with their collected germs. Viola, pneumonia. Symptoms of pneumonia include fever, chills, coughing up stuff from deep in the lungs(usually yellow, tan or green in color), wheezing, and difficulty breathing. If not treated or overcome by the body's natural immune abilities, pneumonia can quickly lead to blood stream infections (sepsis), shock, and death. Or it can linger around for a long time and cause a gradual worsening or leave permanent damage (short breath, wheezing).
  • Punctured lung - this is usually going to show up pretty quickly and only in severely broken ribs (think massive trauma to the chest, like smashing against a steering wheel while not wearing a seatbelt in a 50mph car crash). The space between the injured lung and the ribs will fill up with blood(hemothorax) or air (pneumothorax), squishing the lungs over in the process and making it harder and harder to breath. If there is air moving from the lung into the space, the lungs and eventually the heart will get smooshed over to one side (away from the injury) until they can't expand anymore and the person basically suffocates and the heart can't refill with blood to pump anymore. This is called a tension pneumothorax and MUST be treated immediately.
This illustration depicts the insertion of a chest tub, a flexible tube that is placed into the space that fills up with stuff to allow the blood or air to drain back out. Just sticking a tube into the wound isn't going to help much though. Chest tubes use basic principles of pressure differentials to "seal" the tube so air and blood can leak OUT but air and germs can't get back IN.

All this scientific stuff is neat, but how does it FEEL?

Speaking from experience, broken ribs HURT. And by hurt, I mean it sort of feels like someone is sticking a high-heeled shoe straight into your lungs and giving it a little twist. That said, it is certainly possible to battle through the pain, especially when the injury is fresh and all those endorphins (brain chemicals that tell your brain to ignore pain) and adrenaline are sloshing around inside you. I personally took three good swings with a baseball bat at the jackass who broke two of my ribs before the pain hit. (He was much bigger and stronger than me. The bat evened things out nicely) After the pain hit, I did a lot of walking humped over, holding my side, and generally being miserable for a couple of months. Life went on.

How long does it take to recover?

Bruised ribs and torn cartilage usually take 3-4 weeks to recover. Fractured bones, 6-8 weeks. However, this rate is GREATLY impacted by numerous factors and the healing can take MUCH longer. This is great news for our intrepid writer, as you can really play with the time factor here. My personal rib injury still gives me significant trouble off and on 15 years later.

Factors that increase time to heal:
  • Old age
  • Osteoporosis or generally weak bones
  • Reinjuring the area (like the folks who continue to play football with cracked or broken ribs)
  • Not resting enough (like that character who's going to be dodging bullets or swinging swords)
  • Other injuries - the body has limited resources and not all things are equal
  • Nutrition - bones and cartilage require certain components to heal, like calcium and especially protein. Healing will still happen for folks with very poor diets, because the body will rob from other areas eventually, but proper nutrition will help speed healing and prevent infection
  • Infection - infected tissue doesn't heal. Basically, the body has other things on its mind if it's trying to put out fires
  • Severity of the injury - a complete break along the full thickness of the bone is going to take longer to heal than a partial fracture. Likewise, multiple rib fractures or multiple torn cartilages will not provide adequate support for each other to heal and may slow the process down a bit
Rib injuries can be a nice way to give your characters unpleasant lives for a while and make things just that much harder on them, but by themselves they aren't going to keep a determined hero or villain out of action most of the time. They'll hurt enough to discourage athletics, but those endorphins and adrenaline can work magic even here in the real world.

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Monday, January 19, 2009

Official Cause of Death

A question recently hit my inbox about what the official cause of death would be listed as on a death certificate of a person who died of cancer. As I don't deal much with that end (pun not intended) of the health care spectrum, I did a bit of digging and found out that writing the "cause of death" statement is surprisingly complex and yet also a thing of simple beauty. Ok, so I'm a bit morbid.

A typical cause of death statement might read:

Acute Myocardial Infarct

Now, if you aren't an MD or a nurse, that might look like a load of gibberish, but really it just says "heart attack". Simple, right? er... not quite as simple as that. Actual cause of death statements are written in two parts. The purpose of these statements is to allow tracking bodies to develop statistics on diseases and processes that kill people, and the things that put us at greater risk for these conditions. So if a coroner or MD writing a death certificate has more information (ie from medical history or an autopsy), they are going to fill this section in with as much data as possible.

Part I

The purpose of part 1 is to determine the series of medical events that lead up to the death, in reverse order, starting from the most recent condition and working backwards to the oldest relevant condition that lead directly to the death. So that very basic heart attack up there would become something more like heart attack due to hardening of the arteries that feed the heart, or in medical jargon:

Acute myocardial infarct
due to or as a consequence of Athrosclerotic coronary artery disease

As another example, if you had someone die of a pneumonia because they had AIDS, their cause of death statement would look like:

Klebsiella Pneumonia
due to or as a consequence of Acquired Immune Difficiency Syndrome
due to or as a consequence of Human Immunodeficiency Virus infection


If there isn't a lot of data on what lead up to the death, or if the person was terminally ill from a known disease but there isn't a way to determine what complication of that terminal disease exactly killed the patient, you can sort of guess or just leave it off. As below:

Acute myocardial Infarct
Due to or as a consequence of Probable Atherosclerotic coronary artery disease

Or simply:

Adenocarcinoma of the prostate

Part II

Part II is to list risk factors that lead to the sequence of events that lead to the death. These can include other diagnoses, like high blood pressure (hypertension) or diabetes (diabetes mellitus type I or type II), or behaviors, like alcohol abuse, IV drug abuse, etc..

Do's and Don'ts

Don't report signs or symptoms as the cause of death

So a person cannot be said to have died of a cough, fever, or elevated blood alcohol level. They can die of pneumonia (that caused the cough), or a specific infection (that caused the fever), or alcohol toxicity (with the high blood alcohol level would diagnose, but the blood alcohol level itself is a test, not a diagnosis).

Don't report mechanistic causes of death

Mechanistic causes of death are the physical process that stopped or failed due to disease or trauma, rather than the disease or trauma itself. As in cardiac arrest caused by a heart attack, or respiratory arrest caused by pneumonia. Other examples of things that shouldn't be reported in this class include heart arrhythmias like asystole (flat line), or ventricular tachycardia (V-tach, a fatal change to the electrical impulses in the heart. See photo).


Do be specific and exact

Don't oversimplify or under-report. For instance, a doctor wouldn't write that high blood pressure killed anybody. High blood pressure may have lead to stroke that killed someone, or it could have lead to hardening of the arteries and a heart attack. It's better to include too much information rather than too little.



Relevant for fiction?

Depends on your fiction. If you have a doctor or coroner talking about a cause of death, then this statement is going to be very important. Doctors are trained to analyze cause of death in this pattern, and so it's going to be this pattern that they are most comfortable with when reporting cause of death at trials, to reporters, to family members who want more specifics, etc.. They will also use this basic pattern of understanding to ask for permission to do an autopsy on cases where they don't understand exactly what progression led to the death. ie "We believe your aunt died of an overwhelming urinary tract infection, but we would like to be sure/we need to understand what caused this infection to be so severe."
Why is cause of death important?

In my particular line of work, (in a NICU with newborn, premature, and young babies) the official cause of death can be very important. Information like genetic or infectious reasons for the death can help us council families who wish to have more children. Information also needs to be gathered to prove that everything was done as it should have been, that the death was not do to medical error (either ours or the birth hospital's), or some other process that can be prevented or mitigated in future pregnancies.

Cause of death statements also allow us to track which diseases and problems are killing us, and thereby allow us to work harder on cures, treatments, and solutions to those same diseases and problems. Keeping mortality and morbidity statistics is one of the best ways to start tracking the impact of disease and death. Of course, the cost of disease and death can't just be measured in death. Quality of life, healthcare costs, the costs to survivors, and other factors must be weighed as well.

Autopsies and how they help us understand death




Autopsies are frequently requested when children or young people die and the exact cause of death was not well understood. Autopsies can be requested by the hospital, the coroner, or the family, though the latter option can be prohibitively expensive for the family. Autopsies can be done even if the deceased was an organ donor.

There are also legal reasons why an autopsy would be required. If there is suspicion of abuse, murder, or death by unnatural causes, the family might not have a say as to whether or not an autopsy takes place. In these cases, cause of death statements must be exact and as complete as possible because they might effect future prosecution. Cause of death statements can be amended if new evidence later comes to light in these situations.

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Sunday, January 18, 2009

Hollywood Flub-Ups: The dying breath

The dying breath

How many times have you seen that pivotal death sequence, where the character lives just long enough to gasp out his last words of wisdom to the protagonist. Often either giving the answer to the plot all along or one word short of it and frustrating the protag even more? I've seen it a few too many to count.

Our Flubber: Serenity (which still manages to be my favorite movie of all time)

Shepard Book has been shot. He's covered chin to belly button in fake blood. He has time to give Mal (Captain Malcolm Reynolds) all the benefits of his sage advice and swing the plot drastically sideways. Then he keels over and dies mid-sentence following some witty banter and a tear-jerking moment.

The trouble here? Book has a mouth full of blood and is wheezing and coughing. Which means... you guessed it. Lung shot. When the lung is punctured, the space between the lung and the chest wall starts to quickly fill up with air and blood, as the lung itself starts to fill up with blood. The person in question is going to feel like a fish out of water. He won't die instantly, but he sure won't be giving any sermons.

On another related note, Book also had one side of his mouth drooping. And since he didn't have any damage on that side of his face, I'm guessing they were going for a stroke. And I think you can figure out for yourself why that might make the sermon a bit hard to deliver.

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Friday, November 28, 2008

Hollywood Flub-Ups: watering the unconscious

In this repeating column, I will explain how Hollywood (and various TV mini-series and shows) get it all too wrong.

Our first culprit: Legend of the Seeker (and yes, I know it sucks. Bare with me here)

The great wizard, Zedd (left), has been struck by an underworld creature and is unconscious. His trusty companions Kahlan and Richard (right) are sitting around worrying about him. Kahlan tilts a canteen of some liquid, presumably water, into Zedd's mouth while complaining that "his breathing is getting worse."

OK, OK. I know you don't have to be a rocket scientist to figure out where they went wrong on this one. People tend to breath worse when you are drowning them.

For the love of Pete and all his Pete-like friends, please folks, do not have your characters pouring liquids into unconscious companions (unless they are secretly trying to kill said companions). Aspiration pneumonia or drowning is the much more likely outcome of that than oh, keeping the person well hydrated.

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Monday, November 24, 2008

Special Topic: Death in Childbirth *long post*

Death during childbirth is an oft-used ploy in fiction. If done convincingly, it can add an intensity of tension, emotion, and tragedy to a story that few other events can, probably because the death of a mother and/or child is one of the most prevalent and deeply-held fears of our species. At the moment of miraculous life-giving, life is suddenly and unexpectedly ripped away.

So why is it that death in childbirth has become such a groaner in most fiction? The childbirth death scenes I have read revolve around the dramatic moment (often melodramatic) where the dying mother gasps out a name for her squalling, healthy infant with her last breath and timely expires. The likelihood of this scenario is so miserably small, not just in our modern society, but in every society across time, that it's frankly laughable to anyone who understands the birthing process.

But fiction is all about making the improbable seem plausible, so if death in childbirth interests you as a plot line, read on.

The Risks of Childbirth Today

In modern day US, maternal mortality - the measure how many women die during pregnancy, birth, or the postpartum period from problems related to childbearing, is 12.1 women in every hundred thousand. That's right, 12.1:100,000. Pretty sharp odds against. And remember, that's any woman who is pregnant, giving birth, or having given birth in the last 42 days. The number of women who actually die during the physical act of giving birth to a baby or soon enough afterward to gasp a name and promptly kick the bucket is minuscule in the extreme.

Non-developing nations, including parts of Africa, have much higher rates of maternal death, as high as 920:100,000 in the last 10 years. Reasons for this include lack of prenatal care, unsanitary conditions, lack of qualified, train professionals to oversee the pregnancy and birth, and poverty. Deaths occur for similar reasons as in developed countries.

What about the past?

Historically, maternal death rates have been higher than they are today. In 1915, the rate for US mothers was just over 600:100,000. Still pretty good odds of mom living through the process.

How does home birth fit into the picture?

That's a trickier question. The answer is, it depends on who you ask. Studies and papers published by MDs proudly proclaim that home birth is three times more likely to kill babies and mothers than hospital births. Studies done by non-medical affiliated groups and groups with vested interest in home birth show a maternal death rate that is much better than modern hospital births. Studies done in other countries, including studies of US births, report a remarkably low rate of maternal death when home births are attended by trained, licensed midwives. Those figures are consistent with home birth statistics in countries with much lower risks of maternal death than the US, like Sweden and Norway, where most births are attended by midwives and many are conducted in a home setting.

I'll leave it up to you to decide which to believe.

All research I could find on the subject agrees that unassisted childbirth or 'free childbirth' is extremely dangerous to mother and baby, with an exponentially higher risk for both.

Going to give mama the ax anyway? Here's how.

The biggest killers of women giving birth are blood loss, eclampsia (seizures from very high blood pressure), unsafe purposefully-induced abortion, obstructed labor, and sepsis (aka childbed fever). The graph below indicates the percent of total causes of maternal death worldwide and is provided by the NIH (National Institute of Health) based on data from the WHO (World Health Organization). Unsafe abortion is a topic for another day, but let's consider the other methods.



Blood loss, is generally going to kill much quicker than infection, for obvious reasons, but the tiny trickle of blood folks seem intent to pass off as 'bleeding to death' in childbirth is pretty funny. Pregnant women have a third more blood volume than non-pregnant humans. What's more, the end of pregnancy is the only time in the human life-span when someone can easily lose 30-40% of their total blood volume without going into shock and probably dying. That means a woman would have to lose liters of blood during the birth and shortly after, not counting the amniotic fluid which can dilute and falsely "pump up the volume" of blood being lost. And that's just for shock to set in.

Blood loss this significant is usually caused by:

  1. a baby that won't come out and let the uterus (womb) shrink back to it's normal size

  2. a uterus that is floppy and unable to contract after the baby and placenta (after-birth) are delivered

  3. the placenta is not expelled after the baby is born

  4. something completely unexpected, extremely rare, and oh-shit worthy happens.

Option 1 and you'd end up with dead mom, dead baby after probably 2 days of unsuccessful labor without a C-section. With C-section technology, this situation would likely not continue longer than 24 hours and they'd both be fine, barring surgical complications.

Option 2 has several quick solutions. Putting the baby to the breast will stimulate the uterus to contract as hormones called oxytocin flood the bloodstream. Oxytocin is a hormone that provides a dual function - contracting the uterus and releasing milk from the breasts. Another potential treatment in a modern setting is a "pit-drip" or an IV infusion of a drug called pitocin, which is a synthetic form of oxytocin. Finally, just giving the stomach a good, deep, firm massage will help get the lazy uterus to do it's job.

Option 3 can benefit from all the suggestions for Option 2, plus a possible surgery called a D&C, or dilation and curettage, which means the doctor opens up the cervix (part of the womb the baby exits through to the birth canal) and scrapes all the stuff on the inside of the womb out. This can be done with a relatively low level of technology, but using non-sterile instruments is a HUGE risk for infection, and there's also a slight risk of damaging the cervix to the point that the woman would miscarry any future pregnancies.

Option 4 would depend on why she's losing blood. Rupture of the uterus, part of the placenta covering the mouth of the uterus and preventing baby from leaving, abruption (where the placenta separates from the woman before the baby leaves the womb), or some other trauma would be best guesses for this factor. They are all pretty rare but usually require emergency c-section and surgery to correct the situation. They may end in hysterectomy (removal of the womb), but with a skilled surgeon on hand they are very survivable. A woman suffering one of these problems prior to modern medicine would probably not survive.

In any case, a modern setting is likely to have such life-savers as IV fluids, blood transfusions, and surgical intervention.

Sepsis, or infection was a big killer prior to the advent of antibiotics. Before the move of birth from the home setting to early hospitals in the last century the rate was still relatively low. Once birth moved to hospitals, with questionable sanitation and physicians who were practicing procedures on cadavers and then delivering babies without gloves or hand-washing, the infection rate soared. It remained high despite attempts to treat birth as "sterile" in the middle of the century. Today, a combination of infection control measures and antibiotics has significantly reduced the number of women who die from infection associated with pregnancy, but it still happens today.

The most common reasons for infection, today and in the past, have been unsanitary environments, non-sterile instruments like forceps or surgical tools, unwashed hands, shaving the pubic area, and prolonged labor that goes longer than 24 hours after the amniotic sac ruptures ("the water breaks"). The solutions for these seem pretty easy for the most part - work clean! Of course, in the era before germ theory and the knowledge that infection was spread by microscopic organisms, physicians didn't wash hands between patients. Why would they? As for the rupture of membranes, the solution for that is easy, too - deliver the baby. In a modern setting, this can be done by C-section, induction of labor (get it started) using a pit-drip or other medications. In a less tech-oriented society or among women who chose a more "natural" venue for birth, nipple stimulation, walking, certain foods, certain herbs (not recommended in modern times), and even sex can kick labor into gear.

The trouble with infection for the scenario that started this discussion is that it takes time to get septic (infection that is generalized throughout the body), usually 3-4 days before symptoms show up and a quick finale afterwards if they aren't treated promptly. Symptoms include high fever, chills, muscle aches, and foul-smelling drainage from the birth canal. This can progress to shock (low blood pressure), loss of consciousness, and death.

High Blood Pressure in pregnancy is called pre-eclampsia, which can lead to eclampsia. Eclampsia is life-threatening seizures caused by extremely high blood pressure. Signs of pre-eclampsia include swelling of the hands and face, dizziness, headaches, and changes in vision. The only cure for pre-eclampsia or eclampsia is delivery of the baby, but pre-eclampsia can be treated with medications to reduce blood pressure and medications called anticonvulsants can be used to prevent seizures

Obstructed labor, or the inability to push the baby out, can be caused by the position of the baby - breach (feet or butt down) or transverse (side-lying) are the most common positions that cause this. Other causes include weak contractions by the uterus, a very large baby, a very small pelvis in the mom, or a shoulder dystocia (shoulder gets wedged into position behind the pelvic bones). All of these require some intervention from a trained professional. In the case of a positional problem with the baby, a procedure called 'external version' can be done, in which the doctor or midwife uses hands on the outside of the belly to gently push the baby around in the fluid-filled womb until it's in the right position, which is head-down. External version is sometimes successful, but in most cases a C-section will be performed in modern times, and likewise a C-section is indicated for most other causes.

Again, obstructed labor can be a very dramatic event, both in the modern setting and in the historical/fantasy setting, but without prompt intervention, both mother and baby are likely to die, and with it, mom is not at significant risk, though if prolonged, baby can develop brain damage from lack of oxygen.

Summing it up

As you can see, death in childbirth isn't quite like the movies and books portray it. It can be just as heart-wrenching and dramatic, though, to have a mom die after several days of exhausting labor or a quick descent into infection. And if you have a near-miss planned, you now have a basis of information on the how, when, and why mom's die in childbirth. If you want more specific information not provided in this post, email me a question or try the following search terms:

  • Maternal mortality

  • Post-partum infection

  • Placental abruption

  • Placenta previa

  • Shoulder dystocia

  • Cephalopelvic dysproportion

  • Cesarean section

  • Home birth

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VISION: Written in Blood

A few years back, before I had this wonderful blog as a place to dump all my writerly nursing advice and medical error pet peeves, I wrote an article for a great little e-zine called Vision: A Resource for Writers. (My first sale for actual cash!)

The article was called Written in Blood, and I think many of you might enjoy a look at it. It addresses some of the common myths and misinformation found in novels and hollywood/TV filmography about blood, bleeding and the human body, including some information about how to describe blood in a sensory fashion - sight, taste, touch, smell.

blood spatter photo

You can find the Written in Blood here: http://fmwriters.com/Visionback/Issue36/writblood.htm

Also, browse through the current edition of Vision here: http://www.lazette.net/vision/ The archives are available at the bottom of the screen and are well worth a look - they are truly a wealth of writing wisdom.

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Wednesday, October 29, 2008

Alcoholism: Long-term Effects and Withdrawal

So your character has a habit. A bad habit. And of course, writing fiction is all about making the characters day a little more difficult. What better time to go cold turkey off the booze than the middle of an action-filled, intensely stressful plot?

Alcohol consumption can be good for the body, in small regular doses. A glass of red wine a day has been proven to have protective benefits for the heart and contains many cancer-fighting anti-oxidants. A pattern of binge drinking or heavy consumption of alcohol, however, can have major negative impacts on social situation, health, and well-being. Alcohol withdrawal can cause life-threatening problems called DTs, or delirium tremens.

Long-term complications

Most of the long-term complications of alcoholism fall into two categories - damage from the drug itself and damage caused by the exceedingly poor nutritional status of most chronic alcoholics.

Probably the most well-known complication of alcoholism is cirrhosis of the liver. Basically, the liver fills up with scar tissue. Below, you'll find photos of both a healthy liver and a scarred liver with cirrhosis. Cirrhosis can also be caused by viral infections, including several strains of viral Hepatitis, an infection alcoholics and drug users are particularly prone to get. The healthy liver is on the right.


















Other direct complications of alcoholism include withdrawal (DTs), physical dependence, inability to abstain from drinking, tolerance (needing more and more alcohol to get drunk), or are primarily social complications like inability to hold a job, dysfunction of relationships, homelessness.

Indirect complications are sometimes worse for the body than the direct ones. Every system of the body is impacted by excessive alcohol intake. Just a few of the massive list of possibilities are below:

  • Altered brain function, including decreased ability to think and reason
  • Impaired judgment both when drinking and when sober
  • Ulcers of the stomach and intestines, bleeding from the intestines (coffee-grounds appearance to the poop)
  • Extreme malnutrition - alcohol has more calories per gram than sugar and carbohydrate foods (breads, cereals, fruits, vegetables), but none of the protein, vitamins or minerals the body needs to stay strong. Weight is not a predictor of nutritional health.
  • Brittle teeth and bones - I once took care of a fellow in the ICU who broke his neck by falling off a couch onto carpet after a bender and 20 years of hard drinking. He is now quadroplegic (unable to move arms or legs)
  • Bleeding - alcohol "thins" the blood, making blood clotting take longer from cut to clot, so chronic alcoholics bleed longer when cut, bruise easier, and are more prone to strokes and brain bleeding with head traumas
Cold Turkey: Delirium Tremens
Cutting the stuff out? If your character has been an addict for a while or has gone on a major binge (even just one if the blood alcohol level was super-high), they can suffer Delirium Tremens. These very uncomfortable physical signs of withdrawal can last for up to a week after the last drink and can get very suddenly worse. People have died from Delirium Tremens and for very chronic alcoholics or long-term very heavy drinkers, the best place to withdrawal is at an in-patient treatment facility. Symptoms of the DTs are below.

  • Tremors/shakes
  • Agitation, confusion, deep sleep for very long periods (a day or longer), stupor, inability to fully wake up,
  • Delirium - a loss of the ability to determine person, place, time, or situation - the person might not be able to remember what year it is, not recognize family members, not understand where he/she is or why things are happening
  • Hallucinations - seeing, hearing, smelling, feeling physical sensations, or tasting things that aren't really there
  • Fear, anxiety, restlessness, excitement, nervousness, irritability
  • Very sensitive to light, sound, touch, jumpy
  • Rapid changes of mood, depression
  • Seizures - usually full body large motor jerking (to see a seizure click HERE). Seizures of this type are very rhythmic and often involve eye rolling, teeth grinding, a bluish tinge to the face/lips and severe confusion and tiredness or feeling too heavy to move afterward. Seizures are most common in the first 1-2 days after the last drink
  • Pulsing headaches
  • Loss of appetite, nausea, vomiting, stomach pain
  • Pallor, heart palpitations (feels like your heart is doing cartwheels), chest pain
  • Heavy sweating (especially facial and on the palms)
  • Fever
After the physical withdrawal period, the patient is no longer physically dependent on alcohol, but they may continue to by psychologically addicted. They feel like they need alcohol to function, to escape, or just because. Psychological addiction can be a powerful enemy. Alcoholics Anonymous is a 12-step program to help people cope with alcohol addiction. It works. It also requires one to profess a belief in God or a higher power, which isn't something everyone can do. Cognitive-behavioral therapy and aversion therapy (where drinking is repeatedly associated with a very noxious stimulation, vomiting for instance) have also show to be very successful.

In severe cases where alcohol addiction has become life-threatening, controversial medications which cause the body to violently react to ANY alcohol consumption have been used. These include Antabuse and Disulfiram. Other medications are available for treatment of alcohol addiction, including anti-depressants and drugs to control cravings.

Recent studies suggest that alcoholics who continue to smoke while attempting to stay sober are more likely to relapse than those who quit smoking and drinking at the same time.

For more information on alcoholism, its symptoms, effects, treatments and complications, see:
As an added disclaimer, if you think you or someone you know has an alcohol addiction, seek professional help. Resources in your community can be found through Alcoholics Anonymous, your physician, the local health department, and at any hospital. Remember, information here is for fiction-writing purposes only.

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Tuesday, October 28, 2008

Infection: Malaria

I vant to suck your blood!

What better time than Halloween to be thinking about blood suckers. The one you see to the right is Anopheles mosquito, and its bite probably doesn't even hurt, though it might itch later. 41% of the world's population lives in the home territory of these little vampires, but the loss of blood isn't that harmful. What your characters have to be wary of is the VTD - Vampire Transmitted Disease. Anopheles mosquitos are often infected with tiny, microscopic parasites that are the cause of one of the most common parasitic diseases in the world - malaria.

Every year around the world, 350-500 million cases of malaria are diagnosed. This disease is anything but rare.

Malaria is caused by several species of parasites - P. falciparum, P. vivax, P. ovale, and P. malariae. These yummy little microscopic bugs have a powerful hunger for red blood cells. The parasites are injected into the body through the bite of infected mosquitoes. Once injected, they race to the liver and begin to multiply. Victims rarely know they are infested during this stage as the 15-100 parasites build an army 30,000 strong before attacking the choice buffet that is the blood stream.

Once inside the blood cells, the parasites multiply and feed, eventually rupturing the blood cell and causing the symptoms of malaria. Symptoms begin anywhere from 7 to 30 days after the mosquito bite, but can be suppressed up to a year by modern anti-malarial drugs. How fast the symptoms start depends on which species of the parasite are infecting the person, and on the person's own body. Classical malaria attacks are rarely observed these days, but attacks occur every 2-3 days and last 6-10 hours each. The reason for this timing is that the parasites incubate inside infected red blood cells for 2-3 days before the blood cells rupture. In classical episodes, the victim goes through three distinct stages of illness.


  • The cold stage - shivering, chills

  • The hot stage - headaches, fever, possibly seizures (especially in children), vomiting

  • The sweating stage - sweats, normal temperature, extreme tiredness
In general, a victim can experience any of the following symptoms, in any order: chills, fever, weakness, vomiting, sweats, headaches, nausea, muscle aches and generally feeling under the weather. In cases of infection with P. falciparum jaundice (yellowing of the skin and whites of the eyes) can occur along with enlargement of the liver and fast breathing.

Right. Sounds like a nasty case of the flu. What's the big deal?

Malaria infection killed nearly a million people in 1995 alone, and accounts for over 10% of all childhood death in developing nations. The strain of parasite, P. falciparum, are much more aggressive than the others and can lead to "severe malaria" in which one or more organ system fails to function. Systems and their symptoms are listed below:

  • Brain infection - abnormal behavior, seizures, decreased ability to remain awake, coma or death

  • Severe anemia leading to extreme tiredness and breathing trouble

  • Respiratory distress (breathing trouble) - flaring of the nose, head bobbing, panting, fast breathing, blue tinge to the fingertips, lips or mouth, the inability to get enough air, passing out, death

  • Longer bleeding times before clotting - this can lead to strokes, bruising, actual bleeding, gut-bleeds (bloody or coffee-ground appearance to the poop), bloody urine, etc..

  • Cardiovascular collapse (failure of the blood stream to hold enough fluid in to meet the body's needs or failure of the heart to pump blood) - symptoms can include chest pain or difficulty breathing or may mimic shock - low blood pressure, loss of consciousness, rapid heart rate, shaking, cold extremities, sweating, lightheadedness, confusion

  • Low blood sugar (starving the brain) - symptoms include dizziness, hunger, headache, shaking, anxiety, and heart palpitations (feels like your heart's doing flip-flops in your chest. On this I speak from experience)
Today, treatment with antimalarial agents reduces the severity and duration of malaria infection. A list of drugs used appears below, taken from the Centers for Disease Control website.

chloroquine
sulfadoxine-pyrimethamine (FansidarĀ®)
mefloquine (LariamĀ®)
atovaquone-proguanil (MalaroneĀ®)
quinine (Best bet for pre-modern settings)
doxycycline
artemisin derivatives (not licensed for use in the United
States, but often found overseas)

One more nasty little surprise, malaria caused by the P. ovale or P. vivix strains can lay dormant for months to years in the liver, eventually re-emerging to cause symptoms all over again.

A pound of prevention

Currently, the gold standard for prevention of malaria is using mosquito netting around beds and cribs to prevent mosquito bites. A multitude of non-profit organizations exist whose mission it is to send mosquito netting to poor and under-served populations in areas where malaria is endemic. Other methods include draining wet areas and eliminating standing water where mosquitoes breed, using pesticides to reduce mosquito populations, and using anti-malaria drugs prophylactically (to prevent infection) for pregnant women and individuals traveling to areas where the infection is endemic (native).

An evolutionary twist

One of the most fascinating phenomenon I studied in nursing school was Sickle Cell Anemia. This disorder is a genetic change to the shape of red blood cells that can cause severe problems and even death in those who are symptomatic. However, the trait for Sickle Cell disease actually conveys a protective factor against malaria infection! Considering that this trait developed in the part of the world where malaria have been endemic for the whole of human history, it's interesting that a twist of genetic selection could breed a trait to keep people from getting sick.

Despite this protective factor, those who develop full-blown sickling, where many red blood cells actually change shape to resemble a curved sickle (see picture), can have life-long severe pain and complications.

Addendum - you can find a map of the parts of the world where malaria is currently endemic (native) at the World Health Organization's website, this URL http://www.who.int/malaria/malariaendemiccountries.html.

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Fellows in Need

The idea for this blog came about because of the literally hundreds of medical questions I have answered over the years at NaNoWriMo.org and Forward Motion for Writers. So despite my personal no-ads policy, I'm going to throw up this link.

Forward Motion is a free site for writers with over 13,000 members and a hefty history of chewing a hole in its owner's personal pocket. Said owner - Lazette Gifford - is in need. Click the button to find out how you can help her and maybe help yourself in the process.

Pssst! Help Zette.

Thanks to Holly Lisle for organizing this grassroots and undercover operation to help out a fellow writer in need.

This post expires 12/31/08.

Friday, October 10, 2008

General Info: Comments

Comments are always welcome on this blog. I have moderation turned on to reduce spam from companies that web-crawl and look for topics to sell their products.

If you want help finding more information on a topic, have questions, want to request a new topic, or just generally have something to say, please leave a comment! I'll read every one and use any feedback I get to improve the blog.

Happy Reading!

Thursday, October 9, 2008

Character Psychology: PTSD

I write dark fantasy. Very, very dark fantasy. My characters go through hell and back on the page, and they genuinely suffer those events. Despite the most recent trend in fiction of the blase hero who shrugs off torture, maiming and psychological terror with a witty one-liner, my characters get to experience the full range of horror, grief, self-doubt, and pain as well as the relief, joy, and love that accompany their travails.

If yours do, too, this is the post for you.

Self-Defense

The human psyche is set up to defend us against long-term dysfunction associated with traumatic events. Factors that modern psychology label "defense mechanisms" - like denial and overcompensating - are meant to prevent us from being overwhelmed by all sorts of nastiness - warfare, muggings, rape, torture, natural disasters... you name it.


Most of the time, the defense mechanisms do their job - they defend the integrity of the person's mental state until the person has a chance to cope with the problem. But when defense mechanisms fail, or are carried on well beyond the period when acceptance and healing should have begun, mental health problems can set in.

Dysfunction

One of the best tools in the resource bag of an writer whose characters genuinely suffer their tragedies, is PTSD, or post-traumatic stress disorder. Originally used to describe the mental health problems of post-war combat veterans, this term has come to mean an anxiety disorder that comes about following significant traumatic exposure in any age group or population. Examples include folks who experience, have loved ones experience, or observe violent events like mugging, rape, murder, torture, kidnapping, terrorism, natural disaster, child abuse, or any form of significant physical or threatened harm.

So how do you know if your character has PTSD? Symptoms of PTSD include sleeping disturbances (especially nightmares), irritability, loss of pleasure in things once enjoyed, apathy or numbness toward people once close to, jumpiness or being easy to startle, and the potential to become aggressive or even violent.

The hallmark of PTSD are flashbacks - intense, uncontrollable memories of the traumatic event that have the power to remove the person from the here-and-now and take them right back to the moment of greatest trauma. Flashbacks are often triggered by everyday events, sounds, or smells. A backfiring car, the smell of a certain cologne, flashes of light, the sound of a balloon popping, certain phrases of dialogue - anything that triggers a memory can, in PTSD, trigger a flashback. Not every person with PTSD will have flashbacks, but all will suffer from vivid emotional or memory recurrences of the event. Fear, anxiety, and a sense of helplessness are very common.

People with the disorder often describe flashbacks as replaying the event in their minds, of forgetting where they really are and reliving the experience, of being in a bubble of terror. Unlike normal memories, flashbacks trigger not just an emotional response, but a physiological response as well. Release of adrenaline (the fight-or-flight reflex hormone) causes pounding heart, increased blood pressure, sweating palms, stomach upset (up to and including vomiting), a tendency toward aggression, dry mouth, an intense desire to flee...

All writers have some experience with adrenaline to draw from for painting their character's emotions. Just think of a time when you've been utterly terrified, or even nervous. The hormones that control your body's reaction to these emotions are the same. Maybe asking Susie Q to the spring formal got your heart pounding and your palms sweating. Maybe it was a traumatic event of your own that you have overcome or not yet faced. Draw on these experiences to let your characters experience emotions as real as those you felt when you stood there shaking, pupils dilated to take in more light, heart racing, mouth dry.

The purpose of adrenaline is to get your body ready to either flee from immediate danger, or to fight for your life. With PTSD, it's just a matter of that hormone being triggered strongly at inappropriate times, for memory rather than immediate threat.

Not every character needs to experience PTSD, but every character should have some reaction to horrible things that happen in their experience. If you think PTSD might be just what your character needs, read on.

The symptoms of PTSD usually occur within six months of a traumatic event, but can take years to show up. Symptoms must last longer than a month to qualify as a disorder under current psychological diagnosing guidelines.

Most individuals diagnosed with PTSD today get relief from a class of drugs known as selective seritonin-reuptake inhibitors (SSRI), which are also used to treat depression. Drugs in this class include Prozac, Lexapro, Zoloft, and Paxil. Individuals not treated medically can see symptoms resolve over time or by 'working through' their delayed reaction to the trauma. Psychotherapy and even virtual reality have been successfully employed in resolving PTSD. However, for some individuals, PTSD symptoms can become chronic, lasting years or throughout the remainder of life.

Women are more likely to develop PTSD than men, and individuals who experience traumatic events that were intentionally caused by another person, such as rape, kidnapping, or torture, are more likely to develop the disorder than survivors of natural disasters or events that are not directed specifically at the individual, like car accidents. People who suffer from severe PTSD may have difficulty keeping jobs. Some may attempt to avoid situations that trigger flashbacks or engage in "escape" behaviors like heavy drinking and drug use or attempt suicide.

PTSD, in fiction, can be a powerful tool to draw tension and internal conflict (and external if your PTSD sufferer gets violent). As in the real world, it can be devastating to the person's life and overall well-being. Combat soldiers, particularly from the Vietnam era, have been widely known to suffer PTSD to varying degrees. New therapies have been successful at helping many, but chronic PTSD remains a problem for many.

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Saturday, September 27, 2008

On Wet Nurses and Non-Species Specific Milk

Someone asked me the other day if a pregnant woman could act as a wet nurse. Short answer - sort of. Pregnant women make a substance called "colostrum" in their milk glands. Colostrum is a thick, golden-yellow, nutrient rich substance that is the precursor to milk. It is powerfully packed with antibodies that help the baby's immune system, and with enough nutrition to keep the baby healthy until the mature milk comes in, around 3-4 days after the birth, thanks to the fall off of a hormone called progesterone that the placenta manufactures to keep the pregnancy going. Until the progesterone falls off, the body will continue to make colostrum and prepare the breasts for milk production. Colostrum is great stuff. Unfortunately, there isn't a lot of it. The amount of colostrum in a breast is measured in drops to a teaspoon, not in ounces. Which makes feeding a baby problematic beyond the first few days of life.

Further, it's a bad idea for a very pregnant woman to try to nurse a baby. Stimulating the nipples releases a hormone called oxytocin that does two things. First, it stimulates the body to release the milk from the breast glands. Secondly, it stimulates the uterus to contract, which means it's a significant risk of sending Mama into preterm labor. Handy thing to know in a pre-medical society if the pregnancy is overdue and the midwife needs to induce though.

So then what? If the baby's mother isn't around to nurse and the pregnant woman won't work, what about giving it milk from a cow or goat?

Attempts have been made in the past to feed babies milk from non-human species - cows, goats, etc.. Those attempts have mostly failed. There are proteins and substances in human milk that are specially formulated for human babies. Feeding cow's milk that hasn't been processed into baby formula is a surefire way to kill the kiddo or at least make her dog sick, as many of the proteins and substances in cow's milk is formulated specifically to feed baby cows, which aren't much like baby humans. The same goes for goats, cats, dogs, ferrets, and any other mammal out there. Species-specific milk is the best way to feed a baby in any species, even in today's world.

Shoot, now what?

In an era before commercially prepared baby formulas, you've really got one choice for keeping a baby alive and healthy in the absence of it's mother following birth - a wet nurse. Like I said in the post on what happens to babies in famines, anybody with nipples can breastfeed, whether or not they have ever had a baby of their own. It's easier to get things going if pregnancy has already made the changes to the breast that are required for nursing, but even a woman who has never been pregnant can breastfeed if she works at it hard enough. Finding a wet nurse who is already lactating (making milk) might be the easiest option though. Getting supply going is going to require days to weeks of stimulating the nipples, a lot. Babies nurse approximately 140 minutes in a day, and that's about how much time a woman would have to spend stimulating her nipples to get a supply of breastmilk going. Around the clock, every 2-3 hours for 10-20 minutes at a time. It's not easy, but if you're talking the life of a child, it's worth doing. In the modern age, a double, hospital-grade, electric breastpump is woman's best friend, but in the age before all those gadgets, grandmothers and aunts and neighbors still wet nursed by getting supply going the old fashioned way - literally milking the breasts until milk was made.Hand expression, the act of "milking" the breast, involves putting the fingers behind the colored portion of the nipple, press toward the chest, then compress toward the nipple, but not down toward the tip. A woman with a good supply of mature milk should be able to shoot milk across the room if she hasn't fed the baby in a few hours. Point the nipple down into a container, and you can store breastmilk for bottle, cup or spoon-feeding a baby (yes, you can cup or spoon feed a newborn).

Colostrum will "bud" out from several spots on the end of the nipple as droplets and can eventually be collected in a spoon or small cup. When a woman is starting to get a supply of milk for the first time to wet nurse, putting a baby to the breast, even another baby who already is being fed by another woman before the baby eats, will be more effective than hand expression, but with proper technique, hand expression can be more comfortable and more efficient than even the double electric breast pumps used primarily in the US today.

Standford Medical School has an excellent video that shows women with various breast types hand expressing milk for their babies, both well and premature/ill.

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Monday, July 28, 2008

Rare Diseases: Yersinia Plague

Yersinia plague is most famously known as The Black Death, a name given to it in the 14th century pandemic that swept away 25 million souls over the course of five horrific years. When plague is mentioned in modern times, folks often scoff - that stuff only happened in the middle ages, right? Nope. Each year, 10-15 cases of Yersinia plague are reported in the United States, and as many as 300,000 deaths world-wide are attributed to the bacteria which causes three distinct forms of plague - bubonic, septicemic, and pneumonic. Asia and Madagascar are currently experiencing "mostly controlled" epidemics, and three major pandemics, the most recent of which began in the 1980's, have brought this deadly menace to nearly every corner of the globe, with the possible exception of Australia.


Yersinia plague is caused by the bacteria Yersinia pestis (see photo). Y. pestis is a rod-shaped bacteria that has developed a solid reservoir among wild rodent populations, including prairie dogs, squirrels, and chipmunks but most famously associated with rats. In fact, it is speculated that the plague originated in Egypt and was introduced to the rest of the world by the black rat stow-aways on trade ships. It is very rare indeed for a human to be infected directly by a rodent, however. Much more commonly, the fleas that pester the infected rats spread the disease among humans. Y. pestis closes off the throat of the fleas, making them unable to swallow food. The poor starving parasites go on a feeding frenzy and with each bite and unsuccessful suck, spread the bacteria into their intended snacks - other rodents, wild animals, and humans.

Bubonic Plague

The most famous form of Yersinia plague, the bubonic plague, is also the least fatal of the three forms. Initial symptoms include the development of large, painful "bubos" (see photo below). The bubos are actually very swollen lymph nodes which served as points of initial infection and most often show up in the groin, under-arm, or neck. They tend to be red with a bruise around them and the tissue may die, turning the characteristic black color. Other symptoms make the common flu look like a kiddy ride - high fever, nausea, vomitting (possibly bloody), severe muscle/joint pain, sore throat, headache, debilitating weakness, chills, and a general sense of feeling so miserable you'd gladly lay down in front of a steam roller for a little relief. With modern antibiotics, if given quickly, the relief is more likely - only 15% of patients treated with antibiotic therapy and supportive therapy die, as opposed to 40-60% of people who go untreated. Bubonic plague can lead to septicemic or pneumonic plague.

Septicemic Plague

Septicemia is a severe, generalized infection - the bacteria circulate through the blood stream and can impact any organ in the body. Septicemic plague can occur after the formation of bubos or without bubos (rare) and the symptoms listed under the bubonic form of the disease. In addition, septicemic plague can cause symptoms throughout the body depending on which areas are affected - diarrhea (often bloody), constipation, severe belly pain, cough (often bloody), muscle pain, stiff neck, bleeding from just about anywhere, gangrene of the fingers, toes, penis, or nose, seizures, confusion, delirium, or coma. Untreated, septicemic plague is 100% fatal and can lead to pneumonic plague.

Pneumonic Plague

Pneumonic plague can be contracted two different ways - from the advancement of bubonic or septicemic plague or from coming into contact with another person or animal who has pneumonic plague. This form of the disease may include bubos and bloody cough, along with general symptoms of the plague and signs of pneumonia. The difference here is unlike bubonic plague and septicemic plague, pneumonic plague is extremely contagious person-to-person. While the other forms of Yersinia plague can pass person-to-person with close contact and exchange of bodily fluid, stepping within a few feet of a person suffering pneumonic plague and taking a few unprotected breaths can be quite literally a death sentence. Survival if treated with modern antibiotics within the first 24 hours of infection with pneumonic plague is often effective at preventing death, but left untreated, this form of the plague is 100% fatal.

The pandemics that swept through the pre-modern world drastically altered the face of the world, not just in terms of the depopulation, but in political, scientific, and religious terms as well. Volumes have been written which point to the Black Death of 14th century Europe as the single most important disease event in shaping the face of the modern world, creating the infancy of modern medicine and ending the dark ages.

Modern sanitation, pest control, and antibiotics have reduced this one-time mega killer to a smaller stature on the scale of world threats, but modern man might yet feel the real bite of this beast. In the age of terrorism, Yersinia plague in aerosol (airborn) form is considered one of the most feared as a potential biological weapon. And unlike small pox and polio, this deadly disease has host colonies the world over and will very likely continue to be a threat looming over us forever.

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Friday, July 18, 2008

What would happen to a nursing baby in a famine?

The answer: nothing, if the mother was smart enough to just keep nursing (assuming baby is under 6 months old).

Breastfed babies die in famine situations all the time though right? Yep. Because the mother is so desperate, so unable to believe that she can provide adequate nutrition when she herself is wasting away, that she will feed the baby anything. Women have been known to chew tree bark and grass on the side of the road and feed the nutrition-less pap to their babies because of that insecurity.

The truth is, nature is a smart cookie and survival of the species is a pretty strong genetic need. Baby gets the choicest nutrients and the composition of breast milk changes to give baby the best chance of survival, even over the mother. Nursing takes so few calories from the mom that even if she is skeletal and malnourished, baby will be fat, healthy, and happy if nursing continues. Women even managed to nurse babies and keep them alive in the Nazi concentration camps, under the absolute worst conditions.


If, however, mom decides to supplement baby on whatever food can be found, then baby will likely become as malnourished and skeletal as the mom and may die rather quickly. Artificial baby formulas aren't a safe bet either, in modern famine situations. Diarrheal illness is widespread during famine, and without clean water, refrigeration, and proper handling, formula can be every bit as deadly as famine.

Older babies >6 months need some supplemental nutrition, but breastfeeding is still vitally important, as mom's immune system continues to help baby to fight off any pathogens mom is exposed to - including those diarrhea producing bacteria that can rage through refugee camps and the like.

In your fantasy stories, if mom is lost, baby can still survive these conditions if someone is willing to become a wet nurse. Anyone female with breasts will do for starters - any woman can breastfeed. However, pregnant women will only produce colostrum - an immature milk in tiny volumes that won't support a growing baby's needs fully. Establishing a milk supply in an individual who has never been pregnant is a little harder than in someone who has made milk before, but it can still be done. Putting baby to breast frequently, stimulating the nipples, and some herbs (with limited efficacy) have been long-known to restart or start lactation. In modern times, the American Academy of Pediatricians recommends that adoptive mothers of young infants breastfeed. However, wet nursing and milk exchange is highly discouraged in the US today because of the risk of spreading diseases like HIV.

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Thursday, July 17, 2008

Rare Disease Column: Tetanus

Ever gone to the ER for a few stitches in a minor wound and had the nurse ask you when your last tetanus booster was? Oh great. A shot.

Well, don't be too hard on her. Tetanus might seem like no big deal now in the age of the vaccine, but it is still a deadly menace. The number of cases reported in the US has fallen considerably since the invention of tetanus toxoid, which primes the body to immunity against the bacteria that causes this highly infectious (but not contagious) disease - Clostridium tetani (see photo).

Tetanus, known as Lockjaw prior to the 1920's, was described as early as Biblical times, and no wonder. The C. tetani bacteria can live for years in soil or animal carriers and is widespread. While it seems to prefer geographical areas that are warm, moist, and which have high levels of organic matter, it can live just about anywhere and in the inactive spore form can survive most chemical antiseptics as well as autoclaving (heating to sterilize) to 112C or 249.8F for 10-15 minutes. CDC

The real danger of C. tetani is in the toxin it produces - an exotoxin which is one of the most powerful neurotoxins known to man. Less than 200 nanograms of C. tetani's deadly neurotoxin is enough to kill most humans. The generalized form of this disease is among the most dramatic and cruel non-contagious diseases out there. The toxin produces progressive spasming of the muscles, starting with the jaw, which locks tight and prevents opening the mouth or swallowing. Sometimes the illness ends here, with the person having difficulty breathing and a quick death, but most often, the stiffening, uncontrollable muscle spasms progress down the body - the neck stiffens and hyperextends over the back, the arms and shoulders begin to posture and so forth. The spasms themselves can be so powerful as to snap bones, and for those who survive, paralysis from broken spinal cords may be a reality. ~30% of cases will not survive, however, and many will end up looking like this poor soldier (see portrait) who died shortly after this posture was seen.


So how does one get tetanus? A common misconception about the disease is that you have to step on a rusty nail, but in truth, any deep puncture, cut, or chronic wound can become infected, regardless of what caused it. Nails and tools that are left out in soil have an obvious advantage in this regard, as the soil is one of the main places C. tetani is located. However, consider the fiction implications of cultures who thrust their great swords into the dirt prior to battle (please don't try this with your katana or rapier, as your character is more likely to suffer death by virtue of having a broken weapon in battle than to inflict it upon the enemy via tetanus).

In modern times, treatment consists of managing the original wound - keeping it clean and bandaged, plus updating tetanus boosters if appropriate. In individuals who've never had a 3-dose series (which is a standard for children in the US), passive immunity can be confered by giving an injection of antibodies from another human host who is immune. Once symptoms start, the anti-toxin is of limited use, but is often still given to keep symptoms from worsening. Supportive therapy for airway, draining the bladder, providing nutrition, etc are the mainstays of treatment. Each year in the present-day US, approximately 20-100 people still develop tetanus infections, with about 10% dying, most often related to not updating boosters every 10 years or IV drug use (particularly heroin, which is sometimes contaminated with C. tetani).

Another nasty little note about tetanus - surviving it once doesn't protect someone from getting it again. Also, infants can develop tetanus from infection of umbilical cords, particularly if they are cut with non-sterile instruments, but only in mothers who are not vaccinated. The incidence of this worldwide is still relatively high, but in the US, only 2 cases have been reported in the last couple of decades.

For more information on tetanus:

Centers for Disease Control
MedLine Plus, National Institute for Infectious Disease

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Friday, July 4, 2008

Rare Disease Column: Guillain-Barre

Guillain-Barre may sound like a pub with a bit of a French flare, but this nasty little syndrome strikes seemingly at random and causes progressive muscle weakness, loss of sensation, paralysis, and in about 5% of cases, even death.

Guillain-Barre belongs to a class of poorly understood syndromes and disorders known as "autoimmune disease" - which basically means that your body's immune system has got its wire's crossed and is attacking you! A bit of friendly fire later and just about anything can go wrong with a body. In the case of Guillain-Barre, the immune system has set its sights on a very important part of the peripheral nervous system - myelin.

Myelin (see photo) is a layer of cells that cover the long branching fibers of nerve tissue, acting as both insulation and more importantly, speed enhancer for nerve signals. Nerves with myelin coverings transmit signals many times faster than nerves without myelin. That's why Guillain-Barre causes such devastating weakness and even paralysis - with the myelin damaged and out of commission, the signals from the brain to the body and back get crossed and move slower than your average arthritic turtle.

A neuron with its branching nerve fibers and myelin sheath.

All this leads to a rapid progression of weakness, generally starting in the feet and progressing up the body. The weakness can progress all the way to full paralysis. Weakness generally peaks by 2-3 weeks after onset of symptoms and can take a very long time to resolve completely. 30% of patients still experience weakness three years after their initial onset, and a small percentage of patients may have recurrence or relapse of symptoms many years after recovery.

So what causes Guillain-Barre? We'd like to know, too. The truth is, while we know it isn't contagious and it is caused by an auto-immune process, how it occurs is poorly understood. In most cases, symptoms begin within a few weeks of a respiratory or GI infection (cold, flu, stomach bug, vomitting, diarrhea). It makes sense, because after the immune system fights off an infection, it is vulnerable to other problems. Symptoms can also be triggered by surgery or immunizations - two more things that mess with your immune function.

The effects of this syndrome are temporary for most sufferers, but during the worst part of the weakness or paralysis, the person is totally dependant on others for daily needs. Even chewing food or breathing may be too demanding for sufferers of Guillain-Barre and it is not uncommon for artificial feedings, IV nutrition, and even respirators/ventillators to be employed. Guillain-Barre can be mild enough to require a great deal of assistance for a home recovery, but in most cases an admission to a hospital and often an intensive-care unit (ICU) is required.

Side effects of the syndrome - poor nutrition, loss of muscle tone, risk of falls, risk of pressure sores (bed sores), and the risk of failing respiratory effort - can lead to further complications. Recovery requires a great deal of physical therapy, and during the high point of the symptoms and thereafter, sufferers have a significant risk for being unable to emotionally cope with their sudden loss of function and dependence on others for basic needs. Emotional support and counseling are highly recommended.

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Tuesday, July 1, 2008

If a character gets an overdose of pain meds, what will modern medicine do for him?

Pain medications are classified as narcotic or non-narcotic. There are numerous drugs in each class. Non-narcotic pain meds are often used for purposes other than just pain relief. There are also quite a few drugs out there used to help pain that are known as "adjunct therapies" - helpers, basically that work with narcotics to control severe pain. I'll cover a few of the most common drugs to cause overdose and their effects and treatment.

Narcotics


Opiates - this class is composed of drugs like morphine, demerol, codeine, laudinum, opium, and vicodin. It also contains drugs that are mixed with non-narcotic medications, like percocet, tylenol 3, tylenol with codeine, and darvocet. Opiate overdose can cause respiratory depression to the point that someone just stops breathing altogether and then, well... you know what comes next. To counteract that, a hospital would initiate hand-bagging (see photo at left) by putting a mask with a bulb and special valve on the end to force air into the person's lungs. They would then do one of the meanest things you can do to someone - "slam the Narcan". Narcan is an IV drug that completely counteracts opiates, almost instantaneously. What that means is, the person who took opiates for pain relief is going to be in a hell of a lot of pain, real fast. And because opiates mimic the body's own endorphins (brain chemicals that increase pain tolerance), those don't work anymore either. The person who took opiates to get mellow is going to wake up hurting, too, and severely pissed off. It's best to have several muscular coworkers standing by when slamming Narcan into someone.


Fentanyl is a drug used to treat pain in the hospital setting. The trouble with this drug is that if it is administered to quickly via IV, it can cause your muscles to lock solid. Including your diaphragm. Even hand-bagging won't save you, as your chest is too rigid to force air into or let air out. The only way to manage this type of situation is to administer a paralytic - a drug that literally causes temporary muscle paralysis (Vecuronium, called "Vec" by health care workers, is a common one) but not unconsciousness or pain relief. The paralyzed person would then be hand-bagged or more likely have a tube put into his/her airway and be hooked up to a ventillator until the paralytic and the fentanyl wore off. Meanwhile, the person would be awake to experience the whole thing but completely helpless, unable to move or talk, unless the dose of fentanyl was big enough to put them out.


Non-Narcotics


Tylenol (acetaminophen) - overdosing on this might not sound like a horrible thing. It's over the counter, right? So taking a couple extra shouldn't be a problem? WRONG. Tylenol overdose is one of the worst things you can do to your body with over-the-counter meds. Tylenol is safe in the dosages recommended by the manufacturer, but in large doses or prolonged cases of taking just a little more than recommended for several days, it can be extremely toxic to the liver. What this means is that while most people who overdose on tylenol are ok afterwards, there's a chance that you've just managed to kill your liver. Liver failure, let me tell you, is a horrible way to die. A person overdosed on tylenol will usually start feeling ill pretty quickly - nausea, vomiting, looking pale. The bigger the dose, the more likely the symptoms. They may go into a latent (silent) phase for the next two days with no symptoms. Some people never progress to the third stage, which involves necrosis (death) of the liver. While most people who overdose on tylenol eventually resolve without dying, the third stage can progress to death, even if treated. Symptoms includes right upper abdominal pain, prolonged bleeding times, low blood sugar, bleeding, and brain damage. 3-4% of the people who experience large or prolonged small overdoses of tylenol die from complications associated with necrotic liver. Treatment consists of inducing vomiting, stomach pumping (removing stomach contents through a tube), giving activated charcoal through a tube (see photo at right. Yes, it's as gross as it looks, and it's probably going to come back up the hard way), and in cases of high doses or prolonged moderate doses, giving the antidote drug acetylcysteine, which is effective in most but not all cases.


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Monday, June 30, 2008

How premature does a baby have to be to have trouble breathing?

Any baby can have trouble breathing after birth, regardless of prematurity or size, but breathing problems are much more common in babies who are very early, very small and underdeveloped, or very large. Some common reasons for respiratory distress syndrome (breathing trouble requiring oxygen or other support) in newborns include:




  • Prematurity - lungs are underdeveloped. Typical pregnancies last 38-42 weeks gestation (how long the baby is cooking from the mother's last menstrual period). Respiratory distress syndrome is generally mild to moderate from 34-37 weeks in healthy babies and becomes increasingly severe if the baby comes earlier. Babies less than 28 weeks very often require special medication delivered right into their lungs call Surfactant, to help keep their lungs from collapsing between breaths.
  • Infection - infection in the mother can be passed to the baby. Babies who have respiratory distress that lasts more than a few hours or is severe at or shortly after birth are generally screened for infection (also known as sepsis) and given 48 hour courses of Gentamicin and Ampicillin (antibiotics) even if no infection is identified. Because of immature immune systems, even if the baby has no outward signs of infection other than respiratory distress and the cultures come back negative, the baby could still have a hidden infection.
  • Heart and circulatory defects - there are many kinds of heart defects and circulatory problems that can result in poor perfusion to the lungs or to the body, resulting eventually in breathing problems. Some heart problems don't cause noticeable problems until the baby's body starts to accommodate to life outside the womb by closing down special circulatory pathways that the fetus needs, but a breathing baby doesn't. This can take several hours or even days.
  • Diabetic mothers - these babies are usually very large - >9lb at birth and can be very large even if born early. Because of mother's chronic high blood sugar, baby doesn't develop in quite the pattern expected and can suffer respiratory distress, low blood sugars soon after birth, heart problems, and multiple birth defects, particularly if the diabetes was poorly controlled during the pregnancy. Gestational diabetes - a form that goes away after the baby's birth, can cause the same problems.
  • Anatomical defects - certain birth defects which are rare but can cause severe respiratory distress include anything that prevents the lungs from fully forming or expanding, anything that impairs circulation, brain or brain stem malformations, and anything that causes severe pain or nervous system irritability.





A photo of acrocyanotic feet. Acrocyanotic means a bluish tinge on the periphery of the body - the hands and feet. Notice the purplish heels especially

And since this is for writing and I'm assuming you'll be describing the scene and the problems, here's a quick rundown on how a normal respiratory effort looks and some of the trouble signs:

  • Respiratory rate 30-60 breaths per minute - too fast or too slow can be bad. As a nurse, I'd rather see too fast than to slow, though. Breathing too slow (or not at all) is an ominous sign of trouble.
  • No grunting noises - babies in distress often make a little grunting sound at the end of each breath. The reason for this is they are trying to keep a little pressure in their lungs at the end of the breath, to keep their lungs from collapsing. It's imperative that lungs stay slightly open after a breath, because lungs that are completely closed require many times as much effort to open back up.
  • No nasal flaring - The sides of their noses will flare out if they are trying hard to get more oxygen. Think of someone you've seen about to launch into a tirade and how their noses widen a bit as they get their breath to blow like Mount Vesuvius.
  • No head bobbing - Babies in distress will bob their heads with each breath in an effort to open the airways wider to breath in and narrow them down a bit when breathing out.
  • Breath sounds clear and equal - breath sounds may sound a little "wet" or crackly in some babies, particularly if born by C-section as there isn't a lot of squeezing to get that excess water out of the lungs like a vaginal birth. If the breath sounds are decreased or absent on one side, this could indicate that the baby has a collapsed lung, or is having a problem called pnuemothorax, which means baby has developed a hole in the lung which allows air to collect in the cavity between the lung and the chest wall, compressing the lung more and more with each breath and not allowing it to re-expand. This can lead to a life-threatening condition known as "tension pneumo" in which so much air has built up in the chest cavity that it is pushing everything over - the lungs and eventually the heart - and pressing so hard it's decreasing circulation. Pneumothorax and tension pneumos are treated by inserting a "chest tube" into the chest cavity that allows the air to be slowly pulled back out and gives room for the lung to re-expand and heal
  • No central cyanosis (blue tinge around face, lips, or the center of the body). It's ok for baby's hands and feet to be blue or purplish for the first 24-48 hours, but an overall pink color (pink as in a healthy coloring, not as in salmon or caucasian) is preferred. Babies with very dark skin can be assessed by looking at lips and tongue - if those are pink, no worries

Treatment for respiratory distress in the newborn is pretty organized. If breathing, baby would first be given oxygen either by nasal cannula (see photo at right), by "blow-by" which means blowing oxygen across the baby's face, or by face mask. If that doesn't work, hand-bagging would start, which means using a mask and bag with a special valve to force air into the baby's lungs. A baby being hand-bagged will quickly be intubated (have a small plastic tube inserted past the vocal cords and into the lungs) and would either continue to be bagged through the tube or be hooked up to a ventillator. Deep suctioning through the breathing tube is likely to occur and Surfactant may be given to help the baby keep the lungs open between breaths. Unless the lungs are seriously malformed, this is usually sufficient. In some very rare cases, if the baby was born at a fetal care center or a center that was prepared for an unusual defect, a baby unable to be helped by hand-bagging or ventillator might be put on ECMO which is a long-term (up to 3 weeks, sometimes) heart-lung bi-pass machine. This has MANY risks and about a 50% chance of survival, depending on the reason it is used.



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Thursday, June 26, 2008

Rare Diseases: Necrotizing Fasciitis

Necrotizing Fasciitis, or flesh-eating disease as the media likes to call it, is a rapidly spreading infection along the fascia or the layer of tissue that binds skin to muscle. This deadly disease is caused by a virulent strain of the same bacteria also responsible for strep throat, rheumatoid fever, scarlet fever, impetigo, childbed fever, and toxic shock syndrome - Group A Streptococcus pyogenes.

This particular form of strep infection usually starts at an area of trivial skin injury - a bruise, scrape, or small cut. The area becomes reddened and hot to the touch as the infection begins, but over 2-3 days the infected tissue begins to die (necrotize). The skin will gradually darken to purplish or black, and large, blood-filled blisters called bullae will begin to form. The below photo from UCSD med school illustrates both the appearance of skin infected with necrotizing fasciitis and the blood-filled bullae.



Left untreated, this infection can quickly march over enormous areas of the body and lead to death in a matter of a couple of days. Treatment involves surgically removing all dead and infected tissue in a process called debridement (de-breed-ment), which usually leaves the muscle layer intact and simply removes all the superficial tissue and skin in the affected region and for a clear margin around the lesion. If the infection continues to spread over limbs after attempts to debride, amputation may be life saving.

Both the infection itself and the treatment are horrendously painful. The lady in the photo above would likely have all the skin stripped off her leg from below the knee to the crotch if she wants to live, after which she'll look like she's been partially dissected until after skin grafts are applied. Meanwhile, not having skin is a huge risk for other types of infections. Recovery is likely to be a long process, involving physical therapy and plastic surgery and lots and lots of medications.

While very rare, the Centers for Disease Control reports that there are fewer than 1000 cases a year in the US. Even with quick treatment, death occurs in many cases. Some names you may recognize of individuals who have been infected or died from Group A Strep necrotizing fasciitis include Jim Henson of muppet fame, and Melvin Franklin of The Tempations.

For more information, see these articles from:
-- The Centers for Disease Control though this article discusses all invasive forms of Group A Strep together, not just Necrotizing Fasciitis.
-- WebMD

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Wednesday, June 25, 2008

Infected Cuts

Q: What do infected cuts look like?

A: First off, there is likely to be an angry red color around the margins that extends anywhere from a few millimeters to several inches (reasonable size for a smallish cut 1-5cm). The area will be swollen, tender to the touch, and warmer than the surrounding skin.

The wound may drain blood, clear fluid, or pus or a combination of these. Pus colors range based on what the infectious organism is, and can include yellow, yellow-green, green, white, or tan/beige, but can also be tinted pink by blood getting into it. Blood from a wound that is infected will often be very dark or have clumps of pus floating in it.

The wound may form a moist-looking yellow scab or a dark, hard scab as it attempts to heal - these are both composed of dead tissue and the wound will heal faster and cleaner if they are removed and the wound bed is kept moist but not sopping wet. That said, constantly picking at a wound is a bad idea, too.

The best treatment for a small cut is to wash with soap and water, and cover with a clean dry bandage (and an ointment like Polysporin if modern era). Try to keep it clean and don't do what my son does and leave the bandage on for two weeks or until it disintegrates in the shower.

Large or deep cuts may require sutures or some sort of adhesive glue meant for surgical application (no, please don't use SuperGlue. It works like a charm, but non-toxic really isn't meant to read: safe to pour into open wounds). Again, washing the wound, keeping it clean, and keeping the wound-bed moist or the sutured cut dry will aid healing.

Infected minor cuts rarely turn into systemic problems, but if the red margin of the wound starts to look streaky or the red starts to follow veins in streaks, this is a sign of serious, potentially fatal infection of the bloodstream and needs emergent treatment. Likewise, a sudden, serious increase in pain, or severe swelling of the area can indicate serious infections.

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Sunday, June 1, 2008

About Muse Medicine

What's it for?

Muse Medicine is a blog dedicated to helping writers inject a believable level of realism into their plots which involve medicine or the human body in general.

Why a blog?


As a volunteer, I answered hundreds of questions about medical realism, pregnancy, birth, medical settings, and more for authors on the National Novel Writing Month forums. I have also become a resource to the folks who chat over at Forward Motion a wonderful site for writers, with a wonderful chat room to boot. It struck me that I was getting a lot of the same questions over and over, and that having all the information in one central location would be handy. So here it is

What qualifies Muse Medicine to do this?


As a nurse, I have a pretty good understanding of anatomy and physiology, disease processes and healing, and medical terminology. I know where to find information I don't already possess and how to decode the medical jargon. As a Neonatal Intensive Care nurse, a doula, and a certified lactation counselor, I have a very good understanding of pregnancy, birth, preterm birth, human lactation, infant care, birth defects, genetic anomalies, and childhood diseases. As a writer, I understand how important it is to have a good general idea of whether the plot device that sounded so wonderful at 2am is really plausible. Plus I kind of like gross things, so it works out.

How do you pick questions to answer


Questions can be submitted to muse@nursewriter.com at this time. If I can answer the question and think it will make a good post, I'll post it here. If I can answer and don't think it'll be useful to more people than the questioner, I'll try to respond via email. If you ask me the relative density of concrete made from moon dust, you're on your own.

What if the question is TOP SECRET because someone might steal the super special secret idea?


Then don't ask it. Frankly, there is nothing new under the sun and people do find inspiration in a host of places. Hopefully, this blog will offer a lot of inspiration to many writers. But no two writers are going to write the same book even if the idea is the same. If you are seriously concerned that someone might steal your idea, I suggest you try to find someone in your own community who can help you out without putting it on a blog to benefit the rest of the writers on the net. The purpose here, after all, is to help as many people as possible with each post, not spend all my time doing research for one or two writers.

What if the answer is wrong?

Oops, sorry. I'm only human. I do make every effort to ensure that the information here is accurate. It is by no means complete. Also, there is infinite variation among humans, so your particular experience with a disease, injury, or topic may vary considerably from the "norms" presented here. I strongly suggest that you verify the accuracy and do your own research on anything that is desperately pivotal to your plot, just in case.

What's the catch?


No catch. Just a few disclaimers. Read them. Particularly the one at the top of every single page which states I don't treat real people or real problems. This blog is for fiction ONLY. If you have questions about your medications, your health, your "friend's" new rash or anything else that isn't meant to be on a written page for a fictional character, please see your doctor or pharmacist or other health care professional as appropriate.

By submitting questions to the address above, you agree that the content of the question can be edited for content or brevity and posted anonymously on this blog. The blog author retains all rights. Further, information posted here may some day go into an anthology or be used in various articles of similar purpose to the blog. By submitting questions, you agree to these terms and that you maintain no copyright to the posts here. Further, you agree to be a reasonable human being because you are receiving a FREE service. Don't sue me. There isn't much to win anyway.

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