Marketing and Social Media

Today, I'm taking a short break from all things medical mayhemish and participating in a blitz blog on marketing. My agency, WordServe Literary, through Rachelle Gardner's blog is doing an all out attack on the good and bad of this side of the book business. Several authors are participating so you can find more links on her August 2nd post.

If this is the first time you've ever stopped in at Redwood's Medical Edge... welcome! This blog is devoted to helping authors of historical and contemporary fiction write medically accurate details. So, keep this place in mind for those medical questions and nuances you may need help with.




billypitter/PhotoBucket

 Marketing is the bane of most authors I think. We'd much rather stay in our writing caves than have to worry about this "other side" of the book business. My debut suspense novel has just been contracted and is set to release sometime in the Spring of 2012. I'm just dipping the tips of my toes into the large ocean of marketing possibilities and it is foreign territory. It feels a lot like learning a new language. After all, nursing school didn't have a lot of emphasis on marketing... all right... none.

Here's what I've started doing to "get my feet wet".



1. Begin to build relationships through social media. I've found people to guest blog for me through these avenues. For me, FaceBook has been the most useful social media tool. I like it because you can carry on a decent conversation with people and are not limited in the amount of words you can say. I feel like I'm getting to "know" others who have the same interests as mine through FaceBook. I do participate in Twitter but this is a little bit of an enigma for me. I'm not sure I understand the full potential that exists. I don't often read other people's tweets whereas I do find myself surfing FaceBook to see what my friends are up to. The aspect of Twitter that I do like is that my blog posts go to Twitter and are then posted to Facebook. That's a lot of advertising work that doesn't need my input. I'm on LinkedIn but I don't use it and don't actively network there. LinkedIn has not been beneficial for me.

2. Learn from other authors and marketing professionals. There are lots of resources out there where you can begin to learn about marketing for little money. One place to check out is WildFire Marketing. This site has a lot of free resources that will definitely give you ideas to get started. I read Austin S. Comacho's self published book Successfully Marketing your Novel in the 21st Century. Although it is more geared toward self publishing and e-publishing, I did pick up several helpful hints on how to market with a traditionally published book. I think he covers how to set-up and handle book signings well which many publishers are now leaving up to the author to arrange. Also, he has good tips on press kits. A what? Exactly. He explains it nicely. Also, check out the Murder Must Advertise Yahoo Group.

3. Think about your brand early on. This is one area I'm working really hard on. A brand clearly links you with a product-- be it a novel, record or coffee. You know what Starbucks sells even if you haven't stepped foot into a store. They have a strong brand. I think many authors feel a pressure to get out there in the Internet realm and don't spend a lot of time thinking about their brand. What is it that will make you stand out from the other hundreds of authors who have a blog? I spent a good couple months mulling over what my blog would be because once an impression is out there, it may be hard to change mid-stream. Have a clear identity at the beginning. If you're not gifted as a web/blog designer, this is one area I would consider investing some money to have it professionally done.

If you're in my stage of marketing, what are some things you've done that have worked or not worked?

Guest Blogger: Lillian Duncan

I'm pleased to have Lillian Duncan guest blogging here at Redwood's Medical Edge today. She's discussing her research into diabetes and how she managed this character's disease in her novel Pursued.

Welcome, Lillian!

According to statistics, diabetes affects 25.8 million Americans of all ages which is 8.3% of the U.S. population. It only makes sense that sooner or later one of my character's was going to end up with the disease.

The character’s name is Reggie Meyers and you can find her in my new book, Pursued.  In spite of Reggie being chased by an unknown killer, she manages to keep her sugar level on an even keel while her blood pressure spikes through murder attempt after murder attempt. The woman is seriously committed to eating right and taking care of herself!

In real life, diabetes is not a laughing matter, and I certainly don’t treat it lightly in my book or in my life. I don’t have diabetes; however, my father died from complications of it along with my paternal grandparents, aunts, uncles, and cousins on both sides of my family.

I chose to give my heroine diabetes to bring more awareness of the disease to my readers. I also wanted to show that with a combination of diet, exercise, and other lifestyle choices, a person can live a full and healthy life in spite of having it.

It was easy in my book to keep Reggie making the right food choices and following good medical advice. Unfortunately, it’s a lot harder in real life. People struggle every day with making the right lifestyle choices or suffering from the consequences of not making the right choices.

As I wrote Pursed, I had to walk a fine line between keeping it in the readers’ minds that Reggie was diabetic without belaboring the point. If I wrote about it too much, it would bore the reader. If I didn’t include enough details—especially physical details— it wouldn’t feel real.

An example of this is during a scene where all the characters are drinking a soda. Without mentioning her diabetes, Reggie’s friend simply hands her a sugar-free soft drink. No big deal. Another time, Reggie is given two choices for breakfast—sweet rolls or multi-grain cereal. She is sorely tempted but in the end she made the right choice.

Research was an important component when I decided Reggie had Type 1 Diabetes. In spite of family members having the disease, I wanted to make sure I had the right information, which isn’t always easy in spite of the glut of information on the Internet. I only included a small amount of what I learned, but it was there in the back of my mind as I wrote each scene.

Reggie’s diabetes definitely added to the challenge of writing Pursued, but I’m glad I included it. I wanted to show a character who had a serious health issue, but didn’t use it as an excuse to not accomplish her goals and dreams. In Pursued, Reggie makes the choice to be as healthy as she can be in spite of being a diabetic.

Everyone has challenges in this life. The question becomes are we going to let the challenges stop us from being the best we can be? And the answer comes in the form of the choices we make every day.

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Lillian lives in a small town in the middle of Ohio Amish country with her husband, four parrots, one Jack Russell, and a Cavalier King Charles Spaniel. Whether as a speech-language pathologist, an educator, or as a writer, she believes in the power of words to change lives, especially God’s Word. She also enjoys a variety of activities, including traveling, camping, and bowling. She is active in her church where she serves as a sign language interpreter and teaches sign language classes. Lillian believes books can be entertaining without being trashy. She writes the types of books she loves to read, suspense with a touch of romance. Along with writing novels, she writes devotions for ChristianDevotions.us. Previous novels include Shattered and In a Corner of Her Heart. To learn more about Lillian and her books visit: www.lillianduncan.net

Diabetes: Part 2/2

Diabetic emergencies are not uncommon in the emergency room. In simple terms, there are two types of diabetic emergencies: the blood sugar is too low or the blood sugar is too high.

Hypoglycemia: This is a term used when the blood sugar is too low. Often times, in a person with diabetes, it is the result of taking too much of their medication causing sugar levels to drop. This is not the only thing that can cause a blood sugar to be too low.

Unrelated to diabetes, in the pediatric population, particularly among infants, there can be several causes of low blood sugar. Some of the top reasons are sepsis (blood or urinary tract infection), stress, and hypothermia (low body temperature).

Hypoglycemia is relatively easy to treat. If the patient is alert enough to swallow something, we can give them sugar by mouth (orally). It can be as simple as having them drink a small container of juice or giving them a fancy commercial preparation of sugar. If they are unable to take anything by mouth, then an IV is placed and the sugar (glucose) is given intravenously in the form of Dextrose.

Diabetic Ketoacidosis: Otherwise known as DKA. This results from a high level of sugar in the blood. As part of this, there is also a build-up of acids (ketones) in the blood as well. See last post for full explanation of this process. In order to correct this emergency, we have to bring both the blood sugar down and clear the ketones (the acidosis).

1.   Start an IV and get labs. There are several labs that need to be closely monitored in the diabetic patient. We’ll get a BMP (basic metabolic panel). This can also be known as a Chem 7 (or other number depending on how many items are measured). We’re looking specifically at the blood salts: potassium and sodium. These shift as sugar shifts. A BMP is generally monitored every 4-6 hours. Every hour, the patient will get a bedside glucose. We can only bring the sugar down so fast, typically no more than 50-100 points an hour. If the sugar falls too quickly, this can be problematic for the patient.

2.   Give IV fluids in the form of normal saline. Typically, the patient has a relative dehydration. Fluids are given very carefully as rapid fluid resuscitation can cause build up of fluid in bad places… like the brain (called cerebral edema). This is a phenomenon more common in pediatrics than the adult population. Giving fluids will also help the body clear ketones.

3.   Give insulin. Insulin is given to move the sugar from outside the cell (extracellularly) to inside the cell (intracellularly). This will bring the blood sugar level back down.

At some point, when the sugar level comes down to around 250 (remember normal level is 60-120) we will add IV fluids that contain sugar and continue to give the insulin until the ketones are cleared or the patient is no longer acidotic. We can check this by checking the urine for ketones or by testing the blood (a blood gas) to see what the pH level is.

Once both the sugar levels are normalized and the acidosis has cleared, the patient can begin to transition back to their normal diet.

Have you known someone that’s had a diabetic emergency?

Resources for you:

1.   http://www.emergencycareforyou.org/EmergencyManual/WhatToDoInMedicalEmergency/Default.aspx?id=230

2.   http://type1diabetes.about.com/od/schooldaycareandlaws/a/hypergly_emerg.htm

3.   http://diabetes.webmd.com/tc/hypoglycemia-low-blood-sugar-topic-overview

Winner!!

Just a quick post to announce the official winner of Lacy William's contest was Wildflower/Rebecca!

Congratulations and I hope you enjoy those four historical novels. Thanks to everyone who stopped by and left comments. Hope to see more of them from you.

Jordyn

Diabetes: Part 1/2

I thought it would be good to do a few posts about the more common medical conditions. Since I’ll be highlighting Lillian’s novel on Friday, I thought I’d cover the basics of diabetes and then emergency care of the diabetic patient.

There are three major forms of diabetes. Type I, Type II and gestational diabetes.

Type I: This type of diabetes is caused from an autoimmune reaction where the body turns on itself and destroys, in this case, the insulin producing cells in the pancreas. As a result, the person can no longer manufacture insulin. Its onset is usually young children.

Type II: This type of diabetes is the most common form of diabetes in our society. This is a condition where the body produces enough insulin, but the cells are resistant to it.

Gestational Diabetes: Occurs during pregnancy. Generally resolves after the infant is delivered.

When thinking about diabetes, the most important thing to understand is the role of insulin. Insulin is produced by the pancreas. It is a transport agent. It moves sugar (glucose) from outside the cell to inside the cell. Every cell in your body requires glucose to function. It is the primary energy source.

What happens when sugar is not transported inside the cell? First thing that happens is that sugar builds up in the blood stream because it has nowhere else to go. This leads to an elevated blood sugar in the blood stream. This is something we can measure. Normal blood sugar is roughly between 60-120.

When the cells are starved of sugar, the body begins to break down other sources for energy. In this case, fat and muscle. The breakdown of these tissues leads to an increase of acids in the body. The by-product of this process is ketones. You may have heard the term diabetic ketoacidosis.

Now, I need you to think back to basic biology and the process called osmosis. This is where cells try to equalize particles between barriers and they do this by moving fluid. When the sugar levels are high in the blood, the body wants to equalize that out. It does so by craving more water. This is why people with a high blood sugar have increased thirst and increased urination. Also, because the cells are starved for sugar, the patient will actually lose weight.

Your body also has a certain threshold for sugar. Once this level is surpassed, glucose begins to show up in places it wouldn’t normally be. One place we check is the urine. What will also show up in the urine are those ketones that have built up because of the body’s alternative processes for finding energy.

Have you had a character suffering from diabetes?

Next post: Emergency Treatment of Diabetes.

For further information of diabetes, check out these resources:

1. http://diabetes.niddk.nih.gov/dm/pubs/overview/
2. http://ndep.nih.gov/media/Youth_Tips_Diabetes.pdf
3. http://www.diabeteswellness.net/Portals/0/files/DRWFUSdiabetes.pdf

Western Medicine Circa 1890: Part 4/4

Lacy concludes her four-part Friday series today on western medicine during the 1890's. It's been a pleasure to have her and I hope you'll check out her novel. Lacy, best of luck and many blessings on your writing career. I hope you'll stop in again.

I hope you’ve enjoyed the excerpts from Marrying Miss Marshal that I’ve shared the last three weeks. This week, I thought I’d talk a little bit about my current project, which is now on my editor’s desk (hopefully soon to be bought!).

The story is set in the same time period and area as Marrying Miss Marshal but with different characters. In it, the hero has several adopted children and one of them falls off a ladder in the barn and breaks his leg. Because of this, the hero has to rely on the heroine’s help or he risks losing the hay he needs to put up to make it through the winter.

FRACTURES

In the reference Family Physician: A manual of domestic medicine, it is recommended that only medical doctors be allowed to treat fractures, otherwise the results could be lost of use of the affected area (finger, limb, etc.).

However, according to Bleed, Blister and Purge, if there was no doctor available, the only choice was for the homesteader or whoever it was to do their best to repair the broken bone. Treatment included splinting and then wrapping with surgeon’s plaster to put the limb in a cast. I would assume that sometimes in this case, the fracture would not be set exactly right and probably resulted in loss of some functionality of the arm or leg. However, in my story, I did choose to make a doctor available to help.

Here’s an unedited excerpt from my current project. Enjoy!

Penny found the house dark, and a bent-shouldered Jonas sitting on the porch steps. The lightening sky provided enough light to see his head was between his hands. Was he sleeping?

“Jonas?” she called softly and his head jerked up. Not sleeping, then. “Everyone all right?”

He stood and raised a hand to the back of his neck, half-turning from her so she couldn’t see his face.

“Yes. The doctor arrived just after you left—”

“After you made me leave.”

“—and set Maxwell’s leg. It’s splinted now with a plaster cast. He’s supposed to stay off it for a few days—or as long as I can keep him down.”

“Did he get any sleep last night?”

“Doc gave him some pain medication, knocked him right out.”

She couldn’t resist reaching out to touch his arm. He jumped at the contact but didn’t pull away.

“And you?”

He shook his head, ran his other hand down his face. “Couldn’t get my mind to quiet. We’re already behind on the haying, and with the Sumners’ fields to cut, too—without a driver—without Maxwell, I don’t see how we’ll finish.”

“Can you hire someone else?”

He was shaking his head by the time she’d finished her question. “Everyone’s hired out for the season. It’s not likely.”

“Well, what about Poppy?” As she said the words, she thought about her grandfather’s continuing exhaustion, though he’d been trying to hide it from her. “No, he probably shouldn’t be out in the sun all day.”

“There’s no one…”

She’d never heard Jonas so disheartened before. She knew part of his defeated attitude was because of his worry for Maxwell and loss of sleep. Maybe that’s why he’d overlooked the last obvious answer.

“What about me?”

Copyright © 2011 by Lacy Williams.

REFERENCES:

Family Physician: A manual of domestic medicine (1886) is available in the public domain on Googlebooks:

(Treatment of fractures begins page 717)

http://books.google.com/books?id=C1IpAAAAYAAJ&source=gbs_navlinks_s

Bleed, Blister and Purge by Volney Steele, M.D. (2005)

CONTEST REMINDER

Don’t forget to leave a comment to be entered to win a copy of Marrying Miss Marshal and three other Love Inspired Historical books. You’ve have until 11:59pm EST to comment and I’ll be drawing a winner tomorrow! Full contest details were posted June 30th.

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As a child, Lacy Williams wanted to become a veterinarian “when she grew up”. However, the sight of blood often made her squeamish so she gave up that dream before her teen years. As a college student, Lacy was a physical therapy major for approximately two weeks—until she found out she’d have to take a cadaver lab to complete that degree plan. As a writer, Lacy has finally found a way she can handle blood and gore—fictionally. 

A wife and mom from Oklahoma, Lacy is a member of the American Christian Fiction Writers and is active in her local chapter, including a mentorship program she helped to start. She writes to give her readers happily-ever-afters guaranteed and mostly reads the end of the book first. You can find out more about Lacy at her website http://www.lacywilliams.net/. She is also active on Facebook (www.facebook.com/lacywilliamsbooks) and Twitter (www.twitter.com/lacy_williams).

HELLP!: Pregnancy Complications/Heidi Creston

There is a lot of difference between saying you have a cold vs. saying you have bacterial pneumonia. In the world of writing especially medical writing, it is very important that you as the author understand the proper diagnosis and treatment of your character. If it is not clear to you then surely your readers will be confused as well.

Be assured that you will have readers that have either had the condition that your character has, knows someone who has been through it, or like myself, have treated individuals with it. I am more of reader than a writer at this point, and from a readers perspective I will ascertain that nothing will frustrate me faster than an inappropriate diagnosis and/or the incorrect treatment of that condition.

 I focus on the perinatal patient because that is my area of expertise, but I've been known to check on a condition if I'm exposed to it in a story. If your story does not center or pivot around the diagnosis and treatment of your character, then it is best to keep everything as simple as possible and not try to overload your reader with information you've gathered on the internet. All this being said, I would like to take the time to address the three most prevalent pregnancy related complications written about in general fiction: Preeclampsia (PIH), Eclampsia, and HELLP Syndrome.  

Preeclampsia, Eclampsia and HELLP syndrome are all serious complications that are fairly common and can occur during pregnancy. In fiction these conditions are often used interchangeably by writers, but these are three very different conditions requiring different levels of care in the world of obstetrics.

Preeclampsia is also known as toxemia or pregnancy-induced hypertension.  It presents clinically as high blood pressure and extra protein in the urine after twenty weeks of pregnancy. Signs of Preeclampsia include severe headaches, temporary loss of vision, blurred vision or light sensitivity, upper abdominal pain that usually occurs under the ribs on the right side, unexplained anxiety, nausea and vomiting, dizziness, decreased urine output, blood in the urine, rapid heartbeat, ringing in the ears, fever and sudden weight gain such as more than two pounds a week or six pounds in a month.

Eclampsia is a life threatening condition of pregnancy. Signs of Eclampsia are seizures, severe agitation, and unconsciousness, musculoskeletal aches and pains, involuntary movements, the relaxation phase of deep-tendon reflexes may be longer, apnea, and vision problems. Usually the patient has been previously diagnosed with preeclampsia, but this is not always the case.

The most serious complication of Preeclampsia besides death is the HELLP syndrome. Hemolysis (rupture of red blood cells); EL stands for Elevated Liver enzymes; LP stands for Low blood levels of Platelets. Women who have this syndrome may have problems with bleeding, high blood pressure or liver problems. The most obvious signs of HELLP syndrome are nausea, epigastric pain (pain just below the ribs), or right upper quadrant pain, feeling tired, bad headaches, and there may be swelling that occurs in the face and hands. The compromised body functions can cause seizures, liver failure, kidney failure, heart failure or stroke.

Have you written a scene with one of these syndromes?

Medical Question: Opposite Fight vs. Flight Response.

Kristin asks: My medical issues have to do with the female lead who has reverse fight-or-flight reactions. When under extreme stress or in fearful situations her heart rate slows and her breathing becomes shallow sometimes to the point of passing out (at least once in the story). I tried to Google this condition and found almost nothing about it. The only reason I've heard of it is because one of my best friends has it.

Jordyn says: I think what you're looking for is called a vasovagal reaction. It can be the body's response to stress/fear. I don't know that I would classify it as opposite the fight-or-flight but I can see how someone may have explained it this way to your friend. It can be brought on by seeing something traumatic (extreme emotional stress, seeing bloody things). What occurs is that the vagus nerve is stimulated, which leads to a drop in the heartbeat (bradycardia), which leads to less blood flow to the brain, which leads to passing out.

This is a very common cause of fainting (syncope).

 Here's a couple of references:

 1. http://en.wikipedia.org/wiki/Vasovagal_response

 2. http://www.webmd.com/brain/understanding-fainting-basics

Western Medicine Circa 1890: Part 3/4

Lacy continues her four part Friday series today on western medicine. I think her posts have been quite thought provoking! Don't forget, she's running a great contest for a chance to win four historical novels so be sure to leave a comment and check out full contest details as posted on June 30th. I echo Lacy's thankfullness at giving birth with today's medical techniques.

When I was getting to know my heroine, I met a really tough, independent woman. She has to be, to be able to do her job as town marshal. But what most of the other townspeople don’t know is that she does have a softer side… and she desperately wants a family of her own. Her best friend is pregnant and Danna ends up having to help during the delivery… and it is a really poignant moment for her because of her secret desire for a family of her own.

Also, as a mom who gave birth in a lovely hospital with several nurses and my obstetrician attending, I was still plenty scared. Imagining what it would have been like to deliver a baby back in the 1890s makes me shudder…

CHILDBIRTH

During the 1890s, most women gave birth at home. Hospitals existed in the East, but in the West there weren’t a lot of towns big enough to support one. So the best most women could expect was for a doctor to be present. More common was a midwife or even a neighbor to be present. Or sometimes it was just the husband (my husband pretended to be calm during my first delivery but I later found out it was all an act—I can’t imagine what he would have been like if he had been the only person in that room with me…)

According to Bleed, Blister and Purge (2005) a lot of women could have a normal delivery at home with very minimal help. The problems came when there were complications. Because doctors were often far away, sometimes the mother and/or child would suffer or even die because the doctor couldn’t get there in time. Luckily for my heroine, her best friend was a second-time mom and didn’t suffer any complications.

Here’s an excerpt from Marrying Miss Marshal chapter 13:

"Danna!"

"I'm here!" Rushing to her friend's side, Danna saw the face creased in pain, the sweat on Corrine's brow, the marks where she'd obviously clutched the sheets in her fists. "What can I do?"

Corrine let out a long breath, muscles easing. "Nothing yet. I think we have a bit to go, even though the pains have been coming all day."

"Should I get the doctor?"

"He's tied up at his office. The young man from the robbery took a turn for the worse. He's in surgery."

That wasn't good. The "young man" was quite possibly the only lead Danna had to find out anything about where the outlaws were going with the bank's money.

"What about your neighbor…" And why had she rushed out like that?

Corrine clasped Danna's hand as another pain came. Her lips pinched white. "She doesn't…she thinks…Brent killed…your husband." The words came out in spurts and gasps as Corrine panted through the contraction.

Danna found a clean cloth on the end of the bed—someone had prepared things at least—and dabbed at her friend's forehead. "Ssh. Ssh. It's okay."

The contraction eased and Corrine relaxed again. "I don't suppose there's any news…?"

Danna wished she had something positive to tell her friend, but there was nothing. "I'm sorry."

"And Mrs. Burnett," the preacher's wife, "is visiting her sister out of town," Corrine spoke as if the question about her husband hadn't been asked. "So I sent the neighbor boy to fetch you. Will you stay with me? Help me labor this baby?"

Tears sparkled in Corrine's eyes.

A lump of responding tears formed in Danna's throat. "You don't even have to ask," she told her dearest friend.

Copyright © 2011 by Lacy Williams. Permission to reproduce text granted by Harlequin Books.

REFERENCES:

The Modern Family Physician (1915) is available in the public domain on Googlebooks.

Volume 1 (Childbirth information starts page 370):

http://books.google.com/books?id=Oz0pFlKnPikC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false

Bleed, Blister and Purge by Volney Steele, M.D. (2005)

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As a child, Lacy Williams wanted to become a veterinarian “when she grew up”. However, the sight of blood often made her squeamish so she gave up that dream before her teen years. As a college student, Lacy was a physical therapy major for approximately two weeks—until she found out she’d have to take a cadaver lab to complete that degree plan. As a writer, Lacy has finally found a way she can handle blood and gore—fictionally.

A wife and mom from Oklahoma, Lacy is a member of the American Christian Fiction Writers and is active in her local chapter, including a mentorship program she helped to start. She writes to give her readers and mostly reads the end of the book first. You can find out more about Lacy at her website http://www.lacywilliams.net/. She is also active on Facebook (www.facebook.com/lacywilliamsbooks) and Twitter (www.twitter.com/lacy_williams).

Medical Question: Submerged Vehicle Part 2/2

We're concluding Mart's question today about treatment of victims that submerged their vehicle into the water. Last post, Dianna covered the EMS response. Today, I'm going to cover emergency department management.

Jordyn (ED Evaluation):

I'm going to start from the point that EMS brings them to the hospital. You say that one patient, Ruby, is conscious. I'm going to assume she had some period of time in the water and assume she was submerged. Yes, we will treat her. We'll be concerned about how much water she inhaled into her lungs. She'll be placed on a monitor that watches the electrical activity of her heart, her respirations, her oxygen level and checks her blood pressure every so often.

PhotoBucket/tomcat12161

If she has a fairly normal respiratory assessment: she's breathing at a normal rate, her breath sounds when listened to with a stethoscope are clear, and she has a good oxygen level we will likely watch her for several hours to make sure these things stay normal. However, if her breathing rate is elevated, her breath sounds indicate fluid might be building up, and/or her oxygen level are low we will escalate her care.

 We would obtain a chest x-ray to look at her lungs. Supplemental oxygen. A blood gas which is a lab test to see how well her lungs are exchanging oxygen. If she is not breathing well on her own then she will be placed on a ventilator. This is a good medical overview: http://emedicine.medscape.com/article/908677-overview

Patients that are brought in unconscious and without pulse or breathing are essentially dead. It depends a lot on what we get from the EMS crew as to whether or not we will "work" the patient... meaning try to save their life by doing CPR, etc. If EMS says, “we saw the kid go in the water and we got him out quickly”-- we'll probably work that patient for awhile. A patient that is submerged when found with an unknown downtime, no pulse, no breathing, and has a normal body temperature may not be worked at all.

If the patient comes in with no pulse, no breathing and is hypothermic or has a low body temperature, it will be up to the physician whether or not to try and save them. There's this saying in medicine: “you have to be warm and dead”. Many times, we'll try and correct hypothermia to see if this will bring the patient back to life, particularly in cold water drowning.

If the patient is brought to the hospital but dies, the presiding ED doctor will declare death. However, if an autopsy is going to be done, then law enforcement/coroner's office will take possession of the body.

It is possible to come in and be in a coma. This means that you have a pulse but may or may not be breathing. If you have a pulse and are not breathing, we will do that for you by putting you on a ventilator. Whether or not a person comes out of a coma depends on a myriad of factors and writers have a lot of latitude here. The person could wake up. The person could be in a persistent vegetative state on life support for the writer's determined amount of time. The person could progress to brain death and be legally declared dead while still on a ventilator. Or, they could simply die from complications. The sister in the coma will be admitted to the ICU on life support until one of these four things plays out.

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Martha Ramirez has enjoyed writing stories, poetry, and drawing since childhood. Her first children's book entitled The Fabulous Adventures of Fred the Frog was created and inspired by the curiosity and fascination her toddler has with books. Writing continues to be her passion as she strives to create stories children will love as well as learn from.

She is a reviewer for Bookpleasures and a member of YALITCHAT, ACFW (American Christian Fiction Writers), the Muse Conference Board, CataNetwork Writers, American Author's Association, and CWGI (Christian Writers Group International).  She has written articles for Hot Moms Club, Vision, and For Her Information (FHI) magazine. Martha is looking forward to starting new projects and is excited to write in a new genre. She resides with her husband and son in Northern California where she is currently at work on a new series to a YA novel.

Visit her website/blog at: http://www.blogger.com/www.martzbookz.com, http://www.blogger.com/www.martzbookz.blogspot.com%20.

Medical Question: Submerged Vehicle Part 1/2

Mart asks a fairly detailed medical question so I'm going to split this post up over two days. Today, our resident EMS expert, Dianna Benson, will offer the EMS response. Next post, I'll cover the emergency department treatment.

Mart asks:

This is the scenario:

Ruby, Gio and their parents are in a car that submerges in the river.

 Some of the things I need to know:

1.      What happens when paramedics get to them?

2.      Do they do CPR and if so for how long (with no pulse of a drowning victim and one that has a pulse but ends up being in a coma)

3.      Who declares them dead?

I've read that it depends on the state. Sometimes the doctor does. This takes place in NY. Ruby is the only one conscious. Do they treat her in any way? What happens to her sister if she is in a coma? Is that possible? What happens to her dead parents?

Dianna(EMS Response):

Clinical Definitions:

Drowning: An incident in which a victim has been submerged in water and dies within 24 hours of submersion.

 

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 Near-drowning: An incident in which a victim has suffered a submersion but has not died or dies more than 24 hours after the incident. A near-drowning patient must be treated for at least one submersion-related complication or it’s not considered a near-drowning.

Submersion: An incident where a victim is submerged in water and requires some type of emergency care due to the submersion.

When we (EMS) are dispatched to a water-related emergency, we often suspect a possible spinal injury. In the case of a car landing in water somehow, we’d definitely take spinal precautions, and thus apply a neck collar and strap the patient onto a backboard while the patient is still in the water.

Cold water and warm water emergencies are different. If a victim goes into cardiac arrest in cold water (68 degrees or colder), the mammalian diving reflex may prevent death even after prolonged submersion (even 30 minutes)  – a body could be frozen in cold water temperatures to the point all the systems go into a hibernation-like state.

 Firefighters do not extricate victims from submerged vehicles unless they are trained in water extrication. I’m a scuba diver and trained in water extrication, so when I arrive on scene of a water-related incident, I’d be one of the emergency crew members extricating. Emergency crews include: firefighters, EMS, law enforcement, forest ranger, etc. However, if no one on the scene is trained in water extrication, then whoever is there improvises until someone with training arrives, but risking your own life in ways you’re not trained for causes more chaos to the situation.

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A dry team works on shore and a wet team is in the water extricating (removing from vehicle) and immobilizing (collar and backboarding) the patient. The wet team doesn’t just jump in the water (unless it’s safe for us to do so) – we throw the victim a floating device and pull them to the boat we’re in, or dock, or shore (or whatever).

For EMS – we first focus on a patient’s airway, breathing, circulation, and any hemorrhaging issues (bleeding). If Ruby is breathing efficiently, if she has a solid pulse, if she's A&O X 4 (alert and oriented times four), and if she’s not hemorrhaging anywhere, then she’s a stable patient. Submersion patients can develop complications that lead to death even after 72 hours post incident, so EMS transports ALL submersion patients, so Ruby would be transported as a stable patient.      

On-scene the sister would be considered unconscious (not in a comma). As a writer, you can make the situation be whatever you want, so if you want the sister to be in serious condition, have her respiratory system either be failing or have her be in respiratory arrest with a rapid pulse when EMS arrives. I’ve seen a MVC – motor vehicle collision – where in the same car four people died and one person didn’t. I’ve seen an airline crash where two dozen people survived the crash, hundreds of people died on impact, and of the two dozen who survived the impact most died within an hour or so of the crash. So, whatever you write is believable if you make the details of the “after the incident” believable.  

EMS can “call it” – meaning, we can determine if a patient is dead and we can either stop resuscitation attempts or not initiate them. Every county within each state has different protocols (and criteria to follow) on calling death, but they’re all similar. So, you can certainly have EMS “call it”, and that would increase your tension, especially for Ruby, instead of waiting for the ME to arrive on scene. For fiction, there’s no reason to wait for the ME; just have EMS do it. 

For Ruby: We’d insert an IV line and place her on oxygen at 2 liters per minute via a nasal cannula and we’d monitor her. If she’s stable, we’d retake vital signs every 15 minutes en route to the hospital. If she’s not stable, we’d retake vital signs every 5 minutes en route. We’d place a 12-lead on her (cardiac monitor/defibrillator) to obtain her heart rhythm and to monitor her cardiac functions. We’d inject meds depending on her situation and needs.

 For the sister: We’d insert an IV line and inject meds as needed. We’d place her on O2 via a NRB at 15 lmp. We’d place 12-leads on her as well to do the same as I stated above. We’d retake vital signs every 5 minutes and transport her to a trauma center, possibly via a flight for life helicopter.

Any other thoughts for Mart?

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Western Medicine Circa 1890: Part 2/4

Lacy Williams is back with part two of her four part Friday series on western medicine during the 1890's. She is running a fantastic contest so be sure to leave a comment and check out the full details posted on June 30th. Nothing like a chance to win four books!

I know I’m not alone in the fact that Janette Oke really inspired me to want to read and write inspirational fiction (waaaay back when it was just a dream for me). The next inspirational author that I fell in love with was Al Lacy, who writes westerns/western romance (I liked that his last name was the same as my first name…).

One problem that Mr. Lacy’s characters (a lot of times it was the bad guys) ran into was gunshot wounds. Mostly they didn’t survive, which I think is realistic. My issue when writing MARRYING MISS MARSHAL was that I had a main character, a marshal, who found herself trading bullets with some outlaws… What if she got shot? How bad could I make her injury and still reasonably expect her to go about her duties?

GUNSHOT WOUNDS

Difficult enough to treat with today’s modern medicines, I imagine treating gunshot wounds was probably something that Wild West doctors dreaded. Part of the problem was the damage that a bullet could do to a person’s insides—not pretty to put back together. Another problem was the threat of infection. If any foreign object (a piece of bullet, fabric remnant, dirt, etc.) remained in the wound after cleansing, it could cause major problems, which might lead to amputation or death for the wounded person.

Family Physician: A manual of domestic medicine (1886) suggests that serious wounds requiring surgery only be treated by a doctor, and doesn’t go into explicit detail about the treatment of these wounds, which would probably include gunshot wounds. It does share some information on treating “lighter” types of wounds. Here’s an excerpt:

The after-treatment of a wound cannot be of too simple a character. Where there is no pain or discomfort about the wounded part, there can be no object in disturbing the first dressing applied, and this should be left undisturbed for from two to four days, according to the severity of the injury. If all has gone well, it is quite possible that a skin wound may heal at once, and merely require the application of a piece of plaster over it, to protect it for a few additional days. If, however, it is found on carefully soaking off the original dressing that the wound is open and discharging, the best application will be the " water-dressing."…

Because I needed my heroine to be able to be active, not laid up by a gunshot wound, I chose to give her a “flesh wound”, more of a scrape. The bullet that hit her did not pierce her skin, per se. Here’s an excerpt from Marrying Miss Marshal chapter 16 that shows the hero (her husband) helping her treat the wound:

"Do you need help?" He waited for her answer before he turned around.

Danna sighed, a little huff of air to let him know she wasn't happy about it. "Yes. It's difficult for me to reach the wound."

He faced her, and had to swallow hard. She wore an undershirt and had the quilt from the bed wrapped around her; only her shoulder and injured arm emerged. It was her hair that unmanned him, the dark locks falling in waves down her back. She must've loosed them from the braid so they would dry.

His knees threatened to knock together as he approached her. She flushed under his gaze and averted her face, pointing to the array of doctoring supplies she'd laid out across the bed.

"You'll need to clean it out first," she said. "The wound isn't bad, but if infection sets in…"

"Yes, I know." And he did know how bad infection could get. He'd met plenty of men missing limbs or on the brink of dying because of infection from injuries. "I can't believe you went all morning with a bullet wound and didn't tell me."

He located an antiseptic and some clean cloths and moved in front of Danna so her crown was at his chin. He began by wiping the blood off of the inside of her arm. He was entirely too conscious of how soft her skin felt against his palm, and how she smelled sweet, even though the rain must've washed away any scent of soap or perfume.

"There wasn't anything you could do, even if I did tell you."

"You would've told your first husband."

"Fred—" She bit out the one word. That was it.

He kept his gaze on what he was doing, but he could see her jaw flex from the corner of his eye, as if she'd chomped down on what she really wanted to say.

He leaned away so he could look her in the face. He didn't release his hold on her upper arm. "Say it."

Her gaze didn't waver from his. "Fred would've known without me telling him."

Well. Chas looked down to apply the antiseptic to a rag, pretending her words didn't sting. He dabbed the rag against the bloody furrow in her skin—she was lucky the bullet hadn't entered her flesh—and heard her soft intake of breath.

He hated that she was injured. Hated that they hadn't been able to capture the outlaws. Hated that he had no control over any of this.

Copyright © 2011 by Lacy Williams. Permission to reproduce text granted by Harlequin Books.

REFERENCE:

Family Physician: A manual of domestic medicine (1886) is available in the public domain on Googlebooks:

(Treatment of Wounds begins page 712)

http://books.google.com/books?id=C1IpAAAAYAAJ&source=gbs_navlinks_s

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As a child, Lacy Williams wanted to become a veterinarian “when she grew up”. However, the sight of blood often made her squeamish so she gave up that dream before her teen years. As a college student, Lacy was a physical therapy major for approximately two weeks—until she found out she’d have to take a cadaver lab to complete that degree plan. As a writer, Lacy has finally found a way she can handle blood and gore—fictionally. 

A wife and mom from Oklahoma, Lacy is a member of the American Christian Fiction Writers and is active in her local chapter, including a mentorship program she helped to start. She writes to give her readers happily-ever-afters guaranteed and mostly reads the end of the book first. You can find out more about Lacy at her website www.lacywilliams.net. She is also active on Facebook (www.facebook.com/lacywilliamsbooks) and Twitter (www.twitter.com/lacy_williams).