Remember Me: Use of Amnesia in Fiction

Heidi asks:

My question is, if I have a character that drowns but is revived, could they have temporary amnesia, especially if they hit their head? If so, how long might it last?  A few days? I know Goldie Hawn's character in Overboard gets amnesia after falling off a boat into the water, but I'm not sure how accurate that really is.

Dianna says:

The definition of drowning: A submersion event where a patient is pronounced dead within 24 hours of the event.

 If a patient dies 24 hours post the event, it's called a drowning-related death.

That said, your character did not drown and was then resuscitated. Instead, your character suffered a near-drowning event. In order for it to be referred to as a near-drowning event, the patient must be treated for at least one submersion-related complication. You say your character was resuscitated, so I'm assuming the patient was in cardiac arrest, which would definitely be considered a submersion-related complication.

Detail to consider: How long was the patient in cardiac arrest? In cold water, the mammalian diving reflex can prevent death, even after prolonged submersion (a patient in cardiac arrest can be resuscitated after 30 minutes or even longer).

I'd definitely write in that the character hit their head somehow and then suffered a prolonged cardiac arrest due to the submersion post hitting their head. (Basic background information: If the human body loses its oxygen supply, the heart stops. Since we can't breathe under water, we're unable to in-take oxygen.) If cold water isn't fitting for your story, then lower the cardiac arrest time to 5-10 minutes, which is still long. The amnesia could occur simply from the trauma to the head only. The near-drowning event and long cardiac arrest time could worsen the amnesia.         

Anterograde amnesia: Memory disorder only affecting the retention of new information and events. Example: Patient Jim can only identify his friends, recall their names, retell stories about them ONLY if he knew them BEFORE the amnesia. So, when Patient Jim meets anyone after suffering with amnesia, it doesn't matter how much time he spends with them, next time he sees that person he won't remember them at all.   

Retrograde amnesia -- Memory loss of the past or segments of the past.

Some patients can suffer with both anterograde and retrograde.

Some patients fully recover from amnesia, some don't.

Every patient is truly unique with every medical situation -- how one patient's body responds medically, another patient responds completely different. So, you could write whatever you want (within reason) with amnesia and it would be realistic. Again, every patient is very different.

In Overboard, that character's memory returned in a very realistic manner. What happened was she had a strong visual (her husband) of her past, which triggered her brain to remember her past, and pop her memory returned. Sometimes memory return is gradual, other times it comes all at once. However, the situation with her simply falling into the water and losing consciousness then coming to in the hospital with amnesia is over the top Hollywood. If I remember correctly, the storyline was that the cold water and the experience itself (floating in the ocean for hours), was the cause of amnesia.

Sure, it's possible (again, everyone is different) but not a solid storyline. To me, what that storyline says is the amnesia is an emotional issue (the floating experience, plus not being happy in her life), not a medical issue, which is definitely possible, but they should've highlighted that point. Or, adding in head trauma would've made it an even better story.   

The tricky thing about amnesia (but it's good for writers) is it deals with the brain, an organ us humans will never be able to truly understand like we do all other organs and systems, so we have little knowledge on how or why some things occur or don't occur with: memory, personality, personality disorders, mental illness, etc.     

Medical Question: Drugging a Pregnant Woman

Sheila asks: In my WIP, I have the good guy (a doctor) trying to get the pregnant heroine away from a dangerous situation. She resists so I thought he might give her an injection to knock her out. Is any drug available to put a pregnant woman into a deep sleep that is not harmful to the fetus?

Jordyn says: First thing to know is that every drug has a pregnancy classification given by the FDA based on its potential harm to a growing baby. You can find an example of this at this web site: 

http://www.safefetus.com/fda_category.asp

Based on this, you can look up certain drugs and get a hint about their potential harm to the baby.

I looked up several drugs that could be injected to knock a woman out.

Benzodiazepines are all injectable... this would be Valium, Versed and Ativan. Given rapidly IV, they could knock the woman out but also depress her ability to breath. This could harm the baby. They are all category D on the scale which denotes that there is evidence of potential harm. However, how far along is the woman in her pregnancy? Is she near term? Drugs will have different effects given the term of pregnancy and also how long the drug is used for. For instance, a single injection of Valium given late in pregnancy probably will have little effect on the baby as far as causing a birth defect. Also, this doesn't mean you can't pick this drug. It would increase the internal conflict of your character, knowing he is giving a potentially harmful drug to this woman.

Benadryl, which is an antihistamine, can also be given IV. It may make the character sleepy but not totally knock her out. Benadryl's effects aren't at all predictable. It's drug category is B.

Then, I thought of Ketamine. We use this in the ER all the time to sedate patients for reductions of fracture and other painful procedures. It has a very predictable effect and can be given IV or into the muscle (IM-- intramuscularly). The IV duration is typically shorter than the IM duration.

Here's some info regarding Ketamine's use during pregnancy:

Ketamine Pregnancy Warnings

"Ketamine has not been formally assigned to a pregnancy category by the FDA. Animal studies at higher than human doses failed to reveal evidence of teratogenicity or impairment of fertility. There are no controlled data in human pregnancy. Since the safe use in pregnancy and delivery has not been established, the manufacturer recommends that ketamine be considered contraindicated in pregnant women. Ketamine has been assigned to pregnancy Risk Factor B by Briggs et al. as probably compatible." http://www.drugs.com/pregnancy/ketamine.html.

Heidi offers this perspective:  It would be highly unusual for a doctor to get involved with a patient's decision to return to an abusive relationship (or prevent it). The intervening party is usually the nurse. In the case you are describing, if the nurse was trying to keep a pregnant patient out of harm’s way, she/he could do many things but the standard is to get a good reactive strip, then give 2mg Stadol and 25 of Phenergan, this combo will generate a nonreactive strip (put both mom and baby to sleep), the doc cannot release the patient with a non-reassuring strip.

Benadryl can also be used to put a pregnant person to sleep, Tylenol pm is highly used but it does not usually affect the strip. But for all intensive purposes, the drug of choice to stop a pregnant person from going anywhere would be phenergan because it is easily accessed, you do not need a witness to remove from the automated drug delivery system, and it is prescribed regularly for nausea and vomiting which are common in pregnancy. Also, pregnant patients are familiar with it and don't usually question it if the doctor orders it.

Any other thoughts for Sheila?

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A retired middle-grade science teacher and proud grandmother to three, Sheila Hollinghead lives in south Alabama with her husband of thirty years. She has written three books and is seeking publication. She also writes two blogs, one for Christian writers called Rise, Write, Shine!: http://sheilahollinghead.blogspot.com/ and a devotional blog, Eternal Springs:  http://sheilaodomhollinghead.wordpress.com/.

Sarah Sundin: Historical Polio-- Part 3/3

It's been such a pleasure having Sarah Sundin back. There was a lot I didn't know about the history of polio and its occurrence that I learned from these posts. Great job, Sarah!

Polio Part 3—Vaccines

Papa had never truly forgiven Helen for catching polio, as if the doctor’s daughter should have been immune, should have been healthy and strong like Betty, should never have stooped to wearing braces. Some parents coddled their invalids, but not Papa. He’d been harder on her, required more of her. And it was never enough.

In my novel, Blue Skies Tomorrow, which takes place during World War II, Helen Carlisle deals with many repercussions of a childhood bout with polio. Thanks to vaccination, polio is quickly being forgotten, but it was a dread threat in the first half of the twentieth century. If you write fiction set in this time period, it helps to be familiar with this much-feared disease.

On August 22^nd, I discussed the disease, on August 24^th, I discussed treatment, and today the vaccines.

Immunization is the process of artificially creating immunity by deliberate infection with viral proteins, weakened viruses, or killed viruses. Vaccination results in the production of antibodies which protect the patient against infection.

 On January 3, 1938, polio survivor President Franklin D. Roosevelt established the National Foundation for Infantile Paralysis to fund polio research. Nationwide campaigns urged citizens to mail in dimes. The nickname March of Dimes stuck, a play on the popular newsreel, The March of Time. In 1946, the picture of Mercury on American dimes was replaced with the image of Roosevelt to commemorate his work.

The Salk Vaccine

The most famous recipient of those dimes was Dr. Jonas Salk, a medical researcher at the University of Pittsburgh. In 1952 he conducted small trials of a vaccine, and in 1954, a massive nationwide trial. On April 12, 1955, the tenth anniversary of Roosevelt’s death, an announcement was made that the vaccine was effective and available. Church bells rang throughout the nation.

The Salk Vaccine, now more commonly known as IPV (inactivated polio vaccine) uses a killed virus and is administered by injection. The vaccine is safe, since it does not cause the disease. On the negative side, immunized people do not shed the virus in the feces, so the desired “herd immunity” does not occur.

The Salk Vaccine was used in the United States from 1955-1962, when the Sabin Vaccine gained favor. As polio was eradicated, the dangers of the Sabin Vaccine became greater than the risk of the disease itself. In 1998, the United States returned to the use of IPV. Salk’s vaccine is currently in use in the Americas and Europe, where polio has officially been eradicated.

The Sabin Vaccine

What is science without controversy? Dr. Albert Sabin publicly disapproved of Salk’s work and did not receive funding from the National Foundation for Infantile Paralysis. Sabin conducted his clinical studies in the USSR and other countries from 1957-1960.

The Sabin Vaccine, also known as OPV (oral polio vaccine), is a weakened live virus administered orally, either by squirting into the mouth or ingested on sugar cubes. The Sabin Vaccine closely mimics wild-type virus transmission and produces long-term immunity. Virus is shed in the feces of vaccinated people, leading to immunity among contacts as well. These advantages led the United States to switch to the oral vaccine in 1962.

The vaccine is inexpensive and easily administered by volunteers with minimal training, making it ideal for administration in third-world countries, where it is still used.

However, in some cases the oral vaccine leads to actual poliomyelitis, paralysis, and death. Since the last polio case was seen in the US in 1979, the decision was made to return to the safer IPV in 1998.

Eradication

The effectiveness of the polio vaccine can’t be argued. Tens of thousands of cases were seen in the United States each year before 1955. By 1957, the rate fell 90 percent. The last case in the US was seen in 1979 among the Amish, who rejected vaccination. Polio was officially eradicated in the western hemisphere in 1994, in Australia and eastern Asia in 2000, and in Europe in 2002. Currently it remains endemic only in Nigeria, India, Pakistan, and Afghanistan, but hope remains for eventual worldwide eradication.

Resources

http://www.americanhistory.si.edu/polio (Smithsonian Institute’s display on polio)

http://www.marchofdimes.com/

Wilson, Daniel J. Living with Polio: the Epidemic and Its Survivors. Chicago: University of Chicago Press, 2005. (An excellent book describing the disease and its treatment from the patient’s point of view.)

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Sarah Sundin: Historical Polio-- Part 2/3

Polio Part 2—Treatment

Helen pedaled down Sixth Street, harder with the left leg than the right, punishing the left leg for its weakness, as she’d learned on the polio ward.

In my novel, Blue Skies Tomorrow, which takes place during World War II, Helen Carlisle deals with many repercussions of a childhood bout with polio. Thanks to vaccination, polio is quickly being forgotten, but it was a dread threat in the first half of the twentieth century. If you write fiction set in this time period, it helps to be familiar with this much-feared disease.

On August 22^nd, I discussed the disease, today I’ll discuss treatment, and on August 26^th, the vaccines.

There is no cure for poliomyelitis. All treatment revolved around keeping the patient alive and preventing further disability.

Isolation

Since polio is contagious, patients were quarantined, sometimes at home, but more often in hospital polio wards. Early diagnosis was vital, since muscle rest in the acute phase of the illness reduced paralysis.

During the acute febrile phase of the illness, patients were placed in isolation wards, separated from all family and friends. For a young child, this was a frightening experience. They were kept on the isolation ward 2-4 weeks, then transferred to a polio convalescence ward. Visitors were allowed once or twice a week. Since live virus was shed in the feces for 17 weeks after infection, and recovery could take 6-8 months, patients were kept in the hospital for many months.

According to psychological theory of the day, coddling produced hypochondria, so children were often treated in a brusque and unsympathetic manner. A societal stigma against disability caused many families to be ashamed of their polio-afflicted children or to pretend nothing was wrong. Children were encouraged to work hard to overcome their disability, and these patients often became overachievers.

Immobilization

Up until the 1940s, the accepted treatment for polio was to immobilize the affected body parts. Rigid splints, braces, and casts were used, and children’s feet were strapped to boards in the flexed position to prevent foot drop. Immobilization reduced skeletal deformities, but recovery of muscle strength and function remained low.

Iron Lung

The majority of deaths due to polio occurred from paralysis of the diaphragm. About half of patients with respiratory involvement died from the illness. In 1928 the first iron lung was introduced. The iron lung is a negative-pressure ventilator consisting of a cylindrical tank in which the patient lay. Pumps alternately increase and decrease the pressure inside the tank, causing the lungs to inflate and deflate. Improvement in the iron lung occurred throughout the 1930s, and in 1939 the National Foundation for Infantile Paralysis made one available for mass production. The use of iron lungs reduced the death rate from respiratory involvement to about 15 percent.

Tracheotomies also saved many lives during polio epidemics.

Sister Kenny’s Massage Therapy

Australian nurse Sister Elizabeth Kenny (“Sister” being the title for British and Australian chief nurses) arrived in the United States in 1940 and immediately caused controversy. In Australia in the 1930s she had developed a system of polio treatment which rejected immobilization and relied on hot packs, stretching, and massage. Originally derided by the medical community, Sister Kenny’s treatment slowly gained favor. Her patients were more comfortable and had higher and faster rates of recovery.

In the late 1940s and the 1950s, polio patients received a form of Sister Kenny’s treatment. Strips of hot wet wool were wrapped around affected limbs hourly, an often uncomfortable procedure, especially in summer. Stretching and massage was usually painful but was seen as vital to “re-educate” paralyzed muscles.

Rehabilitation

When muscle weakness persisted, braces of metal and leather helped patients to stand and walk. Corsets straightened weakened torsos. Crutches, canes, and wheelchairs aided mobility. Water therapy—performing exercises in warm water—was used on the convalescence wards and at home to relax and strengthen muscles.

Due to the absence of a cure, vaccination was the only hope to avoid polio’s high rate of death and disability.

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Sarah Sundin: Historical Polio-- Part 1/3

I'm so pleased to have Sarah Sundin back. I've missed having her here over the last several months as I'm sure you have as well. This week, she'll be guest blogging about historical polio, the disease, and the polio immunization.

Welcome back, Sarah!

Polio Part 1—The Disease

For months, Helen had lain in the county polio ward. No matter how hard she’d concentrated, her legs wouldn’t do what she asked from them, demanded from them, pleaded from them.

In my novel, Blue Skies Tomorrow, which takes place during World War II, Helen Carlisle deals with many repercussions of a childhood bout with polio. Thanks to vaccination, polio is quickly being forgotten, but it was a dread threat in the first half of the twentieth century. If you write fiction set in this time period, it helps to be familiar with this much-feared disease.

Today I’ll discuss the disease, on August 24^th, I’ll discuss treatment, and on August 26^th, the vaccines.

Cause

Poliomyelitis, also known as infantile paralysis or polio, is caused by an RNA virus and only occurs in humans. It’s transmitted by the fecal-oral or oral-oral route. From the gastrointestinal tract, the virus can travel to the spinal cord, where it leads to inflammation of the gray matter. Spinal or cranial motor neurons die, which causes paralysis of the affected muscles and eventually atrophy of those muscles from lack of use. During recovery, other neurons in the vicinity can sometimes grow extra “buds” to re-inervate those muscles.

Epidemics

Although polio has been known since ancient times, it rarely caused paralysis or death. Due to poor sanitation, most children were infected at a very young age when they were still protected by maternal antibodies, and therefore, had asymptomatic or mild infections. However, as sanitation improved, children didn’t become infected until they were older, and the disease increases in virulence with the age of the patient. The first major epidemic in the United States occurred in Vermont in 1894. Epidemics occurred most years, with severe epidemics in 1916 and 1952. The 1952 epidemic was the worst, with 58,000 cases and 3000 deaths.

Epidemics were most common in July, August, and September. Due to the fecal-oral and oral-oral transmission route, people avoided swimming pools, ponds, drinking fountains, and crowds during the summer. Children who had previous tonsillectomies were at significantly increased risk, not only of contracting polio but of contracting more dangerous forms.

Symptoms

About 95 percent of those infected had no symptoms at all, and another 5 percent had only mild flu-like symptoms—fever, headache, nausea, fatigue, and muscle weakness. Less than 1 percent of those infected developed paralytic polio. Within a week of the development of symptoms, patients experienced neck and back stiffness, asymmetrical muscle weakness and pain, sensitivity to touch, a “pins and needles” sensation, and a sudden onset of paralysis. Paralysis became complete within two to three days of onset.

Spinal Polio

Spinal polio was the most common form of paralytic polio and occurred when the motor neurons in the spinal cord were afflicted. Patients experienced weak and floppy muscles, then paralysis often accompanied by painful spasms. Because sensory neurons were not affected, patients still felt pain, temperature changes, and itching. This form of polio was rarely fatal. About half of patients recovered fully, one quarter experienced minor long-term disability, and a quarter experienced severe disability.

Bulbar Polio

About 2 percent of cases of paralytic polio affected the cranial nerves, leading to difficulties in swallowing, speaking, and breathing. This was fatal in about half of cases if mechanical ventilation was not available.

Bulbospinal Polio

The most dangerous form of polio represented about 1 percent of cases. These patients had paralysis of the diaphragm as well as arms or legs. Respiratory involvement led to death in about half the patients if mechanical ventilation was not used.

Diagnosis

Patients presenting with high fever, fatigue, and nausea were asked to touch their chins to their chest, since a stiff spine was an early sign. Usually diagnosis was made due to sudden falls and paralysis, and was confirmed with a lumbar puncture (spinal tap).

Recovery and Complications

Muscle strength often began to return within one month of illness, and improvement usually in 6-8 months. Any paralysis remaining after 18 months would rarely resolve.

Complications often resulted from imbalanced muscles. When the muscle on one side of the joint was paralyzed and the other wasn’t, the joint became distorted, leading to syndromes such as “foot drop,” and “back knee.” If a child was paralyzed on one side early in development, often one leg would grow longer than the other, leading to a lurching limp. Due to residual muscle weakness, polio survivors are at greater risk for bone fractures, and at higher risk from complications due to those fractures. Later in life they’re at higher risk of osteoporosis.

Post-Polio Syndrome

In the 1970s a new syndrome began to be recognized in former polio patients. New muscle weakness and fatigue in formerly affected muscles appeared after decades of strength. This Post-Polio Syndrome is now known to affect 25-50 percent of people who had childhood polio. The severity of weakness is directly related to the severity of the original acute illness.

Poliomyelitis was a major cause of death and disability through the 1950s and caused great fear for children and parents. Be very thankful for vaccination.

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Sarah Sundin is the author of the Wings of Glory series from Revell: A Distant Melody (March 2010), A Memory Between Us (September 2010), and Blue Skies Tomorrow (August 2011). She has a doctorate in pharmacy from UC San Francisco and works on-call as a hospital pharmacist.

Spinal Cord Injuries

I was reading a well known author when an interesting method of killing was proposed. His villain dislocated his victim's spinal cord manually by prying his fingers between the vertebrae. For that reason alone, I almost did an Author Beware post.Then, what followed was the victim living for a few hours paralyzed but still able to breathe. This is bridging on implausible and here's why.

First, regarding the method of incapacitating this character. Have you ever watched the TV show Wipeout? Our family loves it and it's generally clean (well... there is a lot of mud) fun and the participants often have some teeth-clenching falls where I've been surprised to see a them get up and actually walk away. The point being it that it is difficult to break your neck to the point of injuring your spinal cord. It takes a lot of force. Football players colliding. A serious car accident. Diving into a pool and landing directly on your head. So, visually for me, someone prying their fingers into the gap between the vertebrae (those gaps are small) limits the believability.

Second, let's assume the injury did happen as the author described. Could the character have been prone and alive for a couple of hours? Depends on their level of injury.

The first important thing as a medical person is to determine what level the spinal cord is injured at. Everything below the level of injury is impaired.



http://www.spinalinjury.net/

However, during the acute injury phase, things swell up. The swelling itself my cause impairment but the patient's level of function may improve once the swelling goes down. Two muscle groups help you breathe. First and foremost is the diaphragm. This is a thin layer of muscle that divides your chest and abdomen. It sits beneath your lungs. It is controlled at about C3-C5 (that's your cervical spine and is in the region of your neck). Next are your chest muscles. These are used less for breathing (unless a patient is having difficulty) and are controlled by your thoracic spine which is your upper back.

For this character having a spinal cord injury in the upper neck with subsequent swelling makes me doubtful he would have lived a couple of hours without intervention. Consider carefully level of spinal cord injury and how it will effect your character's good health.

Have you written a scene incorporating a spinal cord injury?

Author Beware: Wrong Medical Procedure

Recently, I was reading a novel by a well-known published author. I'm enjoying the story line a lot which is preventing me from putting the book down and reading another one.

This was the written sentence. "We took him to the OR and drilled a hole in his head just in case there was a subdural hematoma."

WOW! There's a lot going on in this single sentence. A lot that is medically inaccurate and I'll tell you why.

First, a subdural hematoma is a "collection of blood on the surface of the brain"-- between the brain and the skull.  The volumes of this blood collection vary and do not always need intervention. However, if the volume of the blood collection is large enough, it can actually push on the brain and cause its contents to shift. This is termed herniation. In that case, surgical evacuation of the blood clot by a neurosurgeon is the preferred treatment.

Drilling a hole in a patient's head is generally done for two reasons. The first is to drain cerebrospinal fluid and the second is to monitor intracranial pressure or ICP. So, even if the patient did have a subdural hematoma, this likely would not be therapeutic treatment.

The next issue is the just in case part. With CT scanning readily available (even at most smaller hospitals), there should be no reason to wonder whether or not the patient has a subdural. This particular patient took a severe beating to his head and has neurological deficits. Standard treatment would be to do a CT of his head. Then the medical staff would know for sure what they were dealing with.

Which leads us to the last issue. The doctor performing the surgery was an orthopedic surgeon. This is not in their realm of specialty. Drilling a hole in someone's head goes to the neurosurgeon. I can't think of many ortho types who want to be mucking around near the brain. And if they are, they've likely consulted a neurosurgeon.

Scope of practice issues come up commonly in manuscripts. Either the act done is outside that character's scope of practice. For example, an EMT performing a C-section is outside their scope of practice. Or, a specialist is doing something they usually don't do as in this case.

To be clear, I do think it is okay that a fictional character does something they're not supposed to do like operating outside of their scope of practice. This can add great tension and conflict to a scene. Imagine an EMT attempting to do a C-section to save a baby's life when the mother has died. What I would be sure to do is make it clear that the character knows this is outside their scope and is troubled by doing it or maybe cavalier about doing it but that they know where the line is.

You can also take the other bend, the character doesn't know and does it anyway. In this instance, there should be discussion from other characters that this person is known for operating outside their scope and presents a danger to patients. Then, your reader will know that your medical knowledge is good but it is the character running amok.

What do you think? How would you have a character do something outside their norm that won't turn off your reader?

Author Beware: Arterial Bleeding vs. Venous Bleeding

I'm going to start doing these "Author Beware" posts every now and then. When you see that heading, it signals I'm doing a post on something a published author has written that medically is questionable. Now, I won't name the author or book, just the situation. So, if you know the book and/or author, please keep it close to the vest. This is merely for learning purposes.


geology.com

In two novels recently, I've come across inaccurate descriptions of venous versus arterial bleeding. One novel in which a character had slit his wrists clearly described arterial bleeding but called in venous bleeding. Another novel described a puncture wound to the neck and a "geyser" of blood from the wound yet the character made it to the hospital with a dressing around his neck.

First, what is the difference between arterial and venous bleeding? A short anatomy lesson first. Arteries are on the forward side meaning this is blood that has just left the heart. In order for your heart to get blood through the body, it has to pump. The heart's pumping is something you can feel... it's called your pulse. Whereever you feel your pulse is an artery.

Venous blood is on the return side. This is blood that has off loaded its oxygen and is on its way back to the lungs. There's not as much pressure, per se, in those vessels.

When you puncture an artery, it spurts, pretty dramatically, with each heartbeat. I saw a demonstration once of how long it would take someone to "bleed out" from an untreated arterial bleed to the knee which houses the popliteal artery. Now compared to some, this would be a smaller sized artery compared to your aorta. Any guesses?

About three minutes.

Venous bleeding doesn't have the characteristic spurting with each heartbeat. It generally oozes though it can ooze quite a bit. Venous bleeding can also be deadly if there is enough of it left untreated.

Arterial bleeding is generally harder to control than venous bleeding. You have to apply a lot of pressure to get it to stop. Hence, my dismay at how a character who sustained an injury to his neck, likely the carotid artery, could have made it to the hospital with a simple dressing in place.

What do you think?

Drug Abuse in America: Part 3/3

Is there a prescription drug abuse problem in America? If so, what is the scope?

This ABC News piece aired in April and it has been on my mind ever since. Here's a few of the stats that made my jaw drop.

Americans use 80% of all prescription pain killers in the world. The US consumes 99% of all Vicodin manufactured. In 17 states, deaths related to accidental overdose outnumber those deaths caused by motor vehicle accidents. Check out the full story at this link:
http://abcnews.go.com/US/prescription-painkillers-record-number-americans-pain-medication/story?id=13421828

Yes, I think there is a huge prescription drug problem here. There are also some disturbing trends/thoughts I'm concerned about. Should "emotional" pain be treated with narcotics. I say no. There is a purpose for sadness and grief. Why medicate with opiates? Is it not a better answer to work through the emotional pain rather than to numb it?

We are seeing more kids present to the ED within the last two years with complaints of migraine headache, chronic abdominal pain and back pain. We typically don't treat with narcotics. My guess is that eventually, if these children keep presenting with these complaints, someone along the way will give them some. Is that a good answer?

I think it's time that doctors institute tougher measures when prescribing narcotics just like the trend has swayed with overuse of antibiotics. This ABC news piece suggests to only give out pain killers for terminal illnesses. Broken bone, dental visit... only Ibuprofen for you.

What do you think about this issue? Give the narcotics or take a tougher stand? When should narcotics be given? Have you written about this in a fiction piece?

I'd love to hear your thoughts.

Drug Abuse in America: Part 2/3

Have you been to an ER in the last decade? If so, do you remember being asked about your pain level? The infamous question in the adult realm, "Sir, can you rate your pain on a scale of 0-10... zero being no pain and ten being the worst pain you've ever had in your entire life." Every wonder why this was? Maybe you weren't even in pain and they still asked you. Do you remember being in the ER perhaps two decades ago where there wasn't a big push to know what your pain was? Maybe, you weren't even asked.

What is JCAHO and what might it have to do with the drug abuse problem in the US?

JCAHO is an abbreviation for Joint Commission on Accreditation of Healthcare Organizations.  It is an organization made up of individuals from the private medical sector to develop and maintain standards of quality in medical facilities in the United States.Okay, great Jordyn, how can this possibly relate to the prescription abuse problem in the USA?

Joint Commission comes out with goals for medical care of patients. In the 90's, one of their thoughts was that pain was not being adequately addressed among healthcare professionals so it became a standard for them to have us ask, evaluate and treat patients' pain.

This Time magazine piece gives a nice consensus about how well intentioned bureaucracy intrusion can have disastrous effects on how medical care is delivered and ultimately leads to consequences for the patient:

"The U.S.'s opiate jag began, like so many things, with the best of intentions. In the 1990s, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) — the accrediting body for hospitals and other large care facilities — developed new policies to treat pain more proactively, approaching it not just as an unfortunate side effect of illness but as a fifth vital sign, along with temperature, heart rate, respiratory rate and blood pressure. As such, it would have to be routinely assessed and treated as needed. "It was a compassionate change," says Barber. "Patient-advocacy groups pushed hard for it." And, she points out, drug companies did too, since more-aggressive treatment of pain meant more more-aggressive prescribing.

But the timing was problematic. The new JCAHO policy went into effect in 2000, which was not only about the time the new opioids were hitting the market but also shortly after the Federal Trade Commission began allowing direct-to-consumer drug advertising. When market, mission and product converge this way, there's little question what will happen. And before long, patients were not only being offered easy access to drugs but were actually having the medications pushed on them. No tooth extraction was complete without a 30-day prescription for Vicodin. No ambulatory surgery ended without a trip to the hospital pharmacy to pick up some Oxy. Worse, people with chronic pain were getting prescriptions that could be renewed again and again."

What other government policies do you think are having a negative effect on patients?

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Drug Abuse in America: Part 1/3

Dr. Edwards is here for his monthly post and I thought his topic of choice was very timely. He sent me a piece on dealing with chronic pain patients in the ED. This is a problem for every ED... including pediatrics.

In the past two years, I've been shocked by the number of chronic pain patients we are seeing in those under the age of 18. If you're writing an in-depth novel with an ED worker in the center, this is one area of conflict you could explore.

How do we deal with these patients? Is there a component of drug addiction in this patient population? To say no for all cases would not be the truth either.

I think this trend bodes for some introspection on all of us. Here is Dr. Edwards post. On Wednesday and Friday this week I'm going to explore this topic more in depth and why there might be such an explosive prescription drug abuse problem in the US... and believe me... there is.

Desperately Seeking

Frank J. Edwards, MD

I hadn’t been practicing emergency medicine very long when I saw this particular patient, a thin woman in her mid-seventies wearing an old fashioned lace-collared evening gown.

“Doctor, I’ve passed another kidney stone,” she said.

My mind’s eye narrowed.  Was this a narcotic seeker?  Kidney stones are like white-hot ice picks thrust into one’s flank and violently twisted, over and over again.  Marine drill sergeants cry with kidney stones.  But there she sat smiling.  I was young.  Did she take me for an easy mark?

“Oh really,” I said.  “Are you looking for some medication, ma’am?”

“Heavens no,” she said.  “I thought you might like to see it.  I have these things all the time.”

“See it?”

Out of her cloth handbag, she fished a chunk of coarse roadbed gravel and plopped it in my hand.  Driving in the hospital entrance that muggy Sunday morning I had noticed a pile of similar stone.

“You can keep it if you like, doctor,” she said.

Since then, I’ve seen hundreds of patients feigning illnesses, but unlike the lady of the road gravel, they definitely want something more than the smidgeon of attention and sympathy she needed.   They may have headaches, back spasms, abdominal cramping or severe pelvic pain, but kidney stones do remain a common theme.  And, unlike her, they come in writhing and wincing.  When asked to give urine, they may prick their fingers and squeeze a drop of blood into the sample so the dipstick comes back positive. 

The typical drug seeker will have a genuine history of a disease characterized by recurrent episodes of agonizing pain.  Along with kidney stones, such conditions include migraine headaches, lumbar disc disease, fibromyalgia, inflammatory intestinal disorders (Crohn’s disease, for example), and pelvic problems such as endometriosis and interstitial cystitis.   Thanks to the powerfully addicting properties of the narcotics used to treat their pain, a handful gradually awaken in the labyrinth of Morpheus, from which escape is very hard.

These patients generate a swirl of negative emotions in healers.   You want to give everyone the benefit of the doubt, but you do not like the sense of being manipulated.  You do not want to reinforce their addiction, but on the other hand, you understand they are suffering.  You just do not really know how much of the suffering is physical pain and how much is . . . whatever.   And, Lord help the healer who pigeonholes a drug seeker and misses something disastrous.  Drug seekers get sick too.

So you examine them carefully and maybe run some tests, and you look for the usual clues.  Drug seekers often frequent many local EDs.  They’ve had multiple work-ups that never reveal anything new.  If you are blessed with the ability to look up records on the Internet (an innovation which can’t come too soon), you may discover they were in the ED at a hospital down the road just last week and neglected to mention it.   They are allergic to all the non-narcotic pain relief options and they know exactly which agent on the menu works best.  They demand the dose IV and require amounts that would kick most opiate virgins into a coma.

  

I know some healers who pretty much give in and give the drug seeker whatever he or she wants just to sweep them out quickly, and who may even discharge them with substantial prescriptions for more narcotics (a real mistake).  Other healers get angry and point to the door immediately.  Most of us are in the middle somewhere, but it is never a happy situation.  At some level, you feel like a drug dealer.  I assuage my conscience by counseling them on the dangers of secondary addiction, and try referring them to pain centers.  I’ve also stopped calling them drug seekers.  They are chronic pain patients until proven otherwise, which removes some of the tendency to pass judgment.

Regarding the danger of cynicism, not long ago, a doctor going off duty passed me a back-pain case.  His plan was to give this young man a single shot and send him packing in the hope he wouldn’t darken our doorway again.    The patient had admitted to visiting an urgent care center the day before and had furthermore confessed to heroin abuse in the past.

Slam dunk drug seeker, right?   Wait a minute.  How many of them volunteer a history of heroin abuse?  That’s either a pretty dumb drug seeker, or a rare instance of honesty.   I sat down and listened to his story, got a sense of his personality and observed the concern of his girl friend.  Then I re-examined him and ended up ordering a CT.  The next morning he had surgery for a severely herniated lumbar disc. 

Then, there are the true professional patients—few in number and slippery—who ply their ailments to score drugs for the street trade.   One patient I recall from many years ago made a circuit of EDs from Florida to Virginia.  He had a draining bone infection—chronic osteomyelitis of the tibia—from a motorcycle accident.  If he took his antibiotic, the wound would start to heal.  If he stopped taking his antibiotic, the wound would boil and drain pus.  He could literally shut it off and on like a faucet.

It was very hard to argue with such an ugly wound, and he reeled me in like a catfish on Valium.  Until I saw him again a few months later at an ED on the far end of North Carolina.  With a different name.

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Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

   

Use of Torture in Fiction

I'd like to welcome Tessa Stockton to Redwood's Medical Edge. Today, she guest blogs about a controversial subject-- use of torture in fiction. How much violence is too much violence?

Welcome, Tessa.

I have an odd fascination with torture and how to apply it in novels with believability. Since I’ve written a political intrigue series based in South America, touching on some of the endless conflicts between the politically left and the right, the subject of torture comes up in my research. A lot.

The interest started about 17 years ago while I worked with human rights groups. During a time where I had read so many testimonies from survivors of torture, I experienced a shift in my life’s direction and began applying what I learned toward what I wanted to convey through writing stories.

Reading testimonies is one thing. They can be incredibly stirring and influential. However, sometimes details need to be backed up by medical facts, such as the physical and psychological responses—not just the emotive. As an example, if a central character endures electric shock treatment, a writer needs to know how their body reacts—not just, “It hurt.” The swelling of a tongue and the immense thirst contribute to a likely residue. Also, if one drinks water too soon after “the session” he or she can suffer a heart attack. If a person’s nails are yanked, sometimes they can grow back in time, sometimes they can’t if the nail bed is too damaged.

This information is important, say, if you base a story around someone who is a political prisoner and who endured sessions in the “operating theater,” (my novel forthcoming), where spiritual healing coincides with physical healing.

While I don’t like my novels to get too graphic, I feel some description of this nature makes them more realistic. I try to strike a balance, inserting key depictions where most appropriate.

My debut novel, The Unforgivable, which released through Risen Books on April 1, 2011, is a love story entangled in the aftermath of Argentina’s Dirty War. In a nutshell, a Christian woman falls in love with a man who is despised by his nation, accused of war crimes, and who faces trial. There is a necessary chapter in my book entitled, “Private Testimony.” It’s necessary, because it causes the protagonist to shift in how she views this man with whom she has fallen in love. When she hears a survivor’s real life experience in undergoing an interrogation, suddenly a giant hurdle blocks the relationship with her love interest—especially with the claim that he was the one who quite possibly conducted and/or ordered the interrogation.

Details, details, details! They’re often gruesome but manageable. Here’s what I did in an excerpt, spoken from “Rosa,” the survivor:

“Electricity became intimate with me—forced its intimacy through pain I had never known—when it made contact with every part of my body, even my tongue which swelled, and under my nails.

 This man, my interrogator, focused especially on those areas that should have been hidden from him and all men, aside from my husband,” Paloma interpreted. “This man preferred applying shock to those parts the most. I did not recognize my own voice when I screamed. It made me feel like an animal. I defecated on myself. I begged for mercy. I remember thinking: this is what hell is. I had died and gone to hell.

“Soon after—but I really do not know how much time had lapsed—everything blurred and things like time became insignificant. Nothing mattered except for the need to survive.”

So, how much is too much?—because too little often doesn’t deliver the same weight—not if you’re a realist. Well, I’m a romantic realist—but that’s another story! While I like to insert a few “special descriptions” to give a scene that sense of horrible reality, I try not to go overboard. I might write a scene but use milder words when pointing out certain body parts for instance. Torture is by nature horrific but can be filtered for generality—if its inclusion is necessary for plot enhancement.

I can never read too little on the subject. Knowledge is useful. The more I learn the better I can write. Strange but true, fiction serves an array of purposes—even with its use of torture.

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A former contemporary dancer and missionary, Tessa Stockton, who has also been active in politics and human rights groups, now writes Christian novels. The Unforgivable, now available in Paperback, Kindle & Nook, is her first book in the political intrigue series, Wounds of South America. For more information, visit her at http://www.tessastockton.com/.