Civil War Amputations and Anesthesia

I'm so pleased to be hosting author Jocelyn Green this week. She e-mailed me a feasibility question and I managed to rope her into writing a few posts about the medical aspects of the Civil War!

I know...I'm a tricky girl.

Jocelyn has graciously agreed to give away a signed copy of her novel Wedded to War. Just leave a comment in the comments section that includes your e-mail address on any of her posts this week and you'll be eligible to win-- though must live in the USA. Drawing will be Saturday, September 1, 2012 at midnight. Winner announced here on Sunday, Sept 2, 2012!

Here is Part I and Part II.

It’s impossible to write a Civil War novel about medical care in the Union army without having at least some text devoted to amputations. Here’s some of the information that helped me as I wrote Wedded to War, and even now as I’m working on the next novel, Widow of Gettysburg.

Contrary to popular belief, the days of “biting the bullet” (or a leather strap) during an amputation were over by the time of the Civil War. Anesthesia was available in the form of chloroform and ether, even in field hospitals. However, if the soldier had been wounded more than 24 hours prior to amputation, the surgeon would not give anesthesia for fear the patient would not recover from it. And unfortunately, the Confederacy had a severe shortage of medicines, including these, to work with. So even though the medicine existed, there were plenty of cases where the patients had to go without it.

Photo courtesy of Kevin Ling

But in the cases where anesthesia was available, there were specific guidelines for how to administer it.

Chloroform

According to the Manual of Military Surgery Prepared for the Use of the Confederate States Army (published 1863):

·         Chloroform should be given in the fresh air with the patient’s head on a pillow and the body remaining horizontal throughout inhalation.

·         Clothing should be loosened about the neck, chest and abdomen so that breathing is not restricted.

·         Only a light but nutritious meal should be given earlier, or the state of unconsciousness during the second stage of the anesthetic might bring on vomiting.

·         Before giving the chloroform, first give brandy. (Union surgeons did not always follow this point. They used alcohol stimuli only on physically depressed patients because they felt it could slow down the induction of anesthesia  in a healthy patient.)

The Confederate manual went on to instruct: “all special instruments of inhalation have been discarded, and a towel or napkin, folded into a cone, by having its corners turned down, is not almost universally employed for the purpose. The chloroform, about a drachm (one-eighth ounce) is poured into this cone, and is held over the patient’s mouth and nostrils which should previously have been anointed.” Holding the cone a half-inch from the patient’s face prevented facial blistering and allowed adequate air flow.

The first stage of anesthesia was one of excitement, producing “muttering, wild eyed, the cries, the exalted imagination” followed by “violent struggles, attempts to rise, and rigid contraction.” If the spasm extended to the larynx, there would be danger of breathing being obstructed. Surgeons were instructed to remove the cone temporarily if this were the case.

The second stage was that of unconsciousness, insensibility and relaxation of the voluntary muscles. Eyelids would no longer contract when touched. The pulse would slow and weaken, respiration became shallow and feeble.

Ether

Ether was slow-acting, had a foul smell patients objected to, and caused coughing. But it was frequently used in general hospitals where time was not as pressing, because, unlike chloroform, it did not cause vomiting, prostration or increased excitement.

It was also far less dangerous if the wrong dose was given. Throughout the Civil War, only four deaths were recorded from overdoses of ether, while chloroform’s rate was 5.4 deaths for every thousand that used it.

The Operation

The book, Civil War Medicine, by C. Keith Wilbur, M.D. has easy-to-understand explanations and diagrams of various types of amputations. Those interested in primary source material for the operations can thank SonoftheSouth.net for posting excerpts from The Practice of Surgery by Samuel Cooper, here: http://www.sonofthesouth.net/leefoundation/amputation.htm The book, written in 1820, would have served as the how-to guide for surgeons in the beginning of the war. These online excerpts provide detailed instructions for amputation of legs, arms, fingers and toes, including photos of original Civil War instruments.

Carl Schurz, commander of the Union’s 11^th Corps at Gettysburg, offers this account of amputations after the battle:

Most of the operating tables were placed in the open where the light was best some of them partially protected against the rain by tarpaulins or blankets stretched upon poles. There stood the surgeons their sleeves rolled up to the elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth while they were helping a patient on or off the table, or had their hands otherwise occupied around them pools of blood and amputated arms or legs in heaps sometimes more than man high. Antiseptic methods were still unknown at that time. As a wounded man was lifted on the table often shrieking with pain as the attendants handled him the surgeon quickly examined the wound and resolved upon cutting off the injured limb. Some ether was administered and the body put in position in a moment. The surgeon snatched his knife from between his teeth where it had been while his hands were busy, wiped it rapidly once or twice across his blood stained apron and the cutting began. The operation accomplished the surgeon would look around with a deep sigh. and then—“Next!”

Read The Reminiscences of Carl Schurz at Google Books here: http://bit.ly/OCf1CD

Recommended Sources:

For more in-depth study, in addition to the resources I listed on my last post, I recommend:

Cooper, Samuel. The Practice of Surgery. London: A and R Spottiswoode, 1820. Available at Google Books here: http://bit.ly/OvS97P.

Hamilton, Frank Hastings. A Practical Treatise on Military Surgery. New York: Balliere Brothers, 1861. Available at Google Books here: http://bit.ly/O72JCN

Teacher Tube video (5 min.) from the Museum of the Confederacy about amputations and artificial limbs. Not graphic at all. http://bit.ly/SZhlEF

I also did a post on ether and chloroform. You can find that here.

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A former military wife, Jocelyn Green authored, along with contributing writers, the award-winning Faith Deployed: Daily Encouragement for Military Wives and Faith Deployed . . . Again. Jocelyn also co-authored Stories of Faith and Courage from the Home Front, which inspired her first novel: Wedded to War. She loves Mexican food, Broadway musicals, Toblerone chocolate bars, the color red, and reading on her patio. Jocelyn lives with her husband Rob and two small children in Cedar Falls, Iowa.

Connect with Jocelyn:
www.jocelyngreen.com

www.heroinesbehindthelines.com

www.facebook.com/jocelyngreenauthor

www.pinterest.com/jocelyngreen77

Chief Camp Diseases of the Civil War

I'm so pleased to be hosting author Jocelyn Green this week. She e-mailed me a feasibility question and I managed to rope her into writing a few posts about the medical aspects of the Civil War!

I know...I'm a tricky girl.

Jocelyn has graciously agreed to give away a signed copy of her novel Wedded to War. Just leave a comment in the comments section that includes your e-mail address on any of her posts this week and you'll be eligible to win-- though must live in the USA. Drawing will be Saturday, September 1, 2012 at midnight. Winner announced here on Sunday, Sept 2, 2012!

Here is Part I.

My novel Wedded to War explores the medical care of the Union army during that first chaotic year of the Civil War. During this time, disease was more of a killer than injury, especially in the Army of the Potomac during their ill-fated Peninsula Campaign in the marshes and swamps south of Richmond, Virginia.

Below are a few of the most prominent diseases that affected troops even before they could shoulder their rifles in battle. This information can be found in many sources, including the National Museum of Civil War Medicine (www.civilwarmed.org) in Frederick, Maryland, which I visited as part of my research for this novel. The statistics for the Confederate side were not tracked as well. (Other sources will be listed at the end of this post.)

Diarrhea and Dysentery

The terms diarrhea and dysentery were often used interchangeably, but both were widespread and seriously debilitating. (Some sources say General Robert E. Lee was suffering with it during the Battle of Gettysburg in 1863, and that it affected his decision-making ability.) On the Union side, there were at least 1.6 million cases with more than 27,000 deaths during the course of the war. Causes ranged from poor diet and cooking practices (called at the time “death by frying pan”) to infection with microscopic organisms. For unknown reasons, chronic diarrhea and dysentery sometimes persisted for the remainder of a soldier’s life. Treatment included a good diet of fresh fruits and vegetables, opiates in alcohol and sometimes oil of turpentine and glycerin.

Malaria

Malaria is a fever-inducing disease caused by microscopic parasites transmitted to humans by the bite of the Anopheles mosquito—but no one knew this during the Civil War. The cause was thought to be “swamp miasma,” an invisible agent which floated through the air. Nearly a million cases of malaria were reported in Union records, with approximately 4,800 deaths. The disease was most common among soldiers of both sides serving in the deep South. Quinine, as the powdered bark of the cinchona tree or as quinine sulfate derived from the bark, served as an effective preventative and cure.

Nutritional Diseases

The major nutritional diseases seen during the war were scurvy (vitamin C deficiency), night blindness (vitamin A deficiency) and malnutrition. With diets often devoid of fresh fruits or vegetables, the vitamin deficiencies were often seen together. In addition to the individual disease symptoms (i.e. tender or bleeding gums), the poor diet led to compromised immune systems which hampered recovery from wounds and other diseases. Decent diet was known to cure and prevent the problems, but field logistics made this nearly impossible. There were 46,000 cases of scurvy in Union records, with 771 deaths.

STDs

“Camp-followers” and city brothels offered ample encounters with prostitutes. Sexually transmitted diseases, primarily syphilis and gonorrhea, were common in the armies of both North and South. Among white Union troops, there were 182,800 cases of both diseases combined. There were no effective treatments, and there would be none until long after the war. Among the techniques they tried were rest, diet, injection of various metals in to the urethra, internal use of mercury compounds and even the application of mercury vapor on the surface of the body. Reports that nearly one-third of post-war deaths in veterans’ homes were due to late-stage venereal disease show the futility of these treatments.

Typhoid Fever

Typhoid fever, an intestinal infection caused by the bacterium Salmonella typhi, is generally contracted from contaminated food or water. Symptoms include delirium, fever, exhaustion, and red skin lesions. Associated diarrhea can lead to puncturing of the intestines and death. Survival of the infection was known to confer immunity from further infection. Union records show 75148 cases among white troops with 27,058 deaths, a 36 percent mortality rate. Similar rates were found in Black Union troops and Confederate troops. Treatments, generally ineffective, included opiates for pain, quinine for fever, various diets and calomel (a mercury medicine).

Recommended Sources:

This is just a general overview of a few of the diseases that afflicted Civil War troops. For more in-depth study, I recommend:

Adams, George Worthington. Doctors in Blue: The Medical History of the Union Army in the Civil War. Baton Rouge: Louisiana State University Press, 1952. [For the South, see Doctors in Gray by H.H. Cunningham.]

Freemon, Frank R. Gangrene and Glory: Medical Care during the American Civil War. Chicago: University of Illinois Press, 1998.

Letterman, Jonathan. Medical Recollections of the Army of the Potomac. New York: D. Appleton and Company, 1866. Available at Google Books here: http://bit.ly/OnmGGw

Wilbur, C. Keith. Civil War Medicine. Guilford, Connecticut: The Globe Pequot Press, 1998.

Woodward, Joseph Janvier. Outlines of the Chief Camp Diseases of the United States Armies. Philadelphia: Lippincott, 1863. Available at Google Books here: http://bit.ly/M0b1b2

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A former military wife, Jocelyn Green authored, along with contributing writers, the award-winning Faith Deployed: Daily Encouragement for Military Wives and Faith Deployed . . . Again. Jocelyn also co-authored Stories of Faith and Courage from the Home Front, which inspired her first novel: Wedded to War. She loves Mexican food, Broadway musicals, Toblerone chocolate bars, the color red, and reading on her patio. Jocelyn lives with her husband Rob and two small children in Cedar Falls, Iowa.

Connect with Jocelyn:
www.jocelyngreen.com

www.heroinesbehindthelines.com

www.facebook.com/jocelyngreenauthor

www.pinterest.com/jocelyngreen77

Winner!!

Special post today to announce the winner of the First Steps Drawing...

Congratulations Heather Marsten! You've won an autographed copy of Proof. I'll be e-mailing you.

Thanks to everyone who participated. Keep in mind, several author's giveaways continue through August 31st. You can find out more about the mega giveaways at the WordServe Water Cooler's Parade of Blogs post here.

Have a great day!

Author Question: Civil War Dead House

I'm so pleased to be hosting author Jocelyn Green this week. She e-mailed me a feasibility question and I managed to rope her into writing a few posts about the medical aspects of the Civil War!

I know...I'm a tricky girl.

Jocelyn has graciously agreed to give away a signed copy of her novel Wedded to War. Just leave a comment in the comments section that includes your e-mail address on any of her posts this week and you'll be eligible to win-- though you must live in the USA. Drawing will be Saturday, September 1, 2012 at midnight. Winner announced here on Sunday, Sept 2, 2012!

Now, let's get on to some exciting stuff!

Jocelyn Asks:

Hi Jordyn: I’m a Civil War novelist and working on my second book in the Heroines Behind the Lines series right now. (My first, Wedded to War, is about pioneering nurses for the Union Army and just released July 1 from River North, an imprint of Moody.) I’ve got a couple questions for you!
1) I read an account by Capt. O.H. Miller of the 59th GA which said he was basically called a lost cause (after an injury at Gettysburg) and “They ordered me to the dead-house where I remained fifteen days.” My question to you is: HOW in the world would he have been able to survive that? Can we believe his first-person statement? I did read in another book an account of a soldier who was left in a field for three days surviving by eating the maggots out of his puddle of blood. (I’m so sorry, that’s gross.) So, I suppose if Capt. Miller was in a dead-house, there would have been plenty of maggots to eat. What do you think? Any insights on this? It seems unbelievable, but I WANT to believe it because I want to use it in my novel!

2) I need one of my main characters to suffer from temporary amnesia from an injury at Gettysburg. What kind of a wound would produce this? I want him to regain his memory in about a month’s time (two weeks minimum).

Jordyn Says:

Hmmm.... okay question #1. Being in the dead house for just over two weeks. According to my research, the dead house is the morgue so there wouldn’t be any provision of food and water. The problem will be this... does he have access to water? If he has something to drink it's probably reasonable to say he could have survived but with NOTHING to drink-- dehydration will kill you in a few days-- around one to three depending on the elements your body is in. So, if you want to use this in your ms—you’ll need to at least have him drinking something. But, he can't just be lying there without fluids for 15 days and not die. I do find that particularly unbelievable.

Here's a previous post that discusses aspects of dehydration.

Regarding question #2-- what type of injury will produce amnesia? Really any type of head injury can produce amnesia so you could have some writerly leeway here.

A fall from a height, blunt force trauma to the head, gunshot wound to the head (though this is hard to survive in today's medical climate so would be probably lethal during civil war times.)

Here's a previous post about amnesia.

I found a few resources that were particularly interesting for my inner medical nerd.

1. This one dealt with treatment of the dead. Very interesting insight here particularly concerning how dog tags for soldiers likely came about. http://www.deathreference.com/Ce-Da/Civil-War-U-S.html

2. Photos of Lincoln General Hospital—A Civil War Hospital. http://southcarolinaavenue.webs.com/civilwarhospital.htm

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A former military wife, Jocelyn Green authored, along with contributing writers, the award-winning Faith Deployed: Daily Encouragement for Military Wives and Faith Deployed . . . Again. Jocelyn also co-authored Stories of Faith and Couragefrom the Home Front, which inspired her first novel: Wedded to War. She loves Mexican food, Broadway musicals, Toblerone chocolate bars, the color red, and reading on her patio. Jocelyn lives with her husband Rob and two small children in Cedar Falls, Iowa.

Connect with Jocelyn: www.jocelyngreen.com, www.heroinesbehindthelines.com, www.facebook.com/jocelyngreenauthor

Up and Coming

Hey Redwood's Fans... how's the week been treating you?

I am fully submerged underwater so if anyone has a life preserver out there... send it my way. LOTS of busyness but goodness going on.

For you this week:

THE CIVIL WAR

So many amazing things changed medically during this war. Author Jocelyn Green will be here all this week to discuss the medical aspects of the War between the States. It is fascinating stuff for sure AND she is giving away her book Wedded to War.

Enjoy the fun!

First Steps....

Welcome to Jordyn's section of the blog parade! I have a fondness for parades as I am a former marching band geek and I do say that with pride. Two of my most fond high school years were spent in the marching band. I played flute, then piccolo, then marching mellophone (which is the french horn.)

For those of you familiar with instruments-- you would know what a hard transition it was going from a wind instrument to a brass one-- and much heavier to march with too!

Today, I'm participating in the WordServe Water Cooler Blog parade. It's designed to help Cooler readers discover more about the authors who write there by sending them to their personal blogs. **Details on a chance to win Proof at the bottom of this post.**

So-- if you're visiting Redwood's Medical Edge for the first time-- this blog is designed to help authors write medically accurate fiction. Or-- as I like to say-- learn how to injure, main and kill your FICTIONAL characters the right way.

We will be getting back to the medical mayhem on Monday.

Today, I'm going to write on the topic of our parade: First steps I took in becoming an agented and/or published author.

1. Finished my novel! This might seem like the easiest steps but first steps are always the hardest. It's like an infant when they first start walking and they have that cute orangutan type maneuvering. Arms high in the air. Their little booty shaking as their knees high march-- just like in marching band. The first words to paper for a writer can be awkward. Just like walking takes lots of practice-- so does authoring a full-length novel. Many people can write a few great first chapters but can they finish a 60,000-100,000 (depending on the genre) novel? This is ultimately what an agent or publisher wants to know. They likely won't take you on until they know you can cross that finish line.

2. Attended a large writer's conference. I do recommend writers conferences for a number of reason. For networking. For finding fellow friends to share this journey with. After all, no one will understand why you seek the perfect poison to kill off a character then a fellow suspense novelist. Honestly, I'm surprised I haven't seen a police presence at writer's conferences for all the talk of murder and mayhem that goes on-- albeit from an unsuspecting, not-part-of-the-conference guest! More importantly, as part of your conference registration, you get an opportunity to meet with agents and editors. Even have a say in which ones (most of the time so register early!) Face to face contact (yes, even for introverts) is important because it puts a personality with the manuscript. Do you and the agent hit it off? Do you have similar goals? Do they like you? Do they LOVE your idea? They should because championing a novel to the finish line takes lots of cheering and faith.

3. Was Persistent. Pursuing publication is definitely not for the faint of heart. You WILL be rejected. You WILL get one star reviews. People will take your months-years of hard work and give it a good tongue lashing just because they can. In these dark moments of the writing life-- you'll need to have it in you to push yourself over these obstacles. To understand, to have it in you-- why it is you're putting yourself through all the torture. Is it to see/catch the moments of brilliance? When your own words make you cry? When a reader writes you to say just how much your story touched them and changed their perspective? Is it for the starred review from a well respected publication?

These were some of my first steps toward becoming an agented and published author? How about you? What steps are you taking?

As a reward for all those who are participating in the blog parade by perusing all these fine blogs, I'm offering a chance to win a free copy of Proof. Simply leave a comment with your e-mail address in the comments section of this post. Drawing will be Sunday night, August 26th, at midnight MST. Must live in USA. I will e-mail the winner and announce here Tuesday, August 28th, 2012.

Nurse as Patient

When my debut medical thriller, Proof, was going through the editorial process there was a question about a particular character's reaction to finding his friend, and love interest, attacked and unresponsive in her home.

Kadin Daughtry is an OB/GYN. So, he's used to being under pressure. After all, babies can be in a rush sometimes to be born.

However, when he finds Lilly, beaten, he does the necessary things-- checks her pulse, calls 911. But he is stunned and having difficulty.

Editorial thought he should have his act much more together-- after all, he is a trained physician.

Hmmm....

It's true, medical people have the knowledge to deal with emergencies. But they still are people and can suffer the same reactions other people under stress will feel.

About nine months ago, I dislocated my shoulder while working out with a personal trainer. Unfortunately, this was not a new thing (to the left shoulder it was!) so, initially, I felt like-- okay, I can manage this. We just need to get it back into place as I'd been able to self reduce my right shoulder before.

The pain was pretty awful. No quite as bad as burning my eyeball with a curling iron (yes, the actual eye!-- I know-- it takes talent) or giving birth but up there. When it became clear that I wasn't going to be able to reduce it myself and wasn't willing to let my trainer try because he doesn't carry Fentanyl in his pocket-- in retrospect I realized a couple of things.

1. Pain makes it really hard to think. It doesn't matter how well versed you are about treatment of certain injuries, pain makes it hard to think through your options. You just want the pain to stop-- quickly.

2. Because of #1-- making decisions is hard. It's not that your clinical brain checks out. You can still assess the injury and walk someone else through the treatment, but it's not seemless. Meaning, there were long moments of silence as people waited for me to tell them what to do because they know I'm an ER nurse.

3. You really want someone else to make the decisions. Even though I am an ER nurse, I really wanted someone else to step up and say-- this is what I'm going to do and this is what I need you to do. We're going to get you up. I'm going to call an ambulance... It's reassuring to feel that someone has your back. When people are doubtful around you and looking horrified at your injury-- you begin to worry about yourself more. That's why having that "doctor face" is important. People want to feel like you can competently handle whatever is wrong with them.

4. Ambulance rides are very bumpy! Don't ever write that an ambulance is a comfortable ride. They are not.

What about you? Have there been times people looked to you to be an expert but you really needed someone else to step in?

Author Question: How Long to Drown to Death?

Kara asks:

I'm a fan of your blog and was hoping you could help me. My current work in progress has a seven-year-old girl die from drowning. After the rest of her family goes inside, she returns back to the pool to retrieve something and then is found minutes later.

My question is two-fold:

1. What is the minimum amount of time a girl that age and of average weight and height would succumb to drowning (assuming she fell & hit her head, then fell into the water.)

2. Physically, what exactly happens when a person drowns? I'm assuming there is a lot more to it than just the lungs filling with water. For example, what would an autopsy show to prove that it was a drowning?

Jordyn says:

I had prepared this post to run long before I got a phone call from a good friend who also happens to be an ER nurse and mother of seven. I don't know what it is about kids and water-- but it draws them like a moth to a flame.

I think personal accounts of situations are good for us to read through as writers because it gives us a glimpse of what it's like to have a moment in another person's shoes. My friend's young son drowned and was subsequently revived with no neurological deficits. This is a MIRACLE and you can read her first hand account of this event here.

Part one of your question-- first thing you need to determine is does she fall into the water unconscious? If so-- she will drown quicker. Versus, if she falls into the water conscious-- she will struggle in the water (you can determine this) before succumbing to the water based upon her ability to swim. Maybe this struggling lasts for 2-3 minutes, then she goes unconscious.

When she goes unconscious, the water will flow into her lungs. When water is in the lungs-- there can no longer be gas exchange. When there is no longer gas exchange, the organs begin to die from lack of oxygen. The most common time frame you'll hear for "brain death" to occur is four minutes.

Now, it would not be all that unusual to revive her at some point after four minutes. We may get a return of her pulse but her brain likely will be past the point of return. So, upon finding her down in the pool, say after 10 minutes of someone last seeing her, you could just have them be unable to revive her at all. That would probably be the easiest way to deal with it. She would likely still be transported to the hospital and worked on because she is a child and pronounced dead at the hospital.

If she is revived-- that's a whole other can of worms you may not want to go into.

As far as what the autopsy would show-- this is an excellent resource I think you should read through. I think it has a lot of what you're looking for.

http://forensicpathologyonline.com/index.php?option=com_content&view=article&id=101&Itemid=125

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Kara Hunt is an inspirational speaker and writer who throughout the years has mentored women on the various aspects of living daily and triumphantly as women of God, despite their past and regardless of their circumstances. Kara’s transparent testimony touches hearts and has helped many women reconnect and refocus on what’s truly important during their spiritual journeys. As Kara ministers out of her own personal experiences, she desires to communicate God’s truth as He reveals it, and wants other women to know that they too can experience God’s merciful and unspeakable joy.

Kara also created the Christian Fiction blog "Fiction With Faith." See her upcoming reviews and news at http://www.kararhunt.com/

Up and Coming

Hey Redwood's Fans...

How's your week been going?

Mine-- crazy. Book #3 in the Bloodline trilogy sits at 64,000 words (tentatively titled Peril) and I'm hoping to get it wrapped up by the grand ACFW conference in mid/late Sept so I can let it brew in my mind before editing in early October.

Plus, did you see the cover for Poison? I think it's awesome. I hope you do to. Releases Feb, 2013.

For you this week.

Monday: Kara Hunt asks an author question: How long does it take to drown?

Wednesday: Nurse as patient. How do you expect a medical professional to act when they're injured?

Friday: It's a parade! I'll be participating in the WordServe Water Cooler blog parade and blogging about the first steps I took to becoming a published author.

Hope your week is well.

Ectopic Pregnancies: Dr. Tanya Goodwin

Today I’m going to talk about ectopic pregnancy. An ectopic pregnancy really means any pregnancy not in the uterus. Mostly this refers to pregnancy in the fallopian tube or tubal pregnancy.

The uterus has a fallopian tube attached to each side. At the end of each fallopian tube are delicate fingerlike projections called fimbriae. These fimbriae function to catch ova (eggs) released from the ovary and help transport the egg(s) down the tube and into the uterus. Sperm actually meet the ovum (egg) in the tube. The resulting early embryo is then wafted down to the uterus where implantation normally occurs. Tiny little hair-like structures inside the fallopian tube called cilia beat rhythmically, also moving the embryo along the tube. If the embryo gets stuck along the way then an ectopic/tubal pregnancy occurs. The embryo grows in the narrow tube until the tube can no longer accommodate it. The tube then ruptures, causing bleeding into the abdomen.

An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age. Wikipedia

Symptoms of tubal pregnancy include missed period (which may be a short irregular one), spotting, and pelvic/abdominal pain. The pregnancy test will be positive. OB/GYN’s specifically look at the blood (serum) pregnancy test result called a beta HCG. This result is typically abnormally low compared to a healthy pregnancy in the uterus. Normally this value, early in pregnancy, should double every 48 hours. If these values do not double appropriately, then a tubal pregnancy is suspected.

If a woman presents with a positive pregnancy test, a tender distended belly, low blood pressure, and rapid pulse, then she must be taken for emergency surgery as blood from the ruptured tube is spilling into the abdomen resulting in shock.

Most of the time, this scenario is not that dramatic. There may be blood leaking from the end of the tube, or the tube may not have ruptured. If caught early enough by pelvic ultrasound, and if the tube hasn’t ruptured, then the tubal pregnancy can be treated medically with Methotrexate. This is an anti-neoplastic medicine (meaning killing growing cells) that is injected into a muscle (ie usually buttock/hip). This hopefully should kill (dissolve) the ectopic pregnancy. Given the appropriate conditions, Methotrexate works well. The pregnancy hormone levels must be watched carefully until they decline to zero. Occasionally a second dose is needed. Sometimes Methotrexate fails and surgery to remove the tubal pregnancy is necessary.

Surgery for tubal pregnancy can involve removing the part of the tube affected if it is ruptured (salpingectomy). If the rupture is slight or not at all, then the tube may be surgically slit open, the ectopic pregnancy scooped out, and the tube heals over time (salpingostomy). These surgeries are usually done laparascopically.

Any woman having a tubal pregnancy is at risk to have another tubal pregnancy in the future. We tell these women to be checked out early the minute they know they are pregnant.

Risk factors for tubal pregnancy are previous tubal pregnancy, scarred tubes from tubal infections, endometriosis (also can scar tubes), smoking (causes the cilia to not beat properly, and previous tubal ligation (sterilization by tying tubes, burning them, or placing special clips/rings on tubes). Tubes can re-cannulize or grow back together. Also assisted reproduction such as in vitro fertilization (IVF) can increase the risk that the embryo can migrate up into the tube.

More rare and extremely dangerous ectopic pregnancies include cornual ectopics (getting stuck in the junction where the tube inserts into the uterus), cervical ectopics (in cervix), and pregnancies inside the abdomen. These pregnancies can get very large and when rupture occurs it can cause extensive blood loss.

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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Apnea in Prematurity

Terri Forehand is back to discuss a common malady for premature infants. Good information for an author writing about this age group.

Welcome back, Terri!

Apnea is one of the most frightening symptoms for parents of premature infants. Apnea is a pause in breathing for 15-20 seconds.  It is associated with the infant’s color changing to a pale or bluish tint and with the heart rate slowing for a period of time. It can be alarming for those witnessing an episode of apnea for the first time and requires reassurance and education from the staff for those frightened parents.

The major reason premature infants experience apnea is their immature respiratory center of the brain. Preemies have bursts of big breaths followed by periods of short or shallow breaths or breathing pauses. It is most common in sleeping infants which is also reason for concern for new parents.

Bradycardia or the slowing of the infant’s heart rate is also a common symptom of prematurity and often goes along with the episode of apnea. Other causes for the premature infant to drop their heart rate include during or after a feeding and during a bowel movement.

Treatment for apnea may include medications such as caffeine or aminophylline to stimulate breathing and CPAP (continuous positive airway pressure) or oxygen by nasal cannula. Nasal cannula is the preferred way to administer this treatment and is done with little tubes into the baby’s nose. Mechanical ventilation may be used for very premature infants until they can manage breathing on their own with the assistance of CPAP only.

Most infants grow out of these symptoms close to their original due date as their brain centers mature. If premature infants still are having apnea spells but otherwise could go home, they can go home on an apnea monitor. Parents are trained to apply the monitor and to know how to use it as well as what to look for in their baby if the alarms go off.

Once the premature infant matures and the apnea resolves, it will not come back. Education and reassurance will help new parents of the premature infant to feel confident in caring for their infant during the last few days before discharge and when finally at home with their new baby.

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Terri Forehand is a pediatric/neonatal critical nurse and freelance writer. She writes both fiction and nonfiction, is the author of The Cancer Prayer Book released in 2011. Her picture book titled The ABC’s of Cancer According to Lilly Isabella Lane is due out in 2012. She writes from her rural home in Indiana which she shares with her husband of almost 30 years and an array of rescue animals.

Editor's Question: Consent for Rape Kit in Unconscious Victim

During my blog tour for Proof I had an interesting question from fiction editor, Ramona Richards, in the comments section of the blog on this post that dealt with collecting a rape kit.

Ramona: If a sexual assault victim is stable but unconscious-- will the medical team do a rape kit and if so-- who do they get consent from?

Jordyn: This is an interesting question on many levels. As a nurse, I'm first an advocate for the patient but also as a nurse and woman-- I want to see justice happen for this woman as a victim.

The central issue is that part of the rape kit is very invasive. Particularly the pulling of the hair from the head and groin area and well as the internal pelvic exam.

No one wants to put a victim through something more traumatizing-- so generally-- permission must be given by the victim in order for the exam to be done.

But say-- the victim looks like she is not going to wake up to give that permission?

Part of the exam can be done. External evidence and swabs can be collected. An external exam of the vaginal area could also be done. Pictures can be taken.

Likely-- we'll wait to see if the patient wakes up. Nothing should be disturbing the internal presence of the evidence if the patient is hospitalized. Exams should be done within 72 hours and one nurse practitioner I work with said semen could be preserved on the cervix for 10 days.

But what if it looks like the victim is never going to wake up?

Then it becomes an issue for the courts. They would have to issue an order for the exam to be done. So either the victim has to give permission (and no-- not next of kin)-- or the court would order the exam to be done.

Up and Coming

Ahhh-- the sumer has come to a close and the kiddos are back in school. This year, I am glad summer is over. It was a tough one for us.

Fall is my favorite season. I love the cooler weather with no snow. The color of the leaves turning and ALL the great comfort food. Chili, caramel apples, pumpkin muffins, tea (in lots of flavors!) with coffee creamer added. I know... I'm a suspense author... I get to be somewhat strange.

Plus... Halloween and scary movies. Who's with me?!?

For you this week:

Monday: I answer editor Ramona Richard's question on whether or not a rape kit would be collected on an unconscious victim.

Wednesday: Dr. Tanya Goodwin is back to discuss ectopic pregnancies.

Friday: Nurse Terri Forehand (now author Andrew E. Kaufman has me referring to nurses this way... oiy!!) is here to discuss one major concern in the preemie population and that is apnea and bradycardia.

How about you? Is fall your favorite season? What's your favorite fall activity? What's the best scary movie you've seen?

A Miracle in the Desert

Today, Dr. David Carnahan concludes his series on the widow maker and finishes up with his first hand experience of a patient surviving this usually fatal heart attack. The first part can be found here.

Now, David....

Then, their expressions dropped.

“I’m sorry I don’t have better news.” I paused, letting the words sink in and waited for their questions to bubble up to the surface.

“Does this mean you aren’t going to do anything else for him?”

“No. We’re going to continue to do everything we can to keep him alive. I just wanted you to know how grave the situation is.”

An hour later, the team stood at the bedside, waiting for another round of electrical shocks and epinephrine to urge his body to fight through the blockage in his heart.

I walked up next to Dr. Winfield again. “He still the same?”

“Pretty much. I think we are at the decision point now.”

“Yeah?”

“He’s on eleven drips.”

Most patients in the ICU are on a couple of drips: antibiotics, sedation, pain meds, but eleven is an unusually high number.

“I’m worried he’s not going to get his brain function back,” Winfield said.

I envisioned him at the end-state: awake, alive but functioning at a third grade level or worse, non-communicative. Are we doing this guy any favors by bringing him back? I rubbed my forehead with my right hand and then scratched the top of my head as I thought again about the consequences of our decision. “I think the next time he codes, you should code him. But, if he doesn’t come right back, then just call it.”

As I finished my sentence the announcement was made again, “He’s in V tach.”

I watched as they pushed on his chest, the patient’s ribs flopped up and down. Dr. Winfield looked over at me and I knew what he was thinking because I was thinking it as well: we’re torturing this poor man.

I walked over to the crowd of co-workers who’d assembled for the impromptu vigil. “Mr. Williams, I’m worried he’s not going to regain his mental abilities. We’re at a point where I feel the best thing to do is to let him go.” They looked at me apparently expecting this because they all held their expressions with little reaction. “I know this is tough, but I think the right thing to do is to let him pass when he codes next.”

“Can our chaplain say a prayer over him?”

“Of course.”

The look of relief on the faces of Drs. Winfield and Bauer told me I’d made the right decision, but I still wondered.

The chaplain stood beside the patient’s bed and the onlookers formed a semi-circle around him as well. “I would like to start by saying, on behalf of his co-workers and his family, that we appreciate the heroic measures you all have taken to preserve his life.” He grabbed the black skinned book in both hands and dipped his head. “Richard loved to laugh. He’s a good man and well liked. I know he will be missed greatly.” He paused, closed his eyes and said, “Will you join me in prayer.”

Several weeks later, I sat at my desk, working on a presentation that I would give to the medical staff of the hospital. I did this every month to relay the outcomes of the patients we sent to a hospital in Germany. I paused on the slide that represented Mr. Hall; the man I predicted would never make it to Germany alive. Tears rolled down my cheeks as I smiled in remembrance.

After the chaplain’s brief prayer, Mr. Hall, who coded almost ten times during the first four hours in the ICU, went the next fourteen without so much as a blip on the telemetry monitor. He then made it to the next hospital while being managed in a plane on a ventilator and eleven drips for eight hours. But most importantly, I later learned that he woke up and began following commands – a sign his brain had made it through the whole ordeal.

To this day, I am humbled at how close we came to “calling the code,” and thankful that God hears the cries of his people. Most of all, I was honored to watch God’s handiwork on yet another Sunday.


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Dr. David Carnahan is a Board Certified Internist, who fell in love with writing while getting his Masters Degree in Epidemiology at the University of Pennsylvania. He has served in the Air Force for the past 14 years as an academic clinician/educator and now works in the area of Healthcare Informatics. He has a wonderful wife and two beautiful daughters, and invites you to read about his life (www.dhcarnahan.blogspot.com), and weekly installments of his current work in progress, The Perfect Flaw (www.theperfectflaw.com).