Mothers Behaving Badly: 1/2

I would be remiss as a pediatric ER RN to not mention that April is Child Abuse Prevention month. Every April comes around and I think I shouldn't talk about child abuse this year. Haven't we overcome this as a society? I delayed it most of the month until we had a significant child abuse case come in to our emergency department.

It appears we still need to talk about it. People are still injuring and killing their children.

I thought I would discuss two interesting cases of recent note.

One is the case of Utah woman Megan Huntsman. I know-- ironic last name, isn't it?

Ms. Huntsman is accused of murdering six of seven infants and then disposing of them in her garage in cardboard boxes. Authorities think one of the babies was stillborn. They were discovered by her ex-husband as he was cleaning out the home in order to move in. Authorities think this happened over a 10 year period from 1996-2006. What's interesting is that Megan evidently hid her pregnancies from everyone. Neighbors noticed that her weight would vacillate between wearing baggy clothes and tight clothes. They never imagined she was hiding pregnancies. DNA testing is pending to ensure these are her children.

What's curious is that she had a daughter born during this time frame that was allowed to live. What was the choice behind allowing this child to grow-up?

Huntsman evidently has told police that she is responsible for their deaths either by strangulation or suffocation. What she doesn't say is why.

What's frustrating from a medical/human perspective is that Utah has a Safe Haven law which allows a person to drop off newborn infants without fear of prosecution if the infant is unharmed.

I'm guessing-- but I think this likely would have been a short car ride down the street.

You can read more about Megan Huntman's case here and here.

Up and Coming

April is Child Abuse Prevention month. Every year I try not to talk about it but then quickly realize that we as a society haven't overcome this issue.

We are still injuring and killing our children intentionally.

In light of this, this week I'll be discussing two infanticide cases of note.

Tuesday: The Megan Huntsman case.

Thursday: The Stephanie Greene case.

And please, if you suspect child abuse, please report it. You might be the only one to save a child's life.

New Medical Device: NAVA

Breathing on a breathing machine is not like you or I breathe. One time, when I was doing an ICU rotation, they allowed us to put the end of ventilator tubing inside our mouth and attempt to breathe as the machine delivered a breath. All of us spat that thing right out.

We breathe via negative pressure. We activate our diaphragm and when it contracts it pulls air in via negative pressure. A ventilator delivers a breath via positive pressure-- by basically shoving air into your lungs.

Although at times a patient needs a ventilater-- just being on a vent adds a whole other set of potential complications which is why some of these other "bridge" strategies have become more popular (like CPAP and BiPAP) which are positive pressure but delivered via mask. It is not uncommon for patients to wear these at home.

One of the problems with ventilators is getting it to deliver breaths when the patient breathes. This allows patients to be more comfortable without requiring a lot of sedation. Ventilator manufactorers began developing different modes of ventilation to achieve this goal.

What was available to patients up until now was synch mode but it basically waited until a patient triggered a breath and then would force the breath in after that. The patient and the vent were more coordinated but still not perfectly synchronized.

What's new is a system called NAVA (Neurally Adjusted Ventilator Assistance) which uses a cathether passed down the esophogus to sense when electrial impulses are travelling down the phrenic nerve (which is what stimulates the diaphragm to contract) and delivers a breath at that time-- which is much closer to the timing of when a patient would naturally breathe. 

I know-- perhaps this is just exciting for medical nerds like me but keep this technology in mind if you're writing an ICU scene in a big-metro hospital. They are likely using this technology already.

Pneumatic Syringes: Fact or Science Fiction?

I had an interesting question from fellow author Eric J. Gates about what medications could be given via pneumatic syringe.

Now, my suspense author mind went to exactly where he was thinking (what kind of toxic medication can I give on the fly without having to actually inject someone with a needle.) Sadly, with current medical technology, the scenario doesn't translate into real life.

First, you have to consider the way medications are given route wise because this is how they will end up working. They are as follows.

IN: Intranasal (up the nose.)
IM: Intramuscularly (into the muscle.)
IV: Intravenously (into the vein-- blood.)
Oral
SL: Sublingual (under the tongue.)
SQ: Subcutaneous (into the fat tissue just under the skin.)

And then we can talk other orifices but they really don't apply here.

When you give something via pneumatic syringe you're pushing the medication under pressure into the tissue underneath which is fat tissue. Few medications work well when given into fat. One of the medications given consistently this route is insulin.

That's author problem #1-- the route in which a pneumatic syringe would work doesn't work with a lot of devious medications.

Author problem #2-- pneumatic syringes aren't really used in human populations for anything at this moment. The closest possibility I could come up with is what we call a J-tip. This is a device that will force medication under the skin using high pressure caused by a chemical reaction. When the medication is delivered, it sounds like three pop cans opening simultaneously. The only use for it now is to inject Lidocaine (which is a numbing agent) painlessly under the skin to numb the site for IV starts.

Even though it may be a great thing in the future as a delivery method for medications and could be used at some point to kill off a fictional character-- right now I would consider it outside the realm of possibilities and more in the realm of science fiction.

Forensic Author Question: Fetal Bones

This month, Amryn has another great author question to answer.

Gloria F. asks: At what fetal age would bones show up with mom's if mom was killed & stuffed in locker for 15 yrs? The body has been above ground in a disused bldg for that length of time.

Amryn says:

It’s important to understand that there are always exceptions to every case, so the answers I give are generalized unless otherwise stated. That being said, there are a couple factors at play here.

First of all, the process of skeletonization will vary with temperature and humidity. In this case, 15 years would be sufficient time for both the mother and the fetus to be skeletonized. This process can actually take as little as a few weeks in a hot humid environment. This is the sort of research done at the Body Farm (see my previous post for more info.)

A fetus will begin to develop its skeletal system around 12 weeks. From that point forward, the bones will grow harder and more dense. Theoretically, you could find fetal bones as early as approximately 15 weeks of gestation. The problem with this is, the bones are not fully articulated and would be very easy to scatter. Also, if you consider the average size of a fetus at 15 weeks, it only measures about 6 inches long. Those are some very tiny bones!

That’s not to say they couldn’t be detected by an anthropologist or medical examiner, but I would guess it’s more likely to find them if they suspect the woman may have been pregnant. Obviously the larger the bones, the easier they’ll be to see.

Another thing to consider is the idea of coffin birth or postmortem fetal extrusion. Basically, as the woman began to decompose, gases would build up in her body and could force the baby from her uterus… almost as if she was actively giving birth. This article explains it well. It’s something to consider as the fetal bones may not be found “inside” the woman when her remains are discovered.

*********************************************************************

Amryn Cross is a full-time forensic scientist and author of romantic suspense novels. Her first novel, Learning to Die, will be released in September. In her spare time, she enjoys college football, reading, watching movies, and researching her next novel. You can connect with Amryn via her website, Twitter and Facebook.

Author Question: Cerebral Hemorrhage

Carol Asks:



I know that cerebral hemorrhages usually don't show symptoms, but for my plot, I want this young character to die quickly and not of an accident. I want foreshadowing of the event. I've given him headaches and tests will show he's got the bulging artery--they're going to fix it because it had leaked (thus the headaches.) He dies before that.

Is that plausible?

Jordyn Says:

Yes, this is plausible though I don't know if I would say cerebral hemorrhages usually don't show symptoms. This IS bleeding on the brain. Blood, where it shouldn't be, tends to be very irritating and will show up in symptoms (things that only the patient can tell us) and signs (things that we can measure.)

I did a post on the difference between signs and symptoms that you can find here. 

That being said, it also depends on the size of the bleed and the location of the bleed. With a very tiny bleed-- the patient may not experience any symptoms. I would say on the continuum that this would be more rare. If this aneurysm has started leaking already they may not want to postpone surgery. So, I think finding the bulging aneurysm is sufficient enough.

Other signs and symptoms of cerebral hemorrhage are:

• Seizures
• Weakness and/or numbness in an extremity
• Nausea
• Vomiting
• Changes in vision
• Hard to speak/Understand speech
• Balance Issues

Don't forget the FAST acronym for stroke:

• Face: Is their smile equal? If they stick out their tongue-- does is stray to one side and not stay in the middle?
• Arms: Have the person lift both arms and hold them out with their palms up. If one hand turns inward or a whole arm drifts down this is called pronator drift and signals a neurosurgical emergency.
• Speech: Have the person repeat a simple phrase. Is it clear or slurred and strange?
• Time: If any of these are present call 911. 

In the hospital setting, I use this exact tool as a quick screening method for stroke (which can be either caused by bleeding or a clot.) A negative test doesn't mean something didn't happen-- it just means something isn't happening at that moment.

A friend of mine was recently on the phone with her father (who lives in another state) when he confessed to her that one of his arms had gone completely numb. She instructed him to call 911-- which he did and his symptoms completely resolved by the time he got to the ED. However, he did have a transient ischemic attack (or TIA) or mini-stroke which increases his risk of a bigger event happening in the future.

For more information about cerebral hemorrhage (or stroke) you can check out this link.  

Also, these You Tube videos have a very nice, simple explanation of the genesis of stroke.

**********************************************************************

Give Carol McClain a challenge, she’s happy. Her interests vary from climbing high ropes to playing the bassoon to Habitat for Humanity and to stained glass creation. If it’s quirky or it helps others, she loves it. Significant Living, Vista, and Evangel have published her non-fiction articles. In her spare time, she coordinates the courses for ACFW, is team leader for The Christian Pulse, and has written four novels. She lives in upstate New York with her husband, a retired pastor, and their overactive Springer spaniel. You can read her work at http://carol-mclain.blogspot.com.

Up and Coming

Hello Redwood's Fans!

What's everyone up to? Me-- burning the midnight oil. Literally-- I am just writing this post and when it does post-- that will be the actual time I finish. This one is on the fly. I seriously feel like this dog's ears.

This week there are two very interesting author questions.

You know I love these!!

Tuesday: Author question dealing with cerebral hemorrhage.

Thursday: Forensic author question that Amryn Cross will be handling dealing with fetal bones. Super interesting stuff.

They are expecting snow here tomorrow. Bummer. Was loving the sunshine.

Jordyn

Medical Treatment in Medieval Times

I got a very interesting e-mail from a writer (at least I hope it was an actual author-- sometimes I'm not so sure.) about swords. In it, she describes and includes photos of three different types of swords and queeries about what type of "blunt-force" injuries these might cause-- particularly with such and such kind of armor.

Honestly, this is not my strength but I could tell her sword type injures are "blunt-force" trauma. Blunt for trauma is like hitting your chest on a steering wheel or getting punched in the face. Swords are sharp, are meant to impale so these would be termed more like stabbing, impalement, laceration . . .

But, it did get me thinking about treatment of sword injures in medieval times. I guess it is the curse of the medical nerd so I found a few link and some interesting facts but cannot necessarily speak to the medical accuracy of them but they make for interesting reading.

http://answers.yahoo.com/question/index?qid=20081219043021AAFTAs1

And some links from Google books about medieval medicine but they likely don't include the whole text.

1.  Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice

2.  Medieval Medicine

3. Visualizing Medieval Medicine and Natural History, 1200-1550

Do you have other sources for medical treatment during Medieval Times?

Broken Heart Syndrome

I was watching TV at the gym (can't remember exactly which tabloid show it was-- you know, I've got the earphones in blaring music and I'm trying to read subtitles while running!) when a story comes on about a woman who can't remember her wedding day.

Ok-- well that's a teeny bit unusual. I'm surmising she must have been in a horrible car accident later that day or something.

No, nothing like that.

They go on to explain that this woman suffered from Broken Heart Syndrome for which my eyes roll several times around my skull as I'm sure this can't be a real medical thing. I mean, tabloid TV, she can't remember her wedding day, Broken Heart Syndrome-- they have totally made this up.

Evidently, they did not.

According to the Mayo Clinic, Broken Heart Syndrome is a "temporary heart condition brought on by stressful situations." Anyone who has been through planning and actually wedding someone knows how stressful that can be. Because of the release of all these stress (adrenaline) hormones, "the heart temporarily enlarges and doesn't pump well." What differentiates this from a normal heart attack is that the coronary arteries aren't blocked though the symptoms might be similar-- sudden onset of chest pain, difficulty breathing and weakness.

Other names it goes by:

• Takotsubo Cardiomyopahy
• Stress Cardiomyopathy
• Stress-induced Cardiomyopathy
• Apical Ballooning Syndrome 

It is treatable and symptoms reverse in a couple of weeks. In this woman's case, however, she suffered cardiac arrest. Her husband was able to revive her but she was comatose for approximately four days-- hence losing all her wedding memories.

Be careful next time you throw someone a surprise birthday party. Make sure their heart can take it.

The Noah Movie and Up and Coming

Hello Redwood's Fans!

How's your week been? Me? Saw Noah. I actually didn't have quite the negative reaction that many other religious people had. Some of the consistent complaints about the rock people, the fact that the wives weren't present on the ark, and the sleeping smoke didn't bother me so I thought I'd offer a contrary review of the movie.

1. The Rock People.

Supposedly, these creatures were angels who chose to leave Heaven to help Adam and Eve once they were dispelled from the Garden. Because they disobeyed God, he made them into these beings. Sure, these "rock people" aren't in Genesis but we know that consistently in the Old Testament that God handed out punishment for disobedience. I thought that principle was consistent with a lot of Old Testament teaching. I think creative license could have been taken on this and how Noah did built such a big vessel.

2. Noah's sons didn't have wives.

Technically, the girls they adopted into their family had conceived her twin girls prior to boarding the ark so technically-- they were present. I'll give leeway here.

3. The Sleeping Smoke.

In the movie, a smoke is used to put the animals to sleep but does not affect humans. People cry that this could not plausible. So, we're okay that God can summon all the animals to come to the ark but He can't create a smoke that only affects animals. And-- speaking medically-- medications do affect people and animals differently. For instance, some over-the-counter pain relievers we take are quite harmful to animals.

4. Noah as a crazy religious man.

While being confined to the ark, Noah develops the belief that perhaps ALL humanity is supposed to perish and so when he finds out of the pregnancy of the adopted daughter-- he threatens to kill the child if it's female. I get the plot hole-- why not kill the adopted daughter, too, since she's not barren? What I actually found interesting about this is that the Bible doesn't spell out Noah's exact actions on the ark. Little is said. I know people who develop certain beliefs, even very religious people, that aren't necessarily biblical and then eventually come to a new understanding. I think this was depicted in the film-- where he chose not to kill the twin girls in the end. We don't really know what Noah was like and, personally, I'd get a little crazy too being locked up with animals and a few humans for that long of a time period.

This is the one issue, from a religious standpoint, that I did have issue with:

The symbolism of the snake skin being a blessing/birthright to subsequent generations.

In Noah's visions, the snake (being the devil) sheds his skin. In the first scene of the movie, Noah's father wraps this snake skin around his forearm to give Noah a blessing. Before doing so, Noah's father is murdered and the snake skin gets into the hands of the villain. At the end of the movie-- Noah has it back and uses it to "bless" his two granddaughters.

Hmm-- why would you use the skin of the serpent as a blessing? The one thing that tempted you to do evil.

That's what I'd like to discuss.

Did you see Noah-- what were your thoughts?

Now-- back to the medical mayhem.

For you this week:

Tuesday: Broken Heart Syndrome. Is it a real thing?

Thursday: Fascinating author question about what a monitor can and can't tell a nurse.

Hope you all have a great week.

Jordyn

New Medical Device: X-STAT

As a medical nerd, I'm always a little fascinated by new medical devices and what they can do. I was alerted to this device by Mike H. via Facebook (Thanks, Mike!) and found it worthy to post upon to keep all your medical treatment scenes in those novels up to date.

The Blaze

It is true that not all bleeding can be controlled by direct pressure. It is also true that bleeding is the leading cause of death when it comes to bullet wounds (unless you have suffered a direct hit to either your heart, brain, and/or spinal cord which is likely the end of your life here on earth.) Uncontrolled bleeding from limbs is one thing that harkened back the use of the tourniquet. First by the military and now by civilian EMS agencies. They found the concern over tissue damage didn't pan out in the research.

For those other folks who get shot in the chest and/or abdomen, it's always a race to the hospital where definitive control of bleeding can happen-- which usually necessitates a trip to the OR-- which takes time. You may have heard the term "Golden Hour" which is generally the preferred window to get the patient to definitive treatment before they die.

Rapid control of bleeding could actually extend this hour in my opinion.

Enter the X-STAT.  For lack of a better term, the X-STAT is a tampon shaped (sorry, guys) device that is filled with dime-sized medical grade sponges that are coated with a hemostatic (stops bleeding) agent. It is inserted into the wound and the plunger places these sponges deep into the wound where they expand (like the firework snakes) and stem bleeding without direct pressure. The expansion of the sponges prevents them from being forced out of the wound.

Genius.

Thus far it seems to be listed as an investigational device and its use is limited but if it does what it says it does I think this could mean a big difference for trauma patients.

You can read more about the X-STAT here. 

What do you think of the X-STAT? Would you use it in a novel? You can bet I'll find a way to.

New Medical Device: Skin Cell Gun

It's not often that I'm impressed by new medical devices. Many times, they're just refined from old devices with a few new bells and whistles.

This might be different.

It is difficult to treat significant burns-- particularly when grafting the skin is required. There are few options available other than taking sheets of skin from the patient's own body or growing new skin cells on sheets which takes weeks. The problem with the wait time is that your skin is not only your largest organ but also your primary defense against infectious agents entering your body. This is often what burn patients die from-- infections while their wounds heal.

That might all change and change dramatically with The Skin Gun. They take the patient's own skin cells and grow them in a water solution and in a matter of hours grow enough to then spray the skin cells onto the injured area.

The video is impressive as the new skin doesn't even appear to scar down which is another nemesis of burn treatment, but I would like to see some before and after photos of the same patient for me to truly buy into the claimed results. However, if this process can do what they profess-- it will revolutionize care for burn patients.

Check out the video. What do you think?