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.