Injuries Resulting From Getting Stuck in a Chimney

What injuries might be sustained if a man playing Santa became trapped while sliding down the chimney?

Yes, Virginia, Santa Claus has gotten stuck in a chimney.

Despite sometimes appearing large on the outside, the inside of a chimney isn’t very big, usually has an offset course (ie, not straight up-and-down), and typically narrows at the flue. Individuals become trapped at variable distances. Rescue generally involves the fire department extracting the victim from above.

From a medical standpoint, cuts, scrapes, and bruises are very common, and broken bones aren’t unusual. Depending on the length of time before discovery, dehydration may be a factor. The chest may not be able to fully expand, and muscle fatigue can set in if the victim is trapped and not discovered for an extended period. Environmental concerns may also come into play—hot or cold weather.

Without timely rescue asphyxiation (suffocation) can occur, leading to death. As you can imagine, in this case it’s necessary to disassemble the chimney to free the body.
There are bizarre reports of skeletons discovered in chimneys—none in Santa suits to my knowledge.

Moral of the story: leave a couple of footprints on the hearth for the kids, but don’t try sliding down the chimney.

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.
Blog: www.kellywhitleybooks.blogspot.com

A Suspect with Two Different Kinds of DNA

Can a character have one kind of DNA in his semen and another in his blood?

Yes—and it doesn’t require fantasy or magic. You’re describing a genetic chimera.
What is a chimera? In Greek mythology, this was a fire-breathing creature with the body of a lion, a goat’s head growing out of its back, and a tail comprised of a serpent.
Human chimeras are individuals with two distinct populations of cells. This can occur several different ways, but the most common is this:
Two separately fertilized ova start off as fraternal twins. Very early on, the two embryos fuse into a single individual, and the two sets of DNA are contained within that single individual. If chromosome set #1 produces the testicles and chromosome set #2 produces the blood or is responsible for the mucus membranes of the mouth (where a cheek swab for DNA is done), the two genetic profiles won’t match.
Chimeras occur more frequently in cases of in vitro fertilization.
Placental transfer of cells between mother and fetus can result in microchimerism—very small populations of genetically different cells in the mother or the fetus or both. The presence of fetal cells in the mother may have some connection to autoimmune disease (conditions in which the body perceives some of its own cells as foreign and attacks them).
Blood transfusion has been connected to microchimerism as well.
Most chimeras go through life without being discovered. The most popularized cases have been related to genetic matching for organ transplant and child custody.

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.
Book blog: www.kellywhitleybooks.blogspot.com

A Fatal Disease "Disappears"

The hero in my MS is in his early 30's. I need a disease or medical condition that he thinks is serious enough to leave his company in the hands of his VP for a month and go on a road trip before he dies. By the end of the journey he is healed. What disease or medical condition could he have that would disappear by "believing" it went away?

Hello.
One to consider is possible misdiagnosis of pancreatic cancer. I’ve seen an aberrant artery be diagnosed as this malignancy on a CAT scan. As weight loss is the main symptom, the guy could see a doctor for complaints of unexplained weight loss and have the CAT scan, which could in turn show the “tumor.” The prognosis for this disease is poor, with average survival of two to four months after diagnosis. This diagnosis and prognosis would certainly be grounds for getting affairs in order and completing a “bucket list” like seeing the country.

Another is viral cardiomyopathy. A virus can affect the heart muscle, severely impairing the heart’s ability to pump, leaving it weak and resulting in congestive heart failure. The main treatment is drugs and listing the patient for a heart transplant. Some patients spontaneously improve.

Questions? Comments?
Thanks to Connie at Crime Scene Writers for this question; this answer is cross-posted there. To join: crimescenewriter@yahoogroups.com
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.
Book blog: www.kellywhitleybooks.blogspot.com

Inducing Hallucinations in a Character Using a Natural Substance

I’m writing a character left for dead in the desert in the Southwest USA. He is dehydrated and starving and eats or drinks something that makes him hallucinate. What can I use?

Dehydration alone can cause decreased level of consciousness, but true hallucinations wouldn’t be likely if the character can still walk. Consider having him come across a cactus; here’s why:
Peyote comes from a species of cactus; the active ingredient is the compound mescaline. Peyote causes visual and auditory hallucinations, lasting from a few hours up to a day. In contrast to LSD, most users are aware of being intoxicated, and peyote isn’t associated with flashbacks. It can be psychologically addictive. The character is likely to emerge without negative after effects related to the peyote itself.
Peyote has been used for centuries, including in Native American religious ceremonies. When cultivated, the cactus is cut off at ground level; the new growth consists of nodules, known as peyote buttons. These can be smoked, chewed, or soaked in liquid to make an extract. Because of its bitter taste, some users dry the plant, powder it, and put it in capsules. Excessive peyote ingestion causes nausea, anxiety, a racing heart, and occasionally delusions, during which the user can do self-harm.
Mescaline (the active compound in peyote) has been synthesized and sold as a drug. Like many illicit substances, it is often cut with other drugs or substances, which can contribute to a toxic ingestion. The unpleasant side effects have limited its popularity.

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.
Book blog: www.kellywhitleybooks.blogspot.com

Heroin Addiction in an Undercover Police Officer

I have an undercover narcotics officer. In the course of investigating a gang, he’s become addicted to heroin. After the bust, he goes through withdrawal. How can I write this realistically?

Your undercover police officer is in for a rough ride. Here’s some information about heroin:
Heroin is derivative of morphine. Opium poppies yield morphine, which undergoes acetylation (adding two acetyl groups) to the molecule of morphine.
Heroin’s chemical name is diacetylmorphine hydrochloride or morphine diacetate or diamorphine—street name “smack.” It is a narcotic analgesic, meaning it decreases pain and produces euphoria. Heroin is illegal; it’s been around for over a century, but has been illegal for over eighty years in the USA.
Diamorphine is a legal restricted drug requiring prescription, is tightly controlled, and typically used only for severe pain.
In the body, heroin is a “prodrug,” metabolized to the active form, which is morphine. The drug works by binding to opioid receptors in the brain, inhibiting release of the brain chemical GABA, increasing the action of dopamine, a natural substance occurring in the brain. This leads to pleasure and addiction to the pleasure produced by the drug.
Morphine itself is a weaker activator of this reward pathway.
Heroin is much stronger than morphine, and as an illegal drug is often “cut”—other inactive substances are added to the heroin to amplify the amount of drug. This makes the strength of the drug on the street extremely unreliable and leaves users vulnerable to overdose.
Regular use of heroin results in tolerance and addiction, or physical dependence. Abstinence results in withdrawal within twenty-four hours, which is accompanied by physical symptoms:
Anxiety, sweating, tearing and runny nose, chills, body aches, GI irritation such as diarrhea, nausea, and vomiting; inability to relax and sleep. This is what your character will experience as he comes off the drug. As withdrawal can be fatal, close medical care will be necessary.
In the United States, the legal (but controlled) drug Methadone is used to wean heroin addicts. Many addicts, however, then become addicted to Methadone and never become drug-free. The advantage of Methadone is consistent dosing and quality, which is associated with a decreased incidence of overdose.
Hope this helps!
Cheers, Kelly
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Writing a Code Blue--Cardiac Arrest and Resuscitation

Here's the set-up:
The character is a doctor-in-training (He has graduated from medical school, and is now doing a residency--training in Emergency Medicine).
A young man in his early thirties has coded. No sign of drugs or alcohol. Good health history. It's the third man who has come in with massive cardiac arrest with no known health problems. My doctor doesn't want the patient to die so I have him ordering them to keep doing the chest compressions (like I've seen done on TV shows). Since I am starting this mid scene, the patient has already been intubated. Eventually the doctor's supervisor talks sense into him and he calls it. I really need to know how long should the doctor do this before calling time of death.

Hello.
It's fine to start mid-code with the patient intubated and during chest compressions.
To introduce a little reality, consider having your doctor administer some IV medications. Epi (epinephrine) is an easy one and most people will have heard that used in a TV cardiac arrest scene. Atropine is another. They are usually ordered in doses of ampules, as in "Give him an amp of epi!"
At some point, you may want to have the doctor defibrillate the patient, something like this:
"Charge to 300 Joules. Clear!" (this is when everyone jumps back from the bed) and have him slap the paddles on, press the button on the side of the paddle, and deliver the shock.
Consider a comment about the patient's heart rhythm. "Damn. Still V fib." (Ventricular fibrillation, a fatal rhythm.) Alternatively, it can be a "Flatline" with no rhythm at all.
Your doctor can insist they keep doing chest compressions through all this.
A respiratory therapist to “bag” the patient (use an ambu-bag) to deliver breaths through the ET tube in the throat is appropriate.
The supervising doctor may want to suggest that "The patient's heart is gone," or "It's too late," or "You've done everything possible and it's time to stop."
The duration of a true code can be minutes to nearly an hour, depending on the situation and the determination of the doctor doing the resuscitation.
Cardiac arrest occurring outside a hospital is likely to have a shorter resuscitation period after the patient arrives in the ER. If the paramedics can't resuscitate the patient in the field, it's unlikely the ER will have much better luck.
You may want to consider a time interval of twenty to thirty minutes since the patient is young and apparently healthy, and the doctor is determined.
I hope this helps. If you have questions about the above, or have other ones that crop up, let me know.
Cheers, Kelly
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.


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What Happens to the Knife After the Doctor Removes It?

I was wondering...if a patient comes into the ER with, say, a switchblade stuck in him, what happens to the switchblade after the doctors/nurses remove it and patch him up?

Here's my take--
In the Great Midwest, the switchblade removal/chain of custody depends on where in the hospital the knife is taken out.
In surgery, the knife goes to pathology to be claimed.
In ER, if the cops are there and weapon is removed, it can go to them. I'd check with your local hospital-- many have media departments (yes, you are media!)
Unless the stabee wants to press charges against the stabber, the police may not be involved if there’s no felony assault or death. We see this sometimes in domestic abuse/ fights.
Genuine switchblades (not a pocketknife) may be illegal.


Is there a central location in the hospital where the belongings of unconscious patients are stored? Or do the belongings follow the patient to whatever room he ends up in?
Depends on the belonging(s). In the ER, guns go in a safe until the cops arrive. It’s illegal to bring a weapon into the ER.
The hospital has a safe for stuff like jewelry.
The pharmacy takes custody of meds patients bring in with them.
If a patient goes to surgery, belongings go in a big plastic bag that goes with the patient. Sometimes things get lost—glasses and dentures are on that list. The biggest thing I’ve seen lost was a patient’s prosthetic leg!

~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

How Can a Patient Create a Makeshift Weapon in the Hospital?

I'm working on a story where one of my characters wakes up in a hospital, and I need her to be able to find a weapon that she can use in a future scene to kill something Rottweiler-sized.

What is she killing? Human or animal? Can she get close enough to touch it, or does it have to be from a distance? Ultimately, it depends where in the hospital your character wakes up, what shape they're in (ie, good enough to lift something heavy), and what you make readily available.

Access to a defibrillator would be very effective. One unsynchronized shock would do it.

Oxygen explodes with flame, for instance. The waterless shampoo the hospitals give patients is also extremely flammable. You can spray it and light the spray on fire, and voila! Flame thrower!

Most bed tables have glass mirrors in the table that pop up when you lift the tabletop. Mirror shard as knife.

Plastic sheets/Chux can be used for suffocation. Any tubing also would work.

If you wanted to go MacGyver, a saline IV spill and electricity might work.

An IV pole can be used as a weapon, and the top part (with the hooks) pulls out. That piece is usually about three feet long and could make a blunt stab (belly, maybe).

Good luck!

Questions? Comments?
Thanks to Crime Scene Writer for this question!
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Writing a Comatose Character On a Ventilator After a Stroke

Hi Kelly, My character is 70ish, and is hospitalized after a car accident, broken bones and head injury. While in the hospital, he has a stroke.

1. What would cause the stroke?
A couple of options. Strokes can be ischemic (lack of blood flow) or hemorrhagic (bleeding into the brain). Either would work for an older individual.

2. I'd like him fairly soon go into a comatose state. Could that happen?
Yes—and it can occur with whatever timing you wish, if you want it to coincide with the stroke.

2-A. If he has a stroke and is comatose and ventilated, could he have normal brain activity?
If he has a stroke and becomes comatose, the EEG (Brain wave activity measured by the pattern of electrical impulses coming from the brain) won't be normal. Diffuse slowing is usually noted with a diffuse brain injury, such as lack of oxygen after cardiac arrest.

More abnormal patterns are seen after severe trauma.
Two EEGs seventy-two hours apart are often used to get an idea of prognosis.

If the patient doesn't react to external noxious stimuli, like pain or cold water in the ears, chances are you're looking at a very poor prognosis.
Coma of any source has abnormal brain activity--after cardiac arrest, for example, where the brain can be damaged by lack of oxygen until circulation is restored.
The ventilator can be for many reasons: the patient who doesn't breathe on his/her own; sedation given for seizures or agitation; severe brain injury.
Sometimes in electing to withdraw life support the ventilator is removed. Some patients will breathe on their own as breathing is a brainstem function, not a cerebral "Gray Matter" function.

3. What would lead to a tracheotomy?
A tracheotomy (or tracheostomy) is a surgically created hole in the windpipe, generally used for longterm ventilator patients or in cases of head/neck cancer.)
Need for a ventilator beyond a few days. The breathing tube (endotracheal tube) is held in place by a balloon cuff, which puts pressure on the trachea. After a few days, that can injure the trachea, so a tracheostomy is done.

4. Could he have the ventilator and a tracheotomy?
Both. The trach would be done because of the continued need for mechanical ventilation.

5. What I'm really wanting to do is set him up so that he gets increasingly worse and the children have to debate whether to take him off life support. I'd like the doctor to say a few words that would convince one hesitant grown up child that his prognosis if futile and he should be taken off all life support and be allowed to die, but yet I'd like the patient be open for a miraculous recovery. What words would a doctor use to convince the person to stop treatments?
“No hope of meaningful recovery.” Or, “Severe brain damage.” Or, “His organs have shut down.” Kidneys and liver being biggies in this area and worsening the prognosis.

6. Is it possible to take off the feeding tube and if the patient breathes on his own, to continue giving nourishment, if a decision is made to let him die?
If the patient has enough brainstem function, he can breathe on his own. Nourishment is considered to be supportive care. There’s a lot of controversy about whether it equals life support. Starving a patient will make most medical personnel uncomfortable, and they will likely refuse to starve the patient. This can lead to an ethics inquiry within the hospital.

In these situations (no vent, nourishment given), it’s not uncommon for a secondary complication to lead to death, such as pneumonia or another infection.

7. Say the family all agrees that the vent should be removed, but if he breathes on his own, he should be given treatment. Is that doable?
Anything is doable. There are no absolutes when it comes to these situations.
You can decide not to resume the vent if the patient can’t breathe, decide not to use CPR for resuscitation and use only drugs, use no drugs or CPR.

Another thing you may want to keep in mind: if there is no wife and no medical care proxy, the oldest child is the legal next of kin and legal decision maker. That doesn't mean they won't take the wishes of the others into account, but legally that individual can call the shots.

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Bulletproof Vests and Injuries When Shot With a Hand Gun

Hi.
My cop hero is shot with a hand gun while wearing a bulletproof vest. I want him to be injured, enough that he has to see a doctor, but not enough that he requires hospitalization. What kind of injuries could he have?

Hello.
I’m assuming you want him to be hit in the vest. Let’s consider the factors involved.

The force of the bullet is going to depend on the type of vest, how close your hero is when the shot is fired, and the type of round/bullet.

First, the vest. Most police issue vests are made of Kevlar, a synthetic fiber woven into a dense fabric. Multiple layers strengthen the vest. The weight is proportional to the thickness, therefore these vests are generally not too heavy and very reliable in preventing perforation of small caliber hand gun bullets.

Distance: consider a small caliber hand gun at relatively close range. With a trajectory perpendicular to the chest, the bullet can hit with enough force to knock the cop backward. He could sustain injuries related to falling on a hard surface. The bullet can also hit hard enough to injure the chest wall beneath the vest, including bruising, abrasions, and cracked ribs.

The bigger the round, the more damage. The average law enforcement vest isn’t designed to handle a rifle round. This kind of round can pierce the vest and do as much damage as it would without the vest.

With a cop shot by a hand gun at a short distance, I’d expect him to be knocked backward and possibly fall. He’ll be seen in the ER, and get a chest X-ray to check for broken ribs. If he’s just banged up, he’ll be discharged. If he has cracked ribs, he’ll be sent home with cautions relative to treating this (pain control, deep breathing to prevent pneumonia, follow-up doctor’s visit). In the rare case of a severe rib fracture puncturing a lung, he’ll be admitted.

Good luck with your scene!

Questions? Comments?
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Death by Hanging:Suicide or Homicide?

I have a murder by hanging, but I want it to look like a suicide. The murderer ties a rope to the second floor stair railing, puts a noose around the victim’s neck, and tosses her over. Is there a way to confuse the medical examiner?

Hello.
Most suicidal hangings are from lower heights, and the victim dies from suffocation and lack of blood flow to the brain. The victim typically has a Vee-shaped bruise on the front of the neck. Tiny broken blood vessels can be seen in the eyes and mouth.
If the killer uses a ligature to strangle the victim and then attempts to make it look like a hanging: the medical examiner would find a transverse bruise from the ligature.

If the victim dies from the strangulation, less bruising will occur from the rope. The ME would call this a homicide.

Other trauma that suggests a struggle will cause suspicion about homicide. It would be difficult to subdue a conscious adult, place a noose, and throw the victim over a railing without trauma. Injury from incapacitating the victim—head wound, for example—increases the likelihood of homicide.
The way the knot is tied and secured can give clues as well.

A hanging by the neck with a fall of more than six feet is capable of fracturing the neck. There’s a fair body of evidence on this since hanging is utilized as capital punishment in many countries. Throwing a victim off a second floor balcony is very likely to cause a fracture. Few suicides would choose this method.

Hanging from an intermediate height--such as forcing the victim to stand on a chair and then removing the chair would look like suicide. If the victim is drunk or has taken sedatives, she could be unconscious from this, making it easier to control her. It's not unusual for suicides to takes pills or alcohol.

Questions? Comments?

~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Shock and sucking chest wound at the site of an accident

***A portion of this post appeared previously on Crime Scene Writer.(Link at end of post)

A passerby comes upon an accident. The victim is in shock and has a sucking chest wound.What can be done by a layman armed only with a first aid kit and good intentions?

The Good Samaritan is alive and well and willing to risk a lawsuit to provide aid.

The first weapon in your arsenal is a cell phone. Call 911, then administer first aid.
Shock in this case would most likely be due to blood loss. The damage causing the majority of the bleeding is going to be internal. If the victim is breathing, compressing the wound to stop external bleeding is about all you can do.

Elevating the victim’s feet will keep the blood central, where it will do the most good. Keeping him/her warm by covering the torso will help conserve body heat.
Now for the sucking chest wound.
I’m going to make a leap here and assume you mean a tension pneumothorax. With our accident victim, air enters the chest—it's “sucked” in, but doesn’t exit. This generally happens when air leaks from the damaged lung into the chest, but can’t exit. This so-called “free air” takes up space, and leads to collapse of the lung on that side. The more air that leaks into the chest space and is trapped there, the worse things become.
The treatment is to get the air out. Depending on what you have in your first aid kit (and glove compartment) there are a few options.

First, seal the wounds on the outside of the chest. With penetrating trauma, this means entry and exit wounds. Doing this prevents air from entering from the outside.

Next, look at the patient’s neck—are the neck veins standing out? Normally they wouldn't be, especially in shock. Is the trachea (the breathing passage in the front of the throat). Normally, it should be straight up and down. If it's shifted to the side opposite the wounded side of the chest, this is a sign of pressure in the chest.

The air must be evacuated. In an emergency, a needle between the ribs will let the air out. Inserting the needle will give the trapped air an exit. This is a favorite TV scenario, but it's right on the money as far as a first step.

If no needle is available, any small tube will do. In a MacGyver moment, you can make a hole between the ribs with a pocket knife, and use a pen (take out the innards) and use this as a tube. A drinking straw will work, but is harder to keep from collapsing.
By this time, hopefully the sweet music of an approaching ambulance will fill your ears, as you did the right thing and called 911 first.

~*~
Crime Scene Writer is a forum for asking and answering crime scene investigation, applied forensics, and police procedure questions for fiction or non-fiction writers.
***Click here to join Crime Scene Writer.
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Monday is for Questions

Have a question?

Anything you'd like to see discussed? A scenario you'd like to see laid out in black and white?
~*~

Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com

A Man With Erratic Behavior, Shaking, and Nausea

Hello, Pencil Neck here.
What would the ER personnel do if a patient showed up presenting:
1) Cold sweats
2) Shaking
3) Stomach cramps and complaining of hunger
4) Nausea
5) Erratic behavior
6) Dark rings under the eyes and a pallid cast to the skin
7) Possibly sensitivity to light

What would they test for? What questions would they ask? What would they do to try to stabilize him?

This isn’t a simple question without more information, so this is a general overview:
First thing, take his vitals: temperature, heart rate (pulse), breathing rate (respirations), and blood pressure. This will give an idea if there’s a possible infection, whether dehydration might be a factor, if there’s evidence of increased adrenaline (fast heart rate and breathing) suggesting his body is under perceived threat.
We’ll stabilize the blood pressure, heart rate, and breathing.
Start an IV. Do a finger stick blood sugar level. Check blood oxygen level with a finger clip (pulse oximeter). Put on oxygen if necessary.
***If this is an overdose, right away we’ll want to know what was taken, when, and how much. Depending on the substance, we might give activated charcoal to bind the drug (via a tubs through the nose and into the stomach) or do “gastric lavage,” which is pump saline in through the tube and suck it back out—in the layman’s term, “pump the stomach.”
History of present illness:
Age—helps decide if this might be a heart attack (more common in an older person) or overdose (more common in kids).
When did this start, and what was he doing when it started? What were the first symptoms? What did he try for relief (if anything)? What makes it better (if anything) or worse (if anything)? Is anyone else at home or work sick with something similar?
Did he take anything or eat anything? Drugs and poisons can give this appearance.
***In this day of frequent introduction of new “designer” drugs, we’re constantly having to watch for odd presentations—witness the recent “bath salts” scenarios.

If it’s a kid, and he’s alert enough to give information, I usually kick the parents out for a few minutes and ask the kid in private about doing something he shouldn’t have, and about illicit drug use. Typically, the kid needs to know 1) we can’t help him if we don’t know what he took, 2)we’re not going to call the cops, and 3)we’re going to run a drug screen regardless. Most kids will own up if they know anything.

Medical history:
--What medications is he taking? Diabetics can look like this if their blood sugar is low. Quite a few medications in toxic doses can have a profile similar to above. Could the guy have overdosed? (intentionally or accidentally)
--What kinds of health problems has he had in the past?
--Does he smoke (anything) or drink (anything)?
--Where does he work? This goes to environmental exposure.
At this point, we’ll want to get lab cooking.
***Initial Labs: EKG (to check if the illness is affecting the heart rhythm or electrical system—overdoses in particular can have bad effects on the heart rhythm); electrolytes, blood count, urinalysis, drug screen (depending on the hospital, most panels will check for acetaminophen, marijuana, benzodiazepines (valium, etc.), narcotics, alcohol), blood levels for any known drugs that could be at toxic levels—like Digoxin, for example—and a couple of extra tubes for stuff we might want to add on.
Toxic exposure: If the history reveals exposure to something specific—like exposure to ant killer, for example, we consult the Poisindex, a tome that outlines poisons and how to treat them.
***Link: Poisindex
A lot of poisons can’t be assayed on blood tests. Treatment is supportive, meaning we keep the patient stable until the poison exits.
***If there is an antidote, we’ll give it.
Maybe a chest X-ray, or other imaging depending on what’s been learned up until now. Maybe a head CT because of the behavior.
Next, an examination:
General appearance: pale, sweating, shaky. All these make infection near the top of the list. Also add in toxic exposure, overdose.
Head/neck: Pupils dilated? Do they contract with a light shown in the eyes?
Chest: rattly, like pneumonia? Wheezing, like bronchitis? The temp will have given us a heads-up on this one.
Heart: heart rate? Murmurs that could suggest heart valve infection? Scratching that could suggest inflammation of the sac around the heart?
Abdomen: Are gut sounds present? Tenderness, and if so, where? Guarding or rigidity (which typically mean something bad—ruptured appendix, for example)
Extremities: Blue? (low blood oxygen) Pink? Pale palms or nail beds? (anemia)
Neuro: Assess “erratic behavior.” Does he know where he is? The date? The president? (always a challenge when this is changing) Does he know his own name? Is he combative?
Lymph: Any glands swollen?

Pencil Neck, based on what you’ve said alone, I’d favor a diabetic reaction or toxic exposure (drug or poison). After the above assessment, I’d have a much better idea what’s going on.
Hope this helps!
Cheers, Kelly
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Treatment of Trauma After a Fall from a Vehicle in a Remote Area

Hi Kelly,
I’d really appreciate your help with this scene.
My scenario. Hero and heroine’s first meeting. Remote location, time is early 2003. Heroine is driving a horse and cart and finds hero unconscious in a ditch. Hero has catapulted off a moving truck and is suffering a broken leg, shoulder separation, multiple cuts and contusions. (He is not quite human so the injuries aren’t going to kill him.) Heroine must stabilize and transport him in the bed of the cart by herself with what supplies she has at hand. She has experience with farm animals and she washed out of EMT training years ago so she does have some knowledge. For the heroine to physically get the man into the cart the hero must be somewhat conscious.

Which scenario would be more likely:
A)Heroine decides to set the broken leg and the pain awakens the hero, or B) hero regains consciousness and convinces the heroine to set the leg, thereby being awake enough to aid his move?

Hello, DM.
In this day and age (including in 2003), no one would try to set the leg without X-rays. She could try to stabilize it with a splint—a board on either side of the leg banded together with cloth (ripped clothes/blanket/rags).

The hero is likely to wake up if she moves his leg—fractures are very painful. It won’t make it easier to move if his leg is splinted. He won’t be able to stand on it.
He can wake spontaneously—doesn’t have to be from pain.

And how much detail should I put in the scene? Would a reader be interested in how she checks for lung puncture or why she makes a cervical collar out of the SAM split she has in the cart’s first aid kit?

Consider putting in whatever detail anchors the reader in the scene. What is she going to do to check for a punctured lung? I’d suggest he could cough up pink foam (blood mixed with air) as an indication of that.

Come to think of it, would she bother with a cervical collar when she can’t immobilize him in a back board anyway? What do you think?

IMHO, it’s better to focus on a couple of big medical details. I’d skip the collar—if she’s going to move him anyway, it becomes a moot point.

Good luck with your scene, DM!
Cheers, Kelly
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

MONDAYS ARE QUESTION DAYS

Have a question?

Anything you'd like to see discussed? A scenario you'd like to see laid out in black and white?

Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it.

Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

Arrow Wounds

With all the recent popularity of bow and arrows (The Hunger Games, Revolution), can you tell your readers the proper way to deal with injuries like this?
Thanks, Kimber

Hello.

Arrows are an old weapon and a unique weapon. Let’s start by looking at the arrow itself—that lends a lot to the understanding of the injury and treatment.

A Bit About Handmade/Homemade Arrows Ala Hunger Games

The earliest recorded information about arrow injuries and their treatments comes from the 1800s, when the Bow and arrow was still a common weapon—not yet supplanted by guns.
First, let’s look at the traditional hand-made arrow, like in Hunger Games or Revolution.

The arrow was comprised of a head, a shaft, and feathers.

The arrowhead—usually rock or bone—was shaped into a roughly triangular shape. The tip needed to be sharp and able to “cut” the skin, and had to be sturdy enough to penetrate clothing. Arrows were often shot with enough velocity that they could lodge in bone, although perforation of the skull was uncommon unless the victim was hit in the eye socket.

The shaft was typically made of dogwood stripped of bark, then soaked and twisted to ensure a straight shaft that would rotate. The shaft had to be long enough to stabilize the flight of the arrow, but be of a length easily portable in a quiver. A horseback-seated archer needed to be able to reach over his shoulder and pull an arrow out of the quiver.

The end of the shaft was stabilized by feathers. The choice of feather was based on the weight of the arrowhead. The bigger and heavier the head, the bigger the feather needed to balance it. The other function of the feathers was to influence the spin of the arrow. Like a quarterback, an archer wants spin in the flight. A rotating projectile goes farther.

The head was bound to the shaft with tendon and sinew. The reason for this (other than convenience) is this: when the arrow penetrates body tissue, the blood and moisture loosens the binding. When the well-meaning friend went to remove the arrow, the arrowhead remained inside the victim, where it generally did more damage by moving—those sharp edges—and caused infection. Compared to bullets, which are hot (and more likely to be sterile) and blunt (less likely to cause damage once they’ve stopped), arrowheads could not be left in place. The easiest way to get one out was to cut down to the head and extract the whole thing. This was the best chance for survival.

Chest wound were more dangerous, especially if it wasn’t a through-and-through injury.

Poisoning an Arrowhead

An old method was to take a chunk of raw animal liver and entice a rattlesnake to bite the liver. I have no idea how they got the snake to do this. Then the liver was buried and allowed to rot for a few days. The meat was disinterred, and arrowheads (already mounted on shafts) were dipped in the rotten poisoned liver and allowed to dry. The consequence of this—even if the arrow was successfully removed, the victim often died of poisoning, either from nasty bacteria or the rattlesnake poison.

The Modern Arrow

Most arrows today have machine-made carbon shafts and sharp cone-like points. Their shape is conducive to going deep with a low velocity, and tends to cut through body structures in its path. The good news is the arrow tends to act like a plug—if it lodges in the heart, the last thing you want to do is pull it out. Same for penetration of major blood vessels. The upshot is you can’t tell exactly where it is or what it punctured.

DO NOT PULL OUT THE ARROW!

The arrow should be stabilized in place, usually with gauze or cotton around the arrow at the entry site, and the patient should be transported like this. Many patients have a stable blood pressure and heart rate. In the ER, X-rays may be obtained. A CT scan can help map the tract of the arrow and give medical personnel a better idea of what structures may be affected. The arrow is generally removed in surgery.

Barbed arrows are similar to the handmade ones, causing more damage and tend to be fraught with more surgical peril during extraction. Again, don’t pull the arrow out.
In fiction, the choice of the arrow—homemade or machine-made, poisoned or plain—depends on the scene you’re looking for. Just…don’t pull out the arrow.

Cheers, Kelly
~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

A Man Stabbed in the Back of the Shoulder

My hero was stabbed in his shoulder from the back. I don't want him to be kept overnight. I want him to be able to refuse to stay in the hospital. What would the ER docs do for him? The idea is he ducked and the man got him from behind.
thanks--CK.

Hello, CK.
There’s a lot of bone and muscle in the shoulder. The vessels to the arm are in the front beneath the collar bone, and therefore protected when the victim is stabbed from behind.

The shoulder blade protects the back of the shoulder and part of the rib cage. The muscles attached to the shoulder girdle (the “corner” of the shoulder where the outer ends of the shoulder blade and collar bone meet) can be damaged with a knife.
The ER docs will want an X-ray series of the wounded area and a chest X-ray. A blood count (to gauge blood loss) would be reasonable.

If the cut is deep enough and long enough, it'll require stitches. I'd suggest having the knife hit the meaty part of the shoulder (read: muscle) but not sever tendons. Tendon damage equals surgery and admission to the hospital.

A stab wound over the shoulder blade will protect your victim from the knife entering the chest cavity (and protect him from admission).

The wound is likely to require a shot of antibiotic. It’ll also require a tetanus shot if your hero hasn’t had one in the last five years. The wound will need to be kept clean and dry, and no showering (getting water on it) for a couple of days.

He’d be advised to come back for a wound check, and to have the stitches out in about ten days. Of course, he may decide to take them out himself. A common mistake people make when they do this is cut the knot off and leave the loop of the suture beneath the skin. Cut only one side of the suture below the knot—then the whole thing can be pulled out intact.

Undetectible poisoning

Hi.
I’m writing for help on poisoning. I want something that’ll work fast, but can be put in a drink. It can’t be detectible on a blood test. I also want something unique—not cyanide or something like that.

Hello.

Okay. How about something not available in the United States? (Assuming the setting is in the USA)

Years ago, coyotes were poisoned with a substance known as 10 80 (ten eighty), a poison that affects metabolism in mammals. It’s illegal in the USA.

The poison is stable in alcohol, if that helps.

After ingestion, symptoms appear in 30 minutes to two hours. The first indication that something is wrong is nausea, followed by a sense of apprehension. Stomach ache and sweating are next. Twitching starts as the muscles are affected, and progress to seizures. Left untreated, it affects the heart, causing malignant rhythms that kill.

If help reaches your victim in time, a hospital can try to support the patient symptomatically with IV fluids, treatment of heart rhythm disturbances, and meds for seizures. If they know what your character was poisoned with, the doctors can try administering glyceryl monoacetate, which may compete for the poison at the level of the body’s cellular metabolism. There is no laboratory assay for 10 80. Citric acid levels may be elevated in the blood.

Alcohol (the drinking kind) was used as an antidote for many years with little success.

Few (very few) people or animals survive the poisoning.

Questions? Comments?

~*~
Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

What would you like to see?

Well, folks, it's Monday, so it's question day.
What would you like to know about?

After a fall down the stairs, what would keep an elderly witness awake long enough to call for help?

In my WIP, the killer pushes the 80-year-old witness to his previous murder down the stairs in her home. It’s a long, straight flight of 10 carpeted stairs. The elderly woman is otherwise strong and in good health. He thinks she’s dead and leaves before the neighbors can respond to her barking dog.

I want her to be conscious long enough to push a button on her cell phone. And I want her to survive but be in a coma and incommunicado for much of the rest of the story. What injuries would she be likely to have that are severe but allow her to make it?

Your help is much appreciated.

Hello, Susan.

Two choices that would work well—subdural hematoma or epidural hematoma.

What might work is this:

A fall down the stairs with a blow to the head. Doesn’t have to be severe, doesn’t have to cause a skull fracture or even a cut/laceration.

Subdural hematoma—a blood collection between the membrane covering the brain—the dura—and the brain itself. Older people can get these fairly easily, even without severe head trauma. The pupil can be enlarged on the side of the bleeding. This is the one I’d favor for your witness.

Epidural hematoma—a blood collection between the skull and the membrane covering the brain, known as the dura. This type of injury comes tearing the veins between the skull and the dura—the “bridging veins.” The tear results in bleeding, which compresses the brain. These are more dangerous, and less likely to occur in the elderly.

Both the subdural and epidural varieties have the following signs: the patient usually has a “lucid interval” (a period of time where your witness would be awake) of a few minutes up to a couple of hours can occur. This would give her enough time to push the button on her phone. Without prompt treatment, the patient thereafter lapses into a coma.

Depending on whether you want her to have surgery and recover, or be out of it for the rest of the book, either one will work. Again, I’d favor the subdural hematoma given the fall and her age.

Hope this helps!

Cheers, Kelly

Kelly has worked in the medical field for over twenty years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

MONDAYS ARE QUESTION DAYS

Have a question?

Anything you'd like to see discussed? A scenario you'd like to see laid out in black and white?

Do you want to read real-life anecdotes that might be of interest--humorous to scary to gory to...yo get the idea.
MONDAY IS FOR YOU.

Questions? Comments?

Kelly has worked in the medical field for over twenty-five years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous.
Find her fiction at www.kellywhitley.com.

The Ambulance and ER Management of Stab Wound to the Chest

What happens to a stabbing victim in an ambulance and the ER?

This is a general overview—take what detail you want for your scene. The EMTs or paramedics will stabilize his breathing—if necessary, they’ll put a breathing tube down his throat and into his airway. Then they can “bag” him—use a pliable plastic bag to push air into his lungs—breathe for him. The chest wound will be inspected and covered. An IV line will be started (at least one) of a large size to add volume to the blood supply and keep the blood pressure up. This also allows medications to be given. A heart monitor will be attached. Blankets to maintain warmth and help stave off shock. During all this, heart rate, blood pressure, and breathing will be monitored. The ambulance will be in contact with the ER. In hospitals that have the capability of functioning as a trauma center, a surgeon may be waiting for the patient. Otherwise the ER staff will be ready for a “hot unload,” a seriously ill patient in need of immediate attention. The goal in the ER is to stabilize the patient. Depending on how the hero is doing, he’ll get a chest X-ray, maybe a CAT scan of the chest and abdomen (low stab wounds can involve the belly), and a tube may be inserted into the chest to reinflate the lung if it’s collapsed. This tube drains both blood and air. Blood will be drawn for labwork, including a type and cross for blood. The hero might need surgery. This will depend on the extent of his injuries. The surgeon, the ER doc, and the imaging tests (X-ray and CAT scan [if done]) can make this decision. I’ve seen stab wounds minor enough to require very little, up to life-threatening wounds requiring emergency surgery. You can tailor your scenario to give the result you want. The more severe the injury, the longer the hero will be in the hospital. One last minor detail—he’ll need a tetanus shot unless he’s had one in the last five years! Questions? Comments? Kelly has worked in the medical field for over twenty-five years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous. Find her fiction at www.kellywhitley.com.

Stab wound to the chest

Hello. My hero is in an altercation, and is stabbed in the chest. I know he’ll be bleeding. I want him to need hospitalization, but don’t want him to die. What can my heroine do besides call 911?

911 is a good start. After you get expert help on the way, the heroine needs to do the ABCs: Airway, breathing, circulation. Airway—make sure the hero doesn’t have anything blocking his throat that would prevent breathing. Breathing: is he? If not, she’ll need to give him breaths. Circulation: does he have a pulse? If not, CPR is next. The current method is to do CPR to “Stayin’ Alive,” the old Bee Gees’ song. (oh, oh, oh, oh, stayin, alive… one compression for each word). Giving breaths is appropriate, but the current focus is on circulation. Since he’s been stabbed in the chest, it’s good to move the clothing away from the wound to get a look. Is air coming from the wound? Pink froth? Seal the wound with something occlusive—a palm, a waterproof jacket, latex glove. Go with what you have available. If the hero seems to be getting worse, and his neck veins are standing out, he may have a tension pneumothorax—a big term meaning air from the damaged lung is leaking into the chest cavity and compressing the lung. Letting the air out helps. This is the maneuver you see on TV/in the movies where someone jams a needle/pen case/straw between the ribs, and air whistles out. If you choose to have this scenario, please have the good Samaritan punch through at the top of a rib—blood vessels and nerves run through a groove at the bottom of each rib, and you don’t want your patient to get worse! Shock may set in—he’ll feel cold, shiver, have a thready (weak) pulse, and become pale and sweaty. This would be a great time to have paramedics show up, as the hero is going downhill fast. The next entry will cover what happens to our stabbing victim in the ambulance and the ER. Questions? Comments? Kelly has worked in the medical field for over twenty-five years, mainly at large medical centers. With experience in a variety of settings, chances are Kelly may have seen it. Sometimes truth seems stranger than fiction in medicine, but accurate medicine in fiction is fabulous. Find her fiction at www.kellywhitley.com.

Hey. I hear a lot of medical questions from writers, everything from poisoning to stab wounds. What happens in an ER? (It's not pandemonium, and it takes longer than three minutes from door to surgery.) What does the heart look like in surgery? (A picture is worth a thousand words.) How can my character take out his own appendix? (Don't try it.) Seems like a bunch of writers want access to reliable information. This blog will feature entries about items of medical interest to writers, and I'll review comments for requests for upcoming blogs. If you have a question you want answered privately, leave me your email in the comment. I'll do my best to get back to you. So...get out there and write that medical scene with the flavor of being there.