Writing a Character with a Kidney Stone

I have a character with severe abdominal pain and nausea. She is taken to the hospital by ambulance. She has kidney stones.
My questions are:

Would the medic and ER physician suspect kidney stones based on her symptoms?

Yes. Severe flank pain that radiates to the groin; sometimes passing blood in the urine; sometimes passing “Gravel” or “Sand” in the urine. A history of kidney stones also would point the way.

What tests would be administered in the ER to determine the problem?

Urine clean catch with microscopic exam—this will show traces of blood, even if not visible to the naked eye. A CBC (Complete blood count) to look for infection. Kidney stones can contribute to urinary tract infection. A kidney infection (called pyelonephritis) will cause a fever and sometimes cloudy urine, in addition to all the above. These patients need to be admitted for IV antibiotics.

If a fever is present, cultures will be taken from urine and blood.

An X-ray—KUB (Kidneys, ureters, bladder) to look for stones. Some kinds show up on X-ray.

It’s possible an IVP (Intravenous pyelogram) might be ordered. Dye is given through an IV line, and X-ray pictures are taken as the dye is excreted by the kidneys. Stones can appear as negative defects—no dye in those areas. As the dye travels from the kidney to the bladder via the ureter, a stone blocking the ureter will show up as a cut-off—the dye doesn’t get past.

Sometimes an IVP will help pass a stone, but it’s never ordered for that purpose.

I know people with kidney stones are discharged to go home and pass the stone. Not always. A lot of times we’d give them IV fluid to help wash the stone down to the bladder.

Is there ever a time they would be admitted and if so, why? Intractable nausea and vomiting, dehydration, high fever (101 or above), too-low blood pressure would all lead to admission. Kidney infection would lead to admission (see above) because of the need for IV antibiotics.

I want my character to spend the night at the hospital if realistically possible.
Would she be given pain medication to ease the pain? Yes.

If so when would that happen? As soon as they determine there’s no intra-abdominal disaster, like a ruptured appendix or something of that nature. The pain med would likely be morphine or Demerol, and would be given IV.

Would they need to do diagnostic tests first to determine the problem? Yep—see above.

 

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.

**Thanks to MedicineNet.com for the diagram

 

Poisoning by Caterpillar

As summer draws to a close, I got this question from a reader in Texas:
Is it possible to get sick from a caterpillar sting?

Hmm...caterpillars don't sting, not like wasps and bees or even ants. They transfer venom passively when the predator--or human--comes into contact with it. 

The puss caterpillar is the most poisonous caterpillar in the USA. It has dense “fur,” composed of hairs; hidden among these are hair-like hollow spines that deliver poison produced by glands.

Despite the appearance in the photos, it is only 1.3-1.5 inches long.

The caterpillars live primarily in the southern states, especially Texas. They appear twice a year, once in the late spring/early summer and again in late summer/early fall. Favored foods include broadleaf trees and shrubs.
Humans typically come in contact with the caterpillar by accident.

Symptoms of contact include intense pain, swelling, itching, and red blotches.
It’s not uncommon for the caterpillar to have multiple contact points, leading to several affected areas. More serious reactions include nausea, vomiting, cramps, and incapacitation. Death is unusual, but can happen with higher venom loads.

The best way to remove the spines from the skin is with cellophane/clear tape. Because of the risk of a serious reaction it’s a good idea to seek medical attention.

Thought for small children: Don't touch!

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.

**Thanks to Auburn University for the photos.

More About Snakes:Can Venom Clot Blood?

A reader forwarded this video, with the question, "Can this really happen?"

 

 

It's possible.

Snake venoms are complex and usually contain multiple toxins. The main categories are neurotoxins--which affect the nervous system--and hemotoxins, which affect the blood (and often soft tissues like skin and muscle).

 

Some venoms contain hemotoxins. A few types of hemotoxins:

--Some hemotoxins thin the blood--they anticoagulate. 

--Hemolysins are a type of hemotoxin that can rupture (lyse) red blood cells.

--Agglutinins promote coagulation of blood--what you see in the video is a large soft clot.

 

The video looks like a cobra--? Cobras usually have primarily neurotoxic venom. It affects the ability of nerves to transmit impulses and leads to weakness and death. Suffocation from not being able to breathe is part of this. 

 

Rattlesnakes produce a mostly a hemotoxic venom.

 

Hope this helps!

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 Kelly’s fiction at www.kellywhitley.com

 

Writing a Case of Snake Bite in the Wilderness--A Discussion

I'm writing a scene set in a pre-industrial society. Herbal medicines, folk treatments, etc.
One of my characters is bitten by a venomous snake - I haven't really specified what kind. Can you think of ANY treatment for snake bite in this situation that would actually be effective? Right now I have them just sort of treating the symptoms - keeping the wound clean, applying snow when it starts to swell, etc.
Are there any more effective things they could be doing, in the absence of antivenin?

Hello.

Sure. There are a few measures that you can use, depending on how savvy the caregivers are. Right away, first aid measures should be taken as follows:

--Avoid panic—keep heart rate down, keep victim quiet. Most bites are not fatal. In the USA, less than one percent of bites are fatal.

--No ice/snow application. May cause tissue damage.

--No tourniquet.

--No sucking out the venom—this includes older snake bite kits.

--Wash the wound—helps remove any residual venom on the skin, and helps cut down on bacteria. DO NOT use alcohol—this damages the raw tissue in the wound.

--Keep the heart above the wound. Immobilize the extremity (if bitten on extremity)

--Consider carrying the victim. Walking is exercise and will increase heart rate.

--If possible, try to ID the snake. Don’t let the snake get in another bite by trying to catch or kill it.

If you do kill it and transport it, keep in mind the dead snake can still bite for a couple of hours.

It is possible to use a homeopathic remedy if medical help is unavailable or delayed. This isn’t a definitive treatment, but may help.

Plants to treat snake bite:

--Rattlesnake master (false aloe)—clean off roots; scrape well. Cut up and crush root

pieces between pieces of wood. (see photo left)

--Yarrow root—process as above for false aloe.

--Willow bark (from which comes acetyl salicylic acid, also known as aspirin.) Cut into small pieces.

Combine the above and apply directly to the wound as a poultice. Wrap with cloth (strips of clothing, for example).

Over the next few hours there will be a lot of swelling, bruising, and pain associated with the bite. Chewing willow bark may help decrease pain, as can birch bark. Yarrow may numb the wound.

Ultimately, evacuation to a hospital and treatment with antivenin is ideal. Even if it’s a couple of days away, always travel toward the nearest help.

 Hope this helps!

 
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 Kelly’s fiction at www.kellywhitley.com

"Roofied"--How to Write It: A Discussion

If somebody was roofied, passed out and transported to a hospital, what would be the course of treatment. Let’s say, he’s not in a serious condition, but is out like a light for a few hours. Would he be given fluids?  Would he have that thingamajig  on his finger? Anything else?

Hello.

I’m assuming here you want Rohypnol to be the “roofie.”

There are multiple drugs that can be used to a similar effect, including Ketamine (Special K), GHB, and MDMA (Ecstasy, “E”). It’s also not unusual for a multi-drug ingestion to take place, and to have alcohol involved, depending on the setting in which your character is drugged—like a club, bar, or party.

Fifteen or twenty minutes after ingesting the drug, sedation, confusion, slurred speech, and muscle weakness begin. Nausea and headache are sometimes present. A higher dose will lead to loss of consciousness and depression of breathing. Coma can result.

 The paramedics will first do the ABCs: Airway--make sure there is nothing blocking the windpipe) Breathing--make sure breathing is okay and start oxygen) Circulation--A heart monitor will be placed to watch for rhythm disturbances. They’ll check blood sugar. An IV line will be started along with fluids. This is mostly to have IV access for whatever needs to be given. The fluid will contain dextrose (sugar) and saline (salt). The paramedics will gather any obvious drugs, ask bystanders for history—what happened. With illicit drugs, most of the time witnesses don’t offer much.

In the ER, your guy will be hooked up to a heart monitor and a finger pulse oximeter (the finger thingamajig) that measures the oxygen saturation of the blood. Likely oxygen via a tube under the nose (cannula) will be continued.

An EKG (heart rhythm tracing) will be done, and lab work. Usually this will include a standard drug screen for drugs of abuse—THC (marijuana), benzodiazepines (Valium, Rohypnol), opiates. Rarely does the patient arrive in time to catch a trace of Rohypnol. It’s very common to have a multi-drug intoxication.

Blood alcohol level will be measured—regardless of whether the guy had something to drink, it’ll be checked.

Romazicon is a reversal agent for benzodiazepines, and might be tried. This can be hazardous if the patient takes a benzo for a medical condition. Seizures can be precipitated. Most docs won’t chance it.

Naloxone (Narcan) is an opioid reversal agent, and might be tried if there is concern about opiates contributing to his decreased level of consciousness.

Mostly it’s a matter of supportive care. Keep the vital signs stable—temperature, pulse, respirations, blood pressure. Fluids. Observation.

Rohypnol generally sticks around for four to six hours with some effects persisting up to twelve hours. If he’s passed out, he’s going to be admitted. He might be in for three to five days, depending on how he does. He’ll also have some degree of amnesia for the period of intoxication.

Hope this helps!

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 Kelly’s fiction at www.kellywhitley.com

 

 

 

 

 

 

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If somebody was roofied, passed out and transported to a hospital, what would be the course of treatment. Let's say, he's not in a serious condition, but is out like a light for a few hours. Would he be given fluids? Would he have that thingamajig on his finger? Anything else?

 

Thanks!!!

Reply

 

Consequences of Choking--How to Write it

I've put down "The choking damaged his vocal chords" in a scene. Can that actually happen?
 If so, could it lead to never regaining speech? If not... how can I make it happen?

I wasn’t sure what kind of choking you planned to use, so here are both:

External choking (strangulation, homicidal or otherwise) can cause damage to the nerves that supply the vocal cords. It can also cause fracture of the cartilage that surrounds/protects the vocal cords or separation/tearing of these cartilages.

 Two possible consequences of this type of choking:

1)      Vocal cord weakness—this results in hoarseness and early “voice fatigue” when speaking.

2)      Vocal cord paralysis—victim can’t speak, and has trouble protecting airway from secretions like saliva and postnasal drainage.

I’ve included a color drawing to help you visualize the anatomy.

Internal choking (like on food or a foreign body) can cause direct trauma to the vocal cords. Hoarseness and voice fatigue can ensue. Permanent paralysis of the vocal cords is less likely with this kind of injury; therefore not being able to talk at all would be less likely. It could happen, though. (See b/w drawing below)

In the black and white drawing, the vocal cords are the long thin structures adjacent to black oval in the middle.

ANOTHER QUESTION:

If I go with vocal cord weakness... would it be logical for the victim to be unable to talk during his recuperation period?  I need him unable to talk for at least a while (even when he finally regains consciousness).
 Regarding vocal cord paralysis…what are the consequences of being unable to protect the airway from secretions?   

Certainly would be okay for the victim not to be able to talk during initial recovery. The nice thing about a nerve injury is you can control the extent. With external choking, there's bound to be some swelling which will push on the nerves to the vocal cords, in turn leading to weak or no movement of the vocal cords and little or no speech.

 The biggest thing about not being able to protect the airway is saliva, food, drink, etc may end up in the lungs. The recurrent laryngeal nerve supplies sensation to this area, and if no "invaders" are sensed, they can travel downward. The other issue is effective cough. Receptors in the airways send information to the brain, and the brain tells the vocal cords to close, the glottis (path to the stomach) to close, and then generates cough via rapid contraction of the stomach (abdominal) muscles. The air passes between the cords.

Without this sequence working, it's easier for stuff to go down the "wrong pipe," ie, the trachea instead of the esophagus (swallowing tube.)

You may consider also that your victim may need a temporary airway called a tracheostomy when initially injured. This is a hole in the trachea, below the damaged area, that allows free air movement into the lungs. This hole can be closed as the victim recovers.

I hope this helps; if you can give me more details about your scenario, I can offer more specific suggestions.

Good Luck!

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 Kelly’s fiction at www.kellywhitley.com

Pictures courtesy of ADAM and MACC, respectively.

A Near-Death Experience--How to Write One

I have a character that needs to have some sort of medical emergency that would bring on a near-death experience. A trip to the hospital, but not staying longer than a day. What will work for this?

By a near-death experience, I'm assuming you want the victim to be unconscious and require some sort of resuscitation--yes?

A respiratory arrest from any cause would work. Choking on a chunk of steak, for example. It would close off the airway. As the blood oxygen level drops, the victim would pass out. You can do a Heimlich on an unconscious person. The Heimlich depends on forcing air out of the victim's lungs and dislodging the obstruction.

Other respiratory arrests would be chemically mediated (drugs, legal or otherwise), smoke inhalation (fire victims), and respiratory arrest associated with cardiac arrest. If you have a cardio-respiratory arrest, it'd be a handful for a layman to manage alone.

A cardiac arrest (or an ineffective heart rhythm) can cause the person to quit breathing--low blood flow to the brain. The most common cause of cardiac arrest is coronary artery disease--blocked arteries to the heart. An acute blockage--what most laymen refer to as "a heart attack" blocks blood flow to the heart muscle, resulting in irritability if the heart's electrical system; this can degenerate into deadly rhythms--ventricular tachycardia (V-tach) or ventricular fibrillation (V-fib). CPR might work. If your rescuer has quick access to an AED (automatic external defibrillator) that would be better. 

The other thing with cardiac arrest--patients with a history of bad heart pump function (from any cause) are prone to rhythm disturbances out of the blue. This can include young people all the way up to the elderly.

I hope this helps; if you can give me more details about your scenario, I can offer more specific suggestions.

Good Luck!

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 Kelly’s fiction at www.kellywhitley.com

 *Diagram courtesy of www.dmacc.edu

A Less Common Heart Condition that Causes Disability

I need a medical problem for an older man. Serious enough that it might be life-threatening if he doesn't take time off work and look after himself, but not immediately fatal. I want it to start with an attack of some type, followed by a week in the hospital and several months of decreased activity. A cardiac issue seems logical, but is there anything less commonly encountered?

Any ideas?

 

One possibility is an infected heart valve, called endocarditis. The infection can cause a valve to begin leaking, causing an "attack." Sweating, weight loss, hemorrhages under the nails, palpitations (heart skipping beats) can be additional symptoms. Patients may present in sudden onset heart failure (short of breath, swollen legs, can't breathe when lying down).  Older patients may have valvular heart disease on the basis of degeneration (wear and tear). Old unaddressed/unrecognized rheumatic disease (from rheumatic fever) is a possibility as well.

Once the infection was recognized, your patient would need several weeks of outpatient IV antibiotics, and consideration of a heart valve replacement. The infection alone will be cause for seriously decreased activity. If you transition into a valve replacement surgery after the antibiotics, he's looking at several more months of decreased activity.

Myocardial infarction (heart attack with damage to the heart muscle) often presents with a sudden attack of chest pain. In the USA, a blocked artery may be treated with clot buster drugs (like streptokinase) or by opening the artery in the cardiac cath lab (special X-ray suite) by using a wire and a balloon. Other standard treatment includes aspirin (or other platelet inhibitor drug), beta blocker drug (Example: metoprolol), treatment of high cholesterol (ideally with a statin), smoking cessation, weight control, and (if present) diabetes management. The patient would be off work for six weeks, and need a treadmill test to determine residual cardiac disease before clearing to return to work. Outpatient cardiac rehab three days a week for six months is recommended. If the guy had a physical job, he might have to cut back at work to a more sedentary position.

If the heart attack did enough damage to seriously affect the pump function of his heart, he could end up with congestive heart failure. That could also be grounds for decreased activity on a more long term basis.

Hope this helps!

~*~
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 Kelly’s fiction at www.kellywhitley.com

 

Choking on Valentine's Chocolates--How to Write It

My character receives a box of chocolates for Valentine’s Day. When he eats the first one, he chokes. His roommate thinks the chocolates are poisoned, but the guy is only choking. How can I write the choking?

Choking happens when something blocks the airway—the trachea. Food and air share the same route until dividing into the esophagus (passage to the stomach) and

trachea (airway). A specialized flap called the epiglottis covers and protects the airway during swallowing. Anything that makes it past the epiglottis—food or object—can get stuck and cut off the air supply. Drugs, alcohol, and some medical conditions increase the risk of choking.

The victim usually grabs their throat—universal choking sign—and becomes agitated.

The blockage can be partial or complete.

With partial obstruction, there may be gagging, wheezing, coughing, or other sounds. It requires air movement to make sound.

With complete obstruction, the victim can’t talk or make noise. Because of lack of oxygen, he may begin to turn blue (cyanosis) from low blood oxygen.

Treatment on the Scene

Airway obstruction is a medical emergency. Have a bystander call 911. Even if the victim is fine by the time the paramedics get there, it’s vital to call immediately. If there is no one else around, do the following before calling 911.

The Five and Five method:

--Five back blows: using the heel of your hand, strike the victim between the shoulder blades five times. This may dislodge the obstructing object.

--Five abdominal thrusts (Heimlich maneuver): Stand behind victim; wrap your arms around their waist and tip them forward a bit. With one hand, make a fist and place it just above the belly button. Grip the fist with your other hand. Press hard with a quick upward motion—a thrust—the way you’d try to pick someone up. This generates an artificial “cough,” or rush of air from the lungs to “blow loose” the blockage.

If the victim is obese or pregnant, place the fist in the middle of the chest.

NOTE: If YOU are the victim, make the fist and position the same way, and lean on a hard surface. Forcibly push your fist in/up.

Repeat the five and five until effective or help arrives.

If the victim loses consciousness (passes out) position them on their back. Position hands just beneath the ribcage and gently thrust upward.

If there is no response and the victim has no pulse, Begin CPR until help arrives. Do NOT try to drive the victim to the ED yourself.

Treatment in the ED

In the Emergency Department, a needle in the trachea can be used to restore air flow until the obstruction is relieved and/ or a larger more permanent airway can be placed in the trachea. A small cut is made in the skin slightly below the Adam’s apple, and a needle is inserted to make a temporary detour for air.

I don’t recommend a layman try this needle maneuver in real life, but in fiction it’s potentially useable.

In the field, this might be done without the cut. There are blood vessels in this area, so I don’t recommend using a hunting knife to make a big hole—no matter what you’ve seen in the movies. A small pocket knife would be believable.

Yes, you could use any hollow object instead of a needle. A heavy duty drinking straw, a pen casing, etc. would work. Just be sure it doesn’t disappear down the hole and make things worse.

No matter what, call 911 beforehand.

Hope this helps!

Comments? Questions?
~*~
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 Kelly’s fiction at www.kellywhitley.com

Epiglottis pic: nicernet.org; Abdominal thrust pic: ADAM (Mayo Clinic)