Hypothermia--Slowly Freezing to Death

A normal internal (core) body temperature is 98.6 F (37 C). Hypothermia occurs when the body is subjected to a cold environment for a long enough period of time that the internal body temperature drops to less than 95 F (35 C). Hypothermia can also occur when the body’s temperature regulation system is deranged.

Inside the brain, the hypothalamus (a primitive part of the brain) is responsible for temperature control. Normal metabolic processes generate the body’s heat. When too much heat is lost through the skin (or in the case of fever) shivering produces heat through muscle action.

Continued heat loss results in shunting of blood away from the skin internally, to support the internal organs—especially heart and brain. As the body’s core temperature drops, metabolic processes slow, and the heart rate, respiratory rate, and brain waves all slow down. As the internal temperature continues to drop, death will ensue.

Environmental exposure accounts for the vast majority of hypothermia. Individuals with alcohol on board are more susceptible as alcohol dilates the skin vessels and accelerates heat loss; drinking brandy to “stay warm” while scooping snow is a bad idea! Low thyroid, advanced age, drug abuse, and some medications (vasodilator drugs) increase the likelihood of environmentally-induced hypothermia. Psychiatric conditions like dementia—that might cause an individual to wander away without a defined destination—are a risk factor.

Brain conditions that affect thermoregulation ability can put someone at risk.

The gradual onset of hypothermia makes it harder for someone to know what’s happening. Onset may lead to a phenomenon known as paradoxical undressing, where the person sheds clothing even though they’re freezing to death. Drowsiness, followed by drifting into sleep and death follows.

Treatment involves getting the person to a warm environment, out of wet clothes (if applicable) and rewarming. External warmth—hot water bottles, warming blanket, even body-to-body contact—is applied. In a medical setting, warm IV fluids, warmed air, and heated blankets can be used. Warm fluid can be infused into the abdominal cavity.

In worst-case scenarios, the patient can be rewarmed using heart-lung bypass, warming the blood as it goes through the machine.

Caution for heart rhythm disturbances involves avoiding moving the patient more than necessary. As people with profound hypothermia have been successfully resuscitated, most doctors consider a hypothermic patient to be potentially salvageable until they are warm.

The biggest consideration is to avoid situations that may lead to hypothermia, primarily avoiding prolonged exposure to cold weather.

 

Questions? Comments?

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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

Frostbite and the Frozen Character

In honor of April blizzards, here's a bit about what would happen if your character got stranded and had to walk a distance through snow.

 

Mechanism of Frostbite

A normal body temperature is 98.6 F or 37 C. Frostbite occurs when body tissue is exposed to temperatures below the freezing point of water (32 F or 0 C).

The majority of cases of hypothermia occur due to exposure outdoors. Alcohol worsens the problem, as does malnutrition, dehydration, and physical exhaustion.

The areas farthest from the heart are most susceptible: fingers, toes, nose, ears, and the face in general.  

With cold exposure, blood vessels constrict in the extremities (arms and legs) to centralize blood flow to the vital organs and maintain core temperature. These remote areas get progressively colder. Brief dilatation of extremity vessels alternates with constriction. As the body temperature begins to drop, the vessels remain constricted. This is the point at which frostbite begins.

The damage from cold is of two types: ice crystals form between cells, leading to cellular dehydration, and blood vessel damage leading to lack of oxygen to cells.

Degrees of frostbite

First degree: Freezing of the top layer of the skin, but still gives to pressure. Numbness, itching, and some pain. No permanent damage.

Second degree: The skin hardens as it freezes. Blisters form. Usually heals, but may have some insensitivity to temperature long term.

Third degree: Freezing into the deeper layers—the skin, muscles, nerves and vessels are affected. Blisters form, which are blood-filled. Permanent damage leading to the need for amputation can occur. The situation is a complicated mix of clotting in small blood vessels, inflammation, and tissue damage.

Fourth degree: Irreversible cell death. The tissue is dead, and must be removed.

It’s common for the complete extent of the damage to take several months to become clear, and therefore the need for medical treatment extends beyond the initial care.

Treatment

The first assessment involves evaluation for hypothermia—pulse, respiratory rate, and blood pressure. Level of consciousness is next, and then the initial evaluation of the frostbitten areas, based on the degree of frostbite.

Treatment of hypothermia always takes priority. Save the person first, the extremities next.

Next is rewarming of the frostbitten areas, which can be quite uncomfortable (read: painful!) and require pain meds. IV fluids are commonly given as part of this process. Several methods can be used:

Warm water bath—most suitable for first and second degree frostbite. Remove clear blisters. In third degree frostbite, blood blisters are left undisturbed. Pink skin, return of feeling and motion are good signs. Observe for evidence of infection. Some practitioners give a tetanus booster.

External warming with heated blankets—suitable for any degree of frostbite.
Internal warming with warm fluids infused into the abdominal cavity—may be utilized in cases where hypothermia complicates the situation.
In critical cases where hypothermia is life-threatening, the most aggressive rewarming is done with a heart-lung bypass machine.
As with most injuries of this type, prevention is key.
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.

 

 

Killing a Patient Using an Air Embolism

My villain approaches a patient in the hospital and injects a syringeful of air, killing the patient. How would this be done, and how much air would it take?

An air embolism is a quantity of air traveling as a single mass within the vascular system.
There are several factors at work when writing your scenario.

The first is whether it’s a venous air embolism, an arterial air embolism, or a paradoxical air embolism:

Venous air embolism: An IV (intravenous) line in a peripheral vein—like an arm vein—is unlikely to accommodate enough air in a rapid enough fashion to cause much trouble. Air bubbles that go in through such an IV are filtered out by the lungs, and generally cause no problems.

You’d need a very large syringe—fifty cc’s—and need to blow in several boluses of air in quick succession. The air takes up space in the right side of the heart, and restricts blood flow to the lungs.

If the patient has a large IV line in the internal jugular vein (called a central venous line), it’d be fairly easy to blow in a lot of air quickly and within a few centimeters of the heart. This is your best bet for this scenario. Patients with central lines aren’t necessarily confined to ICU. Temporary dialysis catheters are placed in the internal jugular, for instance.

Arterial air embolism: Access to an artery would be necessary. An artery is under pressure, and the air injected will meet more resistance than on the venous side. A few cc’s of air in the carotid artery can cause a stroke. The drawback is as soon as the killer pulls the needle out of the carotid artery, it’ll bleed profusely as the blood is under pressure. The killer’s method would be obvious right away if he left the bedside. Air to the brain isn’t uniformly fatal.

Paradoxical embolism: Air injected into the right sided venous circulation travels to the arterial left side of the heart without going through the lungs. This occurs via a hole between the right (venous) and left (arterial) sides of the heart, usually between the top two chambers (the atria), but can be between the bottom two chambers (the ventricles).

For a paradoxical embolism to work, the killer would need knowledge beforehand that the patient had such a hole, or he’d have to be very lucky to have selected a victim with an undiagnosed defect.

Since the arteries that supply blood to the heart originate where the arterial blood leaves the heart, air can travel down these coronary arteries and cause a heart attack and/or cardiac arrest.

The air can travel straight up into the carotid arteries (that supply the blood to the brain) and cause a stroke.

Hope this helps!

Cheers, Kelly

Diagram: Dr. R. Singer, heartlungdoc.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 Kelly’s fiction at www.kellywhitley.com.

 

 

Writing A Child With Fragile Bones

I have a character who is a young child with a broken bone. When the parents take her to the ER, they’re accused of child abuse, but they’re not abusive. They claim the kid’s leg broke as they changed her diaper. What kind of disease might a kid have that would lead to easy fracture without abuse?

I'd suggest Osteogenesis Imperfecta, or brittle bone disease.

This genetic disorder affects boys and girls equally; it is generally inherited as a dominant trait (at least one parent has the disease) although a few are the result of both parents having a recessive gene (they don’t exhibit the characteristics of the disease). Regardless of the origin, the disease is caused by abnormal collagen.

Bones are initially formed of collagen. Crystals of calcium hydroxyapatite are deposited on the collagen framework, giving the bones strength. An abnormal framework leads to “imperfect” deposition of calcium, and the bones are weak. Although this is an inherited disease, about one third of patients have no family history of the disease, and represent new genetic mutations.

There are several different types of Osteogenesis Imperfecta. The first three are the most common and would be the options for your scenario.

**In Type I, the collagen is normal but isn’t produced in enough quantity. Bones break easily. The patient may have increased joint flexibility, ie, “double-jointed.” The whites of the eyes may be bluish gray in color due to thin collagen. The teeth may or may not be abnormal. Hearing loss is common.

**Type II victims have very abnormal collagen and usually die within the first year of life. Death is due to respiratory failure (due to chest wall deformity) or bleeding inside the head.

**In Type III, the collagen is insufficient in quantity and abnormal. Fractures before birth can be detected, and the bones fracture easily with minimal stress. The affected kids are often short, with wide ribcages and the abnormal blue-gray color of the whites of the eyes. Frequent hearing loss.

Type III would be the most likely type to fit your scenario.

For more information, I suggest the Osteogenesis Imperfecta Foundation: http://www.oif.org/site/PageServer/

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.

 

 

 

Vital Signs During a Cardiac Arrest Scene

I am writing a scene in which a patient goes into cardiac arrest and eventually flatlines. Can you provide a blow by blow of the vitals? What is a bad BP level and how does that progress from caridac arrest to flatline. For example, it might start BP at 110 over 50 and then go above 180. How might a doctor or a member of the crash team say them (e.g., "BP is 180 over 50. Heart rate is 92 and climbing.") Are there other vital signs to look out for?

Hello, Paco.

It’s A, B, C, D. Airway, Breathing, Circulation, Defibrillation.

In a cardiac arrest, the vitals we’re interested in are: respirations—is the patient breathing or not? Pulse—is there one, and what is the heart rate if there is? Blood pressure—which is only present when there’s a pulse. If your patient has no pulse, no need to check a blood pressure—you can’t get one!

During the cardiac arrest, the rhythm will be asystole (“flatline”—no heart beats) ventricular fibrillation (a jerky irregular rhythm) or ventricular tachycardia (a very fast rhythm that generally produces no effective blood pumping action).

As the code blue starts, the person in charge of the resuscitation will keep their fingers on the pulse—often at the groin. Someone will be doing CPR. If the patient doesn’t have a breathing tube down, someone should be holding a mask over the patient’s face and be pushing air in with a bag—(“bagging the patient”)

For any of the above rhythms, the defibrillator will be tried first, at a charge of 300 joules, to shock the heart into rhythm.

So, you’d have:

“No pulse. Start CPR.” (someone starts CPR)

“Charge to three hundred Joules.” (High-pitched whine as defibrillator charges, beeps when charged)

“Everybody clear.” (everyone steps away from the patient and the bed. The person in charge of the code gets the paddles and places one in the center of the patient’s chest, one on the left). “Clear.” (the shock is delivered). “Rhythm is bradycardia at thirty.” (slow pulse, 30 beats a minutes)

Check to see if there’s a pulse. If yes, try to get a blood pressure. It can be low. For simplicity, consider 90/50. Turn up the IV fluids to expand blood volume. If patient is breathing on his own, transfer to ICU if patient not in ICU. A normal pulse is 60-100. A normal BP is 120/70. Too low is 80’s on the top number.

If the shock isn’t successful:

“Resume CPR.”

Epinephrine will be given IV:

“Give an amp of epi!” (CPR continues while this is happening; wait a few seconds for drug to kick in)

“Charge to three sixty.” (360 joules)

If successful, as above. If not, continue CPR, bagging, and give an amp of bicarb (helps correct pH), an amp of atropine (speeds up heart) and another amp of epi. Another shock.

At some point, the person in charge of the code is going to “call the code,” meaning stop due to no success and little likelihood of succeeding with continued effort.

~*~ 

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.

Guarding a Surgeon in the Hospital

My heroine is a surgeon. Someone has made several attempts on her life. The hospital has insisted she have a bodyguard. Here are my questions: 1) Would he be allowed to carry a weapon? 2) Would the bodyguard be allowed to be in the OR with her, or would he be stationed outside the OR doors?

Most hospitals don’t allow “carrying” unless the person is a law enforcement officer (LEO) there on law enforcement business. Hospital security guards don’t carry guns. When a prisoner has to be hospitalized, the LEO guarding him/her would have their service weapon with them.

These days, with HIPAA, the patient/family would likely have to give permission unless the bodyguard works for the hospital as an employee. When someone is admitted to the hospital, they sign a blanket paper that allows hospital personnel to treat them—like nurses and X-ray techs. Still, he’s not going to be involved in patient care, so he’s treated more like an administrator—someone who may be in on patient-related conversations and must keep them confidential. It’s a potential liability for the hospital to have him in the OR if he gets hurt (ie, passes out and hits his head, for example). The hospital might hire him as an independent contractor and require him to provide his own liability insurance.
Chances are he’d be asked to station himself outside the OR doors—but there are two sets. Most ORs have a door to the main hall and a door to the supply hall (usually on the opposite side). Two doors to guard, in other words.
Assuming you cover both doors, you’d have to check ID on anyone entering the room. It’s amazing how much of a “disguise” scrubs and a surgical hat and booties provide.
3) During the operation, a poisonous gas is funneled into the OR through the ventilation.
Heroine passes out; the hero manages to get heroine out of OR before he passes out.
Would the hospital staff remove his weapon when then tend to him?

Yes, they’d remove it. Assuming he was taken to the ER, they’d remove the gun and lock it in the ER safe—unless another officer was there to take it into 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.
Like crime scenes? I recommend Crime Scene Writer. To join: crimescenewriter@yahoogroups.com

Pregnancy Complications in a Postapocalyptic World

My futuristic story is set in a post-apocalyptic primitive world, sort of like in the seventeen hundreds. No electricity. I have an eighteen year-old pregnant woman, and I need a complication of late pregnancy that is likely to kill her but not her child (who is the future hero).

Here are a few:
1) Eclampsia-- a condition of severe high blood pressure, kidney and liver issues. More common in first pregnancies, but can occur with any pregnancy. Very dangerous, and can be fatal.
2) Cardiomyopathy-- the heart muscle becomes weak during the pregnancy, and the woman goes into heart failure. It can happen with any pregnancy. Once it does happen, further pregnancies are not recommended.
3) Heart valve issues, especially narrowed heart valves (specifically the mitral and aortic valves). Rheumatic fever would be a cause of valve disease in a woman without access to antibiotics for a childhood strep throat.
4) High blood pressure in the lungs (pulmonary hypertension). This is most common in women between ages 20 and 40. It may be autoimmune. It causes terrible shortness of breath, swelling of legs, and patients can have a bluish color due to low blood oxygen. Pregnancy is not recommended in women with this problem, as it is often fatal.
5) Blood clots in the legs, breaking off and going to the lungs (pulmonary embolus). Can be fatal. A clot in the leg was known as “milk leg.”
6) Placenta forming over the cervix (the exit to the uterus). Known as placenta previa, it causes bleeding, and can kill both the mother and child.
7) Placenta pulling loose--bleeding, fetal distress. Known as abruptio placenta; the mother can bleed to death.
8) Failure during delivery: baby gets stuck coming out. As C-section wouldn't be an option, mother and child would both likely die.
9) Uterus won't contract after delivery-- severe bleeding. Can be fatal.
10) Twins, triplets-- higher chance of injury to or loss of the babies and the mother.
11) Breech birth-- baby tries to come out feet first. May get stuck, may have fetal distress.
12) Gallbladder disease-- more common during pregnancy. In extreme cases, a stone can get stuck and lead to pain, infection, inflammation of the pancreas. Death can ensue.
13) Appendicitis--an old fashioned killer, but not uncommon when medical care (especially surgical care) is not available.
14) Pneumonia--another old fashioned infectious disease that can turn fatal.

If you want something showy, plague is a possibility. Spread by lice in unclean conditions, this infectious disease scourged Europe in the Middle Ages. Infants sometimes survived when their mothers didn't.

Hope this helps clarify the situation. If you need more help, please leave a question in the comments!
Cheers, Kelly

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.

Like crime scenes? I recommend Crime Scene Writer. To join: crimescenewriter@yahoogroups.com