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)

Trapped by a Snow Blower--Injuries and Setting the Scene

I have a character who is using his snow blower on a slope, and it tips over on him and traps his arm in the blades. He needs to be stuck for at least a couple of hours in the ice and snow. Will this work?

About 6000 people are injured annually (in the USA) by snow blowers. These machines can “clog” with wet snow, and there is the temptation to clear the blockage manually. (NEVER do this. Always use the tool that comes with the snow blower). The most common injuries are to fingers. Because of multiple sharp motor-driven blades, these machines are capable of cutting skin, muscle, tendon, and bone. Amputation of the affected digits is often necessary.

Hand surgeons hate it when people use hands to clear the blades of a snow blower!

Okay. That out of the way, let’s move on to the considerations for your scenario.

It sounds like the machine in your manuscript isn’t jammed. When the operator lets go of the handles, the blades will quit turning. The damage will have to be inflicted by stationary blades.

--The size of the snow blower. The average home use snow blower could cause damage to the arm—not to the extent of a hand, though. The blower might become jammed by clothing.

--The weight of the snow blower. This can range from 25 lb. to upwards of 150 lb. depending on the type. The average man weighs ~155 lb. Unless the victim is elderly, sick, or debilitated, he could probably shove the snow blower off.

--The operator’s clothing. If it’s very cold, he may have on several layers. The blades would have to cut through the clothing to injure him.

--Whether you want blood loss. If you want your victim to bleed, he’ll need to get a lot of muscle damage or cut a blood vessel.

Consider the possibility he’s clearing snow with a bobcat skid loader—a small tractor for home/ranch use. They are prone to tipping over if used on a slope, and can weigh over a thousand pounds—hard to get out from under.

You can write the trauma to the victim any way you like as far as injuries and bleeding. A crush injury to the arm can be severe enough to require amputation or just cause a lot of bruising—depends on how the extremity is trapped.

Bleeding would be believable and easy to add.

Hope this helps. Let me know if you have further 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

 

Death by Compressive Asphyxia

Can an adult die from having weight on the chest?

Absolutely. It’s called compressive asphyxia.

The lungs work like a bellows. The muscles between the ribs and the diaphragm operate together to expand the chest cavity and draw in air—inhalation. Relaxation of these muscles results in exhalation. Anything that restricts this movement leads to decreased oxygen coming into the lungs and then into the bloodstream. Carbon dioxide builds up, oxygen levels drop; the victim passes out and eventually dies from lack of oxygen.

Anything else that depresses the respiratory center in the brain makes it more likely asphyxia will occur—alcoholic intoxication, sedatives, extreme cold exposure, illness, and extremes of age.

Examples include:

Constrictor snake—like a python

An adult sharing a bed with a small child or infant rolls over on them

Crowds and panic, resulting in individuals crushed and unable to breathe

Pinned by a large weight, such as becoming trapped under a heavy box or piece of equipment

Restraint—the victim is facedown and the individual doing the restraining may press or kneel

Burking

A combination of compression and smothering (occluding the airway) was utilized by William Burke and William Hare in 1828 in a series of homicides. The two men got their victim intoxicated and sat on the chest of the victim (compression) while occluding the mouth and nose (smothering).

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

 Photo courtesy of

Plausible Reasons for Collapse

I have a character in his fifties. He’s in good health. In the scene he’s walking along, then just crumples to the ground and is unresponsive. It can’t be a cardiac arrest. What are the possibilities?

There are quite a few. Here are some easy ones to consider:

 

Simple faint is the easiest.

Heart-wise, there can be problems like a very slow heart rate or a very fast heart rate, either of which can cause the blood pressure to be low. If it’s low enough, there isn’t good circulation to the brain and the victim collapses. There may be little to no warning.

Severe pain can cause a victim to pass out.

A blood clot to the lung (pulmonary embolus) can cause the victim to pass out. Associated symptoms include chest pain and shortness of breath. A risk factor for this is immobility, like prolonged sitting with travel or staying in a position like a crouch for a prolonged time. Surgery, especially of the pelvis or hip is a risk factor. Uncommonly a clotting disorder that makes the blood clot too well (hypercoagulability) can be the cause.

Low blood oxygen can cause collapse, but generally this would be due to something going on, like worsening lung disease or infection.

Low blood sugar can cause collapse—like a diabetic who has taken too much insulin (or an oral medication for diabetes) and not taken in adequate food.

Infection that gets into the blood stream can do it, but again, the victim is going to have symptoms beforehand.

Seizure—a big one—can look like collapse if not seen close up.

Dehydration—due to low volume in the vascular system—causes low blood pressure and collapse.

Internal bleeding—similar mechanism to dehydration. Ulcer, ruptured abdominal aortic aneurysm (the aorta is the major artery leaving the heart and descending along the spine. An aneurysm is an enlargement of the vessel, is under increased wall pressure, and can rupture).

If there are other details that might aid in tailoring the scenario, please let me know!

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

 *Photo courtesy of Photobucket/amoore36846*