QueryTracker Blog

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Thursday, March 12, 2009

Your Medical Fiction Questions Answered

Got a burning medical question to give your novel authenticity? As in my previous Medical Fiction post, I'll be answering a couple of medical writing questions today.

Disclaimer: The information provided in this post is intended for writing purposes only and does not represent medical advice. (Sorry, my lawyer-boy husband made me say that.)
First, from Stina:

Hi Heather,


I have a medical question dealing with something my character goes through in my novel.


The seventeen year old starts to have heavy uterine bleeding. Now there’s no real medical reason for it (fantasy element to the novel), but I was wondering what kinds of tests they would run in the hospital and as an outpatient. Also, in what kind of time frame would they occur? She is unconscious when admitted. She isn’t pregnant, though her friends thought she was, and thought she was suffering a miscarriage. She loses a fair amount of blood (nothing life-threatening but it is serious), and is hospitalized. The bleeding doesn’t last for long and it doesn’t start up again. How long would she be hospitalized for? Other than pain killers (she was in immense pain when she passed out), would she be on any other medication?


Thanks for your insights. It’s greatly appreciated.


Stina


Well, your character's friends were definitely right to consider pregnancy (and not just miscarriage, but also ectopic pregnancy) as a possible explanation. But there are a lot of other issues to consider. Creating a list of possible explanations for a patient's symptoms is called a differential diagnosis, and this one would be fairly long, so it's easier to break down by category.



1. OB including pregnancy, miscarriage, ectopic pregnancy

2. Gyne including polycystic ovary syndrome, cervical or endometrial polyps, endometriosis

3. Infectious including sexual transmitted diseases such as chlamydia or gonorrhea

4. Endocrine (hormones) including hypothyroidism or diabetes, as well as any number of issues with the various hormones that control the menstrual cycle.

5. Bleeding disorders including clotting disorders such as Von Willebrand, platelet problems such as ITP. This could also include overdoses or exposure to medications that affect clotting, such as aspirin, warfarin (commonly found in rat poison), etc. Liver disease could also lead to bleeding disorders.

6. Cancers including cervical cancer, leukemia

7. Trauma (such as due to rape or rough sex play with damaging objects)



Now, the fact that she's unconscious when she comes in complicates things quite a bit. Why is she unconscious? Because of the blood loss? Because of the supernatural element at work? If she was really unconscious due to blood loss, she probably wouldn't be out for very long... a few seconds to a minute maybe. And she would respond quickly to things like IV fluid and medications that raise blood pressure. If she'd lost enough blood to be out longer than that, she'd be coding... i.e. she'd stop breathing, heart might stop, etc. If she was unconscious and not actively coding, she would at least buy herself a CT scan presenting this way, because uterine bleeding doesn't explain unconsciousness in a patient with relatively stable vital signs.


To evaluate a patient like this, the doctors would most likely obtain bloodwook to check the level of bleeding that had already occurred, to see the response her body had to the blood loss (i.e. was her body working hard to replace the loss? Had it been going on for a long time?) and to check her ability to clot. This would also serve as a screening test for leukemia, and they would want a pathologist to look at the blood smear to look for abnormal cells. Other bloodwork would probably be done to check hormone levels.


A pregnancy test would be an absolute must.


Once she regained consciousness, they would ask her a detailed history regarding her sexual activity, drug use, prior STD's, etc.


They would do a speculum exam, looking for lesions on the cervix (cuts, warts, polyps, etc.) and test her for GC/Chlamydia


Assuming they didn't find any specific source for the bleeding or infection/cancer to treat, they

would probably assume this was related to hormone balance and would start her on progesterone or birth control pills to regulate her bleeding.


Naturally, if she lost enough blood to have symptoms (meaning she's extremely fatigued, out of breath, etc. from the blood loss) they would have to transfuse her. But they would be very cautious about doing that... uterine blood loss in an otherwise healthy adolescent patient is extremely unlikely to reach a fatal level, and in addition to the risks associated with a transfusion, giving blood products would make some of the blood tests invalid. Unless it was a real emergency, they would at least be sure they'd obtained all the bloodwork before transfusing.


If her pain was well-controlled, she was otherwise well, she would probably be discharged a day after the bleeding stopped.


Hope that's helpful, Stina. Thanks for pitching in your question!


Our next question comes from Kathleen:



Hi, Heather! First, let me commend you and the other QT ladies and
Patrick on what you're doing with the blog. It's a must-read for me
daily. :-)

I have a medical question for you about stitching wounds:

In a contemporary wilderness setting, a man falls and bangs his head
on a rock -- hard enough to knock him out and leave a significant gash
through his eyebrow. Would a veterinarian who is reluctant to do
anything at all (for thoroughly non-medical reasons) stitch the wound
two or three days later (the first opportunity she has), or would the
gash have healed enough on its own by then to make stitching a waste
of time (or too difficult to attempt unless one is a plastic surgeon)?
The injured man won't be getting to a hospital in the foreseeable
future. In fact, he and the vet are trapped in the wilderness, but the
vet has her medical bag with her.

I realize there are concussion and cosmetic issues. The concussion is
dealt with, and appearances aren't a concern. I'm just curious how a
dedicated medical professional, even though she doesn't treat humans,
might approach the injury. (I'm also curious to know whether I've used
enough parenthetical remarks in this email. Cuz, yanno, I can add some
if not. :-D )

Thanks for any insight you can provide! And thanks to both of you QT
docs for offering to provide medical insight. I hope both of you
realize what a boon that is to your fellow writers. :-)

Best,
Kathleen


Aw, gee, shucks, Kathleen. Thanks!

Yours is a fairly straightforward question to answer. At the time frame you mention, stitches would not be indicated. A wound needs to be stitched as soon as possible after the injury. This is not just to help with healing and the cosmetic appearance, but a stitch represents material that is foreign to the body. Any foreign body has a chance of getting infected under the best of circumstances, but a wound left to its own devices for several days would be far from clean. Passing a suture through the wound and under the skin would be introducing pockets of infection and giving them a nice place to thrive.

And, yes, by three days, the wound would probably be fairly well healed on its own (the eyebrow area doesn't have a lot of room for a deep gash, so I assume it's shallow enough to have scabbed over by this time.

So, your veterinarian is off the hook!

Thanks for a great question!

Big to Kathleen and Stina!

And if you have a medical fiction question, you can still email me for future posts. My email address is in the sidebar.

H. L. Dyer, M.D. writes women's fiction and works as the Clinical and Academic Director for the Hospitalist Program at a pediatric teaching hospital near Chicago. In addition to all things literary, she enjoys experimental cooking and composing impromptu parodies to annoy close friends and family. Click to visit her personal blog, Trying to Do the Write Thing.

12 comments:

Stina Lindenblatt said...

Thanks, Heather. That was extremely helpful. This is the kind of info that's difficult to google.

I'm off now to do some editing based on your info, and to dwell on some other possibilities that this has created.

disorderly said...

**groan**

Heather, you didn't just write "off the hook," did you? Don't docs use hook-shaped needles for stitching? Bad puns can sneak up on a person at the weirdest times.... :-D

Thanks for answering my question! It's always nice to have one's suspicions confirmed by someone who actually knows what she's talking about. :-)

Stina Lindenblatt said...
This comment has been removed by the author.
Stina Lindenblatt said...

Hey, Heather. Your answer hit a few plot points that resulted in a couple more questions.

My MC was raped a year ago after she ingested a date-rape drug. She never reported it nor did she go to the hospital. Her mother was an emergency room nurse there (only hospital in town), though she wasn't working that shift. The MC didn't want her parents to know what happened.

Now if the ER physician (who will naturally know the MC) asks her if she was rape, will he or she be required to report it and, since the character is only 17, will he have to tell her parents?

Also, is it right to assume that after a year any physical trauma she experienced would now be healed? Of course STD might be an issue, but at least now she'll have some answers there.

Thanks again for your wisdom. No wonder I just love this blog. It's definitely the best writer's blog around. :D

H. L. Dyer said...

*snort*

No pun intended, Kathleen. We do use curved needles, but I wouldn't have thought of them as "hooked". It's a gentle curve, like a crescent moon. ;)

Stina:

Your new question brings up an important point that I find many people don't know: most states allow adolescents to seek confidential treatment without their parents consent for certain conditions.

In Illinois, adolescents have a right to confidentiality for treatment related to sexual activity (such as STD treatment, pregnancy, etc.) and drug/alcohol use or abuse.

I would be very surprised, though, if your MC 'fessed up about the rape. Most adolescents lie when you ask their histories, and if she's already hiding this from her parents, unless she has a pretty amazing personal connection with the ER doc, she probably wouldn't spill the beans now.

As far as trauma goes, you're correct. It would have to be a recent trauma to cause the bleeding.

And, shucks! *blush*
I'm so glad you're finding our blog helpful. =)

Stina Lindenblatt said...

Thanks, Heather. So if there's no physicial signs, then she can keep on lying. Perfect. You're a life-saver.

Archetype said...

Hey, I didn't realize you were going to answer more questions today -- cool!

H. L. Dyer said...

I didn't either, Archy. I had something else planned originally, but I had these great questions and I didn't want to keep folks waiting... =)

Stina Lindenblatt said...

Believe me, Heather, us folks are sure glad you didn't wait. Of course now I'll be spending my weekend rewriting several scenes. But I'm definitely not complaining. And now my MC won't lose consciousness at any point. I had a feeling that was a little extreme, but it was an easy out for ending a chapter :D

Thanks again!

Marva said...

On the first question about heavy bleeding: How about uterine fibroids? I think palpation of the uterus might answer that, but maybe an MRI would be needed?

H. L. Dyer said...

Hi, Marva!

Uterine fibroids could, indeed, cause dysfunctional bleeding (and would fall under "Gyne") but would be very uncommon in a 17-year-old patient.

An MRI would not likely be the first step in diagnosis (although if you had already demonstrated an abnormal growth in the uterus, an MRI might be done for a more detailed image). An ultrasound would probably be the first screening test.

Suzette Saxton said...

Aaaaaahhhh, fascinating reading!