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Wednesday, July 8, 2009

Medical Fiction Questions Answered: 07/08/09

Okay, gang... the Doctor is IN! More medical fiction questions...

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 a question from Sandy:

Hi there,

Got a medical question for you. I have a guy holding a knife to my MC’s neck. As he’s threatening to kill her, he applies more pressure. Since this is my MC, I don’t want her to die or be severely injured, but I do want her to bleed a lot and think she’s dying. Is it possible for there to be a lot of blood without cutting something important like an artery or her windpipe?

Thanks very much!

Good news, Sandy! You absolutely can do this. The neck is actually quite complicated as far as anatomy goes... there are lots of blood vessels, nerves, and muscles, in addition to your windpipe and thyroid/parathyroid glands.

A cut to the neck can certainly cause severe injury or death, but there are also blood vessels that, while they could cause significant bleeding if injured, wouldn't be fatal.

For the purposes of the scenario you described, the best vessel to injure in this fashion is probably the external jugular vein. It's not deep under the skin, so it would be quite easy for your villain to injure.

So you'll probably want your villain to press the knife off to one side. As you can see from the picture, the middle is where you could injure structures like the windpipe. Also, the thyroid gland sits right in front of the windpipe at the midline. You'll also want to make sure your villain doesn't cut too deeply, or he could hit the carotid artery, which would cause your MC to rapidly bleed out.

So, go for the jugular, Sandy! *snort*

Our next question is from our resident dynamic duo, Lisa and Laura:

Ok, let me just start off by saying that you are a God-send. Laura and I were on the phone tonight discussing this question and it went something like this:

Lisa: Yeah, I don't know, let's google it.

Laura: Nothing. They don't say if this kind of pill would actually exist.

Lisa: We need to ask a doctor. How do I not have any doctor friends?

Laura: Wait! The Query Tracker blog totally has the doctor that answers questions.

Lisa: OMG - you're right. Composing e-mail now.

So, thanks in advance for any insight here.

We have a character in our book who dies from a heart attack. She has a congenital heart defect and had a surgery when she was very young, but still takes medication on a daily basis to keep things under control. Is there a medication that would prevent a heart attack if she felt the symptoms coming on? In the book we have her running from someone, went to get her medication, couldn't find it and died. Are we complete idiots? If so, feel free to inform us of that fact.

Thanks in advance for any help you can provide!
Hmmm... I have to answer this question two ways. Which seems, somehow, appropriate.

First of all, there is indeed medication that can prevent or reduce the severity of a heart attack. The most commonly referenced one would be nitroglycerin, which relaxes the blood vessels of the heart and allows more blood to reach the area that's deprived. Aspirin can also help by breaking up clots that might be blocking one of the cardiac vessels.

Which leads me into a brief discussion of what a heart attack is, exactly, in case you don't already know.

A heart attack is also called myocardial infarction. "Myocardial" means heart muscle and "infarction" means death or injury due to inadequate blood flow. So what's happening during a heart attack is for some reason the heart muscle itself is starved for blood. Part of the heart muscle may die from this, making the heart too weak to pump, or the damaged tissue may cause the heart to go into an abnormal rhythm.

There are many different congenital cardiac defects, but the vast majority of them would not be likely to put this patient at risk for a myocardial infarction. In fact, the most common cause for a young person to have a myocardial infarction (ignoring extreme familial high cholesterol or drugs such as cocaine or methamphetamine) would be one of the heart blood vessels coming off the wrong artery and delivering DEoxygenated blood to the heart muscle instead. Someone with a congenital heart problem would be LESS likely to have this problem, as they would have gone extensive heart evaluations, including 2D-echo (an ultrasound of the heart) as well as cardiac catheterizations (where they pass a camera through the blood vessels to look at them) and direct examination during her surgery.

If you want to give her a congenital heart condition that requires surgery and might give her a heart attack years later, your best bet would be a transposition of the great arteries. In that condition, the artery that usually goes to the lungs and the aorta, which usually goes to the body are switched. So the deoxygenated blood is running around in one circle and the oxygenated blood in another. The patient only survives birth if there is a hole in the heart that allows the two to mix.

The surgery to fix this involves literally cutting and switching the arteries, but depending on where the blood vessels that feed the heart are, they may end up kinking down the line.

I'm not sure that your character NEEDS to have a heart attack. Having had any sort of cardiac surgery could make her more likely to develop an abnormal heart rhythm, which can also be fatal.

Unfortunately, the medications used to treat an emergency arrhythmia are given through a vein, rather than as a pill. It takes 10 - 15 minutes to absorb a medication through the stomach. Arrythmias can also be treated with electric shock, but someone else would have to administer it.

There is a specific form of arrythmia, SVT (supraventricular tachycardia) that can sometimes be stopped by applying ice to the face or by "vagal maneuvers," such as blowing hard into their thumb (like they were trying to blow themself up like a balloon). This arrythmia can degenerate into other more serious rhythms if not corrected. (But unless she doesn't know where the freezer is, this doesn't give her much to search for either.)

I'm not sure what will work best for your story, but I hope that helps!

Big thanks to Lisa, Laura, and Sandy for sending in questions. And if you've got a medical fiction question you'd like me to answer here, please email me (hldyer at querytracker.net) with "medical question" in the subject. You'll receive a email auto-reply confirming that your question has arrived safely to my inbox.

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.


Lynnette Labelle said...

Great stuff and good to know. Thanks.

Lynnette Labelle

Stina said...

Yay! I love the medical question/answer posts. Wow, I even knew some of the answer to Lisa and Laura's question. Looks like all those years of promoting cardiovascular drugs did have some benefit after all. Loved the first question, btw. Interesting stuff.

Can't wait for the next questions.

writtenwyrdd said...

Great stuff! Thanks for sharing.

I have a question for you: Will exsanguination change the timeline for rigor to set in?

It probably sounds like an odd question, but I'm writing a vampire story and I was toying with the idea of rigor onset being change or stopped by a vampire's killing a person, and wanted to double check for any reason that might alter or stop rigor onset. Any thoughts on that?

Michelle D. Argyle said...

This is some awesome information, so thank you so much for your time. This blog is such a great resource!

Alyssa Kirk said...

I'm new to the blog so didn't know about the treat of getting medical questions answered. This is great. Thanks Dr. Dyer!

Rebecca Knight said...

You rock, Dr. Dyer! I might have to use that neck thing one day. That was gross, but incredibly informative :). Thanks!