Your Medical Fiction Questions Answered 2/15/10

Okay, gang... the Doctor is IN!

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

Hello

I saw in the Query tracker members who can help with research topic that you could help with medical problems with children.

Can a fall down a flight of steps at the age of 3 cause a brain injury severe enough to impede a child's educational progress, but not any physical problems?

I appreciate your help.

Cheermom

Well, Cheermom, that's an interesting question. If I was evaluating a 3-year-old after a fall down the stairs, here is how the evaluation would go:

I'm assuming that a fall significant enough to cause permanent damage would result in paramedics being called. They would assess the child's breathing and heart function (and if the child wasn't breathing, would need to intubate the patient). They would apply a c-collar to protect for a potential broken neck. They would take the patient to the hospital where (s)he would have a CT scan to look for bleeding in the brain.

If the patient was not breathing after the injury, this could result in inadequate oxygen to the brain, which could also cause permanent problems.

After a significant brain injury, the child would be at risk for seizures, which could contribute to educational problems for several reasons:

• a prolonged seizure could also result in the patient not receiving enough oxygen
• seizure medications (especially when more than one medication is necessary) can make patients sleepy, which can interfere with their functioning
• frequent seizures can impair learning due to missing the time during and shortly after the seizures.

Head injuries can be quite tricky in regards to symptoms. Traumatic brain injuries can be extremely dramatic or quite subtle. For example, a patient may simply have trouble remembering numbers or retrieving the correct word. The brain is an extremely complicated organ and the exact details of how it works are still not completely understood.

That said, children are extremely resilient creatures. A brain injury in a young child will be much better handled than in older people, as their ability to adapt is much higher.

So whatever injury occurred in this child would have to be fairly serious to cause lasting damage. For example, the fall would probably have to be enough to knock the child unconscious. A head injury that does not cause loss of consciousness generally will cause no permanent damage whatsoever.

It is absolutely possible, though, that the patient may have long term subtle problems that could interfere with his or her educational progress, without causing obvious physical problems. It would also be possible that (s)he may suffer from subtle physical problems as well... such as clumsiness due to decreased balance or problems coordinating their eye movements, resulting in impaired depth perception.

I hope this information is helpful. With a significant head injury, you have a lot of room for plausibility in regards to what problems your character might have. The only limitations, really, would be in regards to some of the physical problems... the motor centers of the brain are mapped out next to each other down a little wedge on the right and left sides of the middle of your brain (the right side of the brain controls the left side of the body and vice versa), so the problems there would have to be continuous (like you wouldn't expect a weak right hand and a weak right foot to be caused by the same injury, unless there were also problems with everything in between.)



Good luck, and thanks for the question, Cheermom!

Remember, if YOU have a medical fiction question, email me at hldyer at querytracker.net and include "medical question" in the subject title. You'll receive an automatic reply confirming that your question has safely arrived in my email box.

Medical Fiction Questions Answered 1/11/10

Okay, gang... the Doctor is IN!

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

Heather,
I saw your post on Query Tracker how you answer medical questions for fiction. So interesting!

I have a question for you. How would a doctor diagnose retrograde amnesia and how would a patient act or think with this type of amnesia?

Thanks and I really loved your website too.
Christy

Ah, amnesia! That's a great topic for conversation in the land of fiction.

Basically, there are two kinds of amnesia... anterograde and retrograde. A patient may suffer from one or both, depending on the circumstances.

Retrograde is RETRO, meaning backwards in time. A patient with retrograde amnesia has lost memories or information from before the insulting event.

ANTERO, as you may have guessed, means forward. A patient with anterograde amnesia has trouble forming new memories or storing new information, and therefore loses information from after the insulting event.

These losses may be temporary or permanent, depending on the injury or insult involved.

For a patient with a head injury due to a sledding accident, for example, they might remember talking about going sledding and getting dressed for the snow and the next thing they might remember is lying on a gurney in a hospital emergency room. They may be confused for several hours or even days afterwards, and ask questions several times over again, having forgotten the answers or that the question had already been asked. They may have no memory of sledding at all, let alone the accident, or the paramedics arriving, ambulance ride, etc. This would be a mixture of anterograde and retrograde amnesia, as the patient would have lost memories from both before and after the event.

Someone with a significant traumatic brain injury, might have anterograde amnesia symptoms on a permanent basis. Patients with Alzheimer's disease often suffer from anterograde amnesia symptoms, becoming less and less able to make new memories, and then moving into retrograde amnesia and losing past memories as well.

Regarding your question of a pure retrograde amnesia, this suggests the common plot device in movies and television stories where the victim suffers a head injury and suddenly forgets everything about their own pasts, including their identities. This is actually extremely unlikely to happen. Even patients with devastating retrograde amnesia generally maintain their sense of identity. And even less likely is the common "remedy" displayed in the media where a second trauma restores the lost memories.

In reality, retrograde amnesia is typically limited to a relatively brief period immediately before whatever insult caused the loss of memory (which could be a brain injury-- either through head trauma, or oxygen deprivation, a seizure, drug and/or alcohol exposure, and any experience that could cause loss of consciousness). Longer periods of time may be lost in the case of repeated exposures to physical/psychological traumas, as in the case of severe child abuse or sexual abuse, due to a defense mechanism called repression.

For diagnosis of amnesia, the physician would primarily rely on the patient's history, as obtained by talking to the patient and his or her family and friends (if available), as well as simple tasks to evaluate the patient's ability to remember new things (such as giving the patient a string of numbers or a random trio of words to remember).

As far as how the patient would act in this situation, this would widely depend on the extent of the memory loss and whether or not there was a co-existing anterograde component. If they were coherent enough to realize they were suffering from memory loss, they would likely be frustrated and possibly embarrassed. They may try to avoid situations that demonstrate their weaknesses. For example, a patient who had trouble remembering words, may avoid talking in public or to strangers.

Amnesia is a fascinating problem, but can be very tricky to deal with in a realistic manner when writing fiction. I hope this information is helpful, and I wish you the best of luck!

Remember, if YOU have a medical fiction question, email me at hldyer at querytracker.net and include "medical question" in the subject title. You'll receive an automatic reply confirming that your question has safely arrived in my email box.

Medical Fiction Questions Answered: 08/12/09

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 makes me say that.)

Hi Heather,

I have character related medical questions (and whoa, very nice to have you as a resource. The QTBlog is awesomesauce!):

Can a school nurse run blood work if requested? What would the nurse check for automatically? Would the nurse screen for drugs? Pregnancy? How would a school verify drug use?

What tests would be run for headaches? MRI? CAT scan? Both? Would the same tests be used for visual hallucinations? Are there different tests for auditory hallucinations--or are all hallucinations covered by say MRI and CAT scans? How else would you diagnose the cause of hallucinations? Could a doctor render a proper diagnosis if information is being withheld, e.g., the character claims headaches, not hallucinations. When might a psychiatrist be called in? If the character admitted seeing things (say, within the context of a therapist visit), what anti-psychotic medications might be prescribed?

Any light you can shed would be greatly appreciated.

Regards,

Ctairo

Wow, Ctairo... that's a lot of questions!

Let's take them one at a time:

Q: Can a school nurse run blood work if requested?

A: Not usually. At least not easily. Most school nurses have very limited resources, and they certainly wouldn't be able to run the blood tests themselves on the premises. So, since any tests would be sent out anyway, what would usually be done is the nurse would simply refer the student to their physician or a clinic or, in an emergency, to a hospital. Also, most lab tests must be ordered by a physician or nurse practitioner, and very few school nurses have that level of training.

Q: What would the nurse check for automatically?

A: I'm not sure what you mean by this, but a school nurse wouldn't typically check for much. She would treat minor illnesses, help students administer their home medications, etc. But diagnostic testing does not typically play a big role in school nursing offices.

Q: Would the nurse screen for drugs? Pregnancy? How would a school verify drug use?

A: Depending on the school facilities, it's possible the school would have the capability to offer pregnancy testing (which is a simple urine test). Drug testing can be done with a simple urine test as well (which usually tests for marijuana, cocaine, opiates, barbiturates, amphetamines, and PCP) and some high schools do perform drug testing, but most require parental consent first and reasonable cause to request them (unless they are required for, say, participating in sports). You would need to research the school district rules in the area your story is set.

(I'm assuming the rest of your questions refer to evaluation in a clinic or emergency room.)


Q: What tests would be run for headaches? MRI? CAT scan? Both?

A: There aren't many tests done for headaches, actually. The first step would be to take a thorough history of the headache. Where it's located, the duration, associated symptoms, aggravating factors, alleviating factors, etc. They would also do a neurological evaluation, including vision. The vast majority of headaches can be diagnosed with just a history and physical.

If the headache was suspicious or unusual in some way, or associated with, say, vision changes or seizures or a head injury, they might do some imaging studies. A CT scan is often done first, since it's quicker and cheaper. A CT is always the best choice for trauma, as it shows blood better than an MRI.

An MRI is better for something like a brain tumor or a stroke.

Neither of these tests would be routinely ordered for someone with just a headache.

If the patient had a fever, or neck stiffness, or mental status changes (or if their retinal exam showed something called papilledema), they might need to do a spinal tap to check for meningitis, encephalitis, or a condition called pseudotumor cerebri.

Q: Would the same tests be used for visual hallucinations? Are there different tests for auditory hallucinations--or are all hallucinations covered by say MRI and CAT scans? How else would you diagnose the cause of hallucinations?

A: Like headaches, hallucinations are first evaluated by a careful history (meaning what the patient can tell you about the problem under questioning) and physical evaluation. There's a nice chart here of some types of hallucinations (by history) and the possible explanations for them.

Q: Could a doctor render a proper diagnosis if information is being withheld, e.g., the character claims headaches, not hallucinations.

A: That would greatly depend on what the diagnosis was. Some problems, like meningitis or a brain tumor, have very specific findings. Many other problems rely on the history for diagnosis. How much influence the patient would have over his or her diagnosis would also depend on their level of function. For example, someone with severe schizophrenia may not be able to appropriately identify or describe their hallucinations, but their behavior might suggest them to the evaluator, as their ability to hide their symptoms would be poor.

Q: When might a psychiatrist be called in?

A: A psychiatrist would be called in if an evaluation for other causes was negative, or if other signs or symptoms suggested a psychiatric diagnosis.

Q: If the character admitted seeing things (say, within the context of a therapist visit), what anti-psychotic medications might be prescribed?

A: That would depend on the diagnosis following a psychiatric evaluation. A chart of some diagnoses and the recommended treatments can be found here.

I hope you find this information helpful. Our resident psychologist, Carolyn, may have some additional helpful suggestions for you, too. ;)

ETA: And, indeed, she does! Here's Carolyn's thoughts:

Great questions, and great answers! All of Dr. Dyer's disclaimers apply to what lies below:

The possible benefits of anti-psychotics (also sometimes called neuroleptics) must be measured against the possible side effects, so the psychiatrist or physician would want to be pretty sure the character is psychotic (ie having hallucinations and/or delusions) before prescribing them. Anti-psychotic medications can have long-term side effects including sedation, weight gain, and the possibility of developing what are called "extrapyramidal side effects" -- small, involuntary movements of the lips and tongue, muscle rigidity, and internal restlessness.

The classic antipsychotics, which you often hear named in movies, are most likely to have these side effects (ie Haldol, Thorazine). Atypical antipsychotics are used much more often, and present a lower risk for extrapyramidals -- Risperdal, Zyprexa, Seroquel, and Geodon. Abilify is also sometimes used -- it has the fewest side effects. (Abilify is kind of a controversial drug right now. The research that says it works seems to be biased. Not unusual, unfortunately.)

Someone who is having hallucinations could have several different diagnoses, including schizophrenia or bipolar disorder, which is also called manic depression (some people hallucinate as part of mania or, even more rarely, as part of a devastating depression).

If the person has bipolar disorder, a clinician is going to notice. People who are manic tend to talk too fast, make bad decisions, feel euphoric or aggressive, and think the whole time that there's nothing wrong with them. People who are devastatingly depressed talk slowly, move slowly, seem sad or angry, and bring a heaviness with them where ever they go. People who have schizophrenia don't just have hallucinations and/or delusions -- they also have strange thought patterns and mannerisms. The disorder is very difficult to hide. Finally, there's something called a brief psychotic disorder that can be triggered by extreme stress. It has to last more than one day but less than a month and can include the symptoms of schizophrenia, but it resolves itself without turning into schizophrenia. All of the links above will take you to more information on the disorders.

It's also possible that hallucinations could be caused by drugs, which would certainly be a consideration in someone who was school-aged.

Hope that's helpful!

Remember, if YOU have a medical fiction question, email me at hldyer at querytracker.net and include "medical question" in the subject title. You'll receive an automatic reply confirming that your question has safely arrived in my email box.

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.

More Medical Fiction Questions Answered

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 Cole:

My MC has lacerations across her neck and shoulder, presumably from a shark. These lacerations, while deep, only exposed her collarbone, but did not damage to the bone. What treatment would she be given in the hospital, and what would her at home care instructions be? Ointments? Oral antibiotics? (I’m assuming she can’t get her wounds wet?)

I must confess that, as a pediatrician in the Midwest, I don't see too many shark bites. But with any bite, there would be concern for infection. The interesting point to consider here would be that the victim would presumably be immersed in sea water during and after the injury, which puts some other unusual organisms into the mix. Most certainly, the wound would be flushed with sterile fluid. She would also receive antibiotics. If the wound was concerning enough, they might give the antibiotics by IV or by a shot (IM).

Depending on how the wound looked, they might decide to close the wound (if the wound looked very clean and they had good access into the wound to clean it out). If they were concerned about infection, though, they might choose to let it close on its own. In that case, they might pack the wound.

Packing a wound involves stuffing a length of thin (like a shoelace), medicated gauze into the wound with the end trailing outside the wound to provide a wick for the infection to drain out of the body. The packing is removed and replaced periodically until the wound is healed enough that there's nowhere left to pack.

And, yes, she'd be told to the wound out of water. And away from sharks. =)

Next, we have a question from Robyn:

In my MG novel I have a story about two thirteen year old girls lost with their horses in the Blue Ridge Mountains.

Now towards the end of the book they meet up with a rabid bobcat. The animal attacks the protag and bites her, cuts her all up, etc. you get the picture.

My question is, how long before the affects from rabies will kill her? I don't want to kill her so I need a time frame here in which to get her rescued. And what physical problems will she have from the rabies? She is also a type one diabetic,(Poor girl). Does she have days? Just hours? Will she be nauseous? Things like that.

Rabies is a strange virus, and I'm not sure it will work well for your story, since it seems you want her to have symptoms, but you also want her to recover.

Rabies is a virus. It has an incubation period that can range from a few days to years, but the average incubation period is somewhere in the neighborhood of a few weeks (20 to 90 days). During the incubation period, the victim has no symptoms of rabies.

To cause symptoms, the virus has to travel through the nerves to the spinal cord and then begins to affect the rest of the central nervous system. The more wounds there are and the closer they are to the brain and spinal cord, the faster symptoms will show up. Since your protagonist suffered multiple bites, she would probably show symptoms within a month.

But here's the catch... by the time someone shows symptoms of rabies, it's too late. If they don't receive the prophylaxis meds during the incubation period, they will die from the disease with rare exception. There have been a handful of cases where a patient has survived, but they are extremely rare and the patients have serious long term consequences.

The first case documented of someone surviving rabies without prophylaxis was in 2004. You can read about that girl's progress and disabilities here.

That said, the progression of rabies goes like this:

• Incubation period (days to years)- No symptoms
• Prodrome period (2 to 10 days)- vague symptoms including fatigue, headache, sore throat, decreased appetite, and fever. They might also have pain or parasthesia (tickling or pins-and-needles sensation, etc.) around the wound.
• Neurologic period (2 to 7 days)- speech problems, incoordination, paralysis, twitching or jerking movements, altered mental status.
• Late stage: coma, low blood pressure, irregular heart rhythm, heart attack, DIC (diffuse bleeding problem), and death.

And, wow! Lost in the wilderness with juvenile diabetes and bobcat wounds... you have certainly given your protagonist plenty of challenges!

Thanks to both Cole and Robyn for contributing some great questions!

If YOU have a medical fiction question you'd like answered, please email me. My email address is in the sidebar.

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.

Weekly Roundup

Jungle Red Interviewee

If you're a mystery fan, check out Jungle Red Writers, which is run by six published mystery writers. They regularly interview authors and other insiders, and today's interview guest is...me! Please do stop by and ask questions if you have 'em!

Ask the Doctors

If you didn't get a chance to ask pediatric hospitalist physician HL Dyer your medical/writing question, you can use her email address at right or drop by her blog and ask there. If you still have psychology/writing questions, please get them to me via my email (ckaufman) to the right! I'll be answering some of the questions next Tuesday.

Tips on Submitting From Agents

Some great tips from agent blogs around the web:

• More Story, Less You by Nathan Bransford
  
• Write Your Own Query Letter by Janet Reid
  
• What Not to Say in a Query by Rachelle Gardner
  
• The Art of the Synop by Kristin Nelson
  

New Agents

The following agents were recently added to the QueryTracker.net databases:

• Willy Blackmore (Bliss Literary)
  
• Sandra Bishop (MacGregor Literary)
  
• Ann Collette (Helen Rees Literary)
  
• Katie Grimm (Don Congdon Associates)
  

Have a great weekend, everyone! We're looking forward to seeing you next week!

Your Medical Fiction Questions Answered

Got a burning medical question to give your novel authenticity? I asked our readers for questions to discuss here on the QueryTracker.net blog and, as promised, 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, we have the following series of questions from Diana (some details removed):

I'm working on a narrative non-fiction piece about a real murder that happened in Burlington, Kansas in 1925. The husband allegedly comes home to find his wife, a 31-year-old farm woman, dead on the floor. Pretty gruesome.

Because of some rumors that surfaced, the woman's body was exhumed three days after she was buried (and five days after she died, which was on May 30). They were verifying whether or not she had been sexually assaulted, and whether or not she had ever had an abortion.

Here are my questions, from the perspective of 1925 medicine:

1. What would the doctor doing an autopsy on an exhumed body look for to determine if a woman had been raped?

2. What condition would the body be in at this point?

3. What signs would a doctor doing an autopsy look for to determine if an abortion was performed?

I'm afraid I can't tell you too much about the 1925 perspective, as my grandparents were all less than 6 years old in 1925. And of course, forensics is not my area of expertise, but I will do my best to answer.

I'm not sure how the fact you're writing narrative non-fiction plays into things, as I would assume that the evidence you describe would have to be accurate to what was actually found during the investigation. But taking these questions as for a fictional scenario:

1. The evidence they'd be looking for would be evidence of sexual activity, which would include checking for pubic hairs not belonging to the victim, and at 5 days, given the fact the woman had died (and therefore was not upright, moving, bathing etc.) they might still find living sperm (although 5 days is pushing that limit). They might also test for acid phosphatase, which can be used as a screening test for semen. As far as evidence of rape, specifically, they'd be looking for evidence of trauma, bruising, tears, etc. Often times, it can be hard to tell the difference between rape and consensual sex on the basis of forensic evidence alone. Aside from the fact they'd have no DNA analysis available, I'm not sure how much the 1925 angle would affect the available investigations.

2. The condition of the body would be somewhat dependent on the weather conditions to which it was exposed. Typically, over the first 2 - 3 days, the body appears grossly intact, but by the time in question decomposing would have reached the putrification stage. The body's bacteria starts breaking it down, causing green discolorations and bloating of the tissue. The green color comes from partially digested hemoglobin (blood protein). The bloating is caused by gases released by the bacteria.

3. Regarding evidence of a prior abortion, the doctor would be looking for evidence of instrumentation, such scars or marks from a clamp on the cervix.


Our second question comes from Susie:

My MC is a thirteen year-old girl. She 's on a ladder, standing about four feet off the ground, when she looses her footing and falls, landing with the full weight of her body on one shoulder. Would this impact be enough to snap her collar bone? Would she be able to get up by herself after this had happened? Would she still be able to walk around and act semi-normal, hiding the fact that she'd broken the bone? Would it hurt if someone hugged her? What would treatment for this type of injury be?

A fall of four feet, at the right angle, could certainly fracture her collar bone. While painful, a fractured clavicle doesn't really impair activity as much as you might expect.

After a clavicle fracture, the shoulder typically sags forward and down. She would have trouble lifting the arm due to the pain, and may feel grinding in the shoulder if she tried.

She probably wouldn't be able to push herself up with the injured arm, but she should be able to get up by herself. She definitely would be able to walk around, and if motivated, could probably hide the fact that she'd been injured, depending on what she was wearing (the displaced bone can often be seen as a lump under the skin.) and her pain tolerance.

It would, indeed, probably hurt her if someone hugged her.

Treatment for a fractured clavicle consists of pain control and immobilization (for comfort, mostly) with a sling or figure-of-eight strap. Right after the injury, ice would help as well. After 4 - 6 weeks, she would have to start working on range of motion exercises for her shoulder to regain normal strength and movement in the joint.

So, BIG thanks to Diana and Susie for submitting your questions for discussion. I hope my answers will be helpful for your writing projects.

I will continue to accept medical fiction questions for future blog discussions. You'll find my email address in the links listed on the right. Or you can reach me through my personal blog, Trying to Do the Write Thing.