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.

The Semicolon

Last month, I blogged about the proper use of quotation marks.  Several people contacted me asking for a similar post regarding the use of semicolons. Well, here we go!

The semicolon (;)

As always, I'm addressing punctuation used in non-technical, non-academic writing for publication in the United States.  As I mentioned in my post on the quotation mark, there are some differences in conventions from one country to the next.

As opposed to the comma, the semicolon is a fairly easy to get right because it has clear rules. 

I'm only going to discuss the three most common uses of the semicolon.  For a more detailed description, I recommend Strunk and White's The Elements of Style and The Chicago Manual of Style.

1.  Semicolons are used to link two complete sentences (independent clauses) that are closely related.  A period can be used, but the semicolon strengthens the meaning.  

Correct:      Suzette finished her manuscript today; she had been working on it for a year. 

Correct:      Suzette finished her manuscript today.  She had been working on it for a year.

Incorrect:   Suzette finished her manuscript today, she had been working on it for a year.  

(The third example is a comma splice since the clauses are independent. A big no-no.) 

2.  Semicolons are used to link two complete sentences with a conjunctive adverb (some common conjunctive adverbs are therefore, however, anyway, consequently). 

Correct: Carolyn and Heather received revision suggestions from agents; consequently, they                           are writing like mad.  

Incorrect: Carolyn and Heather received revision suggestions from agents, consequently, they                           are writing like mad.  

The link for conjunctive adverbs in rule 2 above goes into greater detail and gives more examples of correct and incorrect usage. 

What causes problems is that a semicolon is not used when the independent clauses are joined by a conjunction (but, and, or, so nor etc).  A comma is used. 

Correct:     Elana returned to her classroom to retrieve her purse, but her room was locked.

Incorrect:  Elana returned to her classroom to retrieve her purse; but her room was locked. 

3.  Semicolons are used in a series that would usually be separated by commas, but one or more of the items in the series has a comma in it.  

Correct:    Some of my favorite books are Dune, by Frank Herbert; The Summer Guest, by Justin Cronin; and The Thirteenth Tale, by Diane Setterfield.  

There are other uses for the semicolon, but they occur infrequently and are most often optional.  I recommend the books I referenced at the top of this post if you want to read about the minor uses of semicolons.  

Author's note:  Thank you for your support of this blog.  Our subscribership is increasing every day. We love to hear from you.  Please comment or drop us an email if the mood moves you.  Tell us what you want to see or what's on your mind.  Heck, just email to say, "Hello." 

Also, check out the QT Blog Activities Forum on Rallystorm.  Rallystorm is a forum designed for writers by the creator of QueryTracker.  It's free to join.  If you become a member of the QT Blog Activities Forum,  you can post selections from your work-in progress for critique and see other critiques.  The most recent activity was "showing versus telling."   QT's own Raballard was kind enough to volunteer to go first for a critique of the opening paragraphs of his manuscript with respect to showing versus telling.  Thanks, Ray!  

Mary

Mary Lindsey writes paranormal fiction for children and adults. Prior to attending University of Houston Law School, she received a B.A. in English Literature with a minor in Drama.

Mary can also be found on her website.

Manuscript Formatting

In the year I've been hanging around the QueryTracker Forum, I've seen the topic of manuscript formatting come up repeatedly. For some reason, it always starts a heated debate. Formatting a manuscript is far simpler than people make it out to be.

When I decided to blog about this topic, I sent out a set of questions to 8 of my published and soon-to-be-published friends. I also polled half a dozen of my agented friends. My published friends spanned 5 genres and 12 publishing imprints both large and small. The results confirmed what I already knew. (I am addressing book-length manuscripts intended for publication in the United States, not articles or short stories for magazine or periodicals.)

Format your manuscript as follows:

- White 8 1/2" x 11" paper

- 1 inch margins on all sides

- Double spaced

- Black ink

- 12 point Times New Roman (TNR) or Courier New font ** see note below

- Header should include Last name/TITLE/genre and page number (Titles are traditionally CAPPED in manuscripts, query letters, synopses and correspondences)

- Cover sheet should not be included in page numbering and should include TITLE, genre, word count, your full name and all contact information including address, phone number, and email

- Most authors polled say they turn off orphans/widows in paragraph formatting

- It is standard to start a new chapter 1/3 of the way down a page.

- Italics are preferred to underlining nowadays. If your editor wants you to underline to indicate italics, he/she will tell you so. None of the authors I interviewed underlined to indicate italics either in their submission to agents or editors.

- All those polled use only one space after periods.

That's it. That's all you have to do!

Why is formatting controversial? Because too many newbie and unpublished writers fret the small stuff. Most of the debate occurs over font type. I've seen some forum threads get downright nasty about it. Courier used to be the standard, but that has changed and TNR is almost universally preferred. But it's important to keep in mind that unless the agent is specific as to what type to use, the font will not get you rejected. It's all about the writing.

Here's the deal: If you have a professional-looking manuscript that is not covered in food and coffee and is printed by a printer with plenty of toner and follows the rules above, you are fine. If your agent or editor wants something different, they will let you know. Fear not.

Before you query an agent, read their blog and website including rules for submission! There are several who specify TNR only, but most don't care as long as they can read it and it is clean.

Only two of the published authors I polled said their editor made specific formatting requests. The others said that nothing was ever mentioned about submissions that complied to my rules above.

Another question I asked my published and agented friends is how they indicate that they want to skip a space in their manuscript to indicate a change of scene. This was not uniform. Some used #, some used *** and one just left a blank space created by a hard return. Agents and editors are smart. They read a lot of manuscripts and will not reject you because you use one symbol instead of another to indicate a space is desired.

One thing is certain: Regardless of how perfect your manuscript formatting, it is the writing that counts. Don't fret the small stuff like Courier vs. Times New Roman; fret about the quality of the writing you are submitting. It is the content that will get you published, not what font you use. As long as you review the agents' submission guidelines and follow them, you will be fine. If specifics are not mentioned, format according to my rules above, which are industry standard in the United States.

If you have any questions, feel free to email me at the address to the right or leave a comment below. Have a wonderful day!

Mary

Quotation Marks

Having taught high school English and being a writer who loves to read other aspiring authors' manuscripts and queries, I've read hundreds of poorly punctuated pages.  Even the coolest, most imaginative stories are hard to enjoy when the pages are marred by technical errors.  

One of the most common mistakes I see is the misuse of quotation marks.  Now, let me preface this by saying that I am addressing American punctuation in non-scholarly texts.  It differs slightly from county to country, which is probably the root of some of the confusion. 

RULE 1:  Double quotation marks (" ") are used to indicate what someone said or wrote.  

If you pick up a book and see single quotation marks used for standard dialogue, it is probably not the product of an American publisher.  Although the trend is shifting to double quotation marks in British publications, you will still see single quotation marks (' ') used to indicate direct quotes occasionally.  There are also exceptions in scholarly writings.  

RULE 2:  Single quotation marks (' ') are used to indicate quoted material (or titles of poems, stories, articles) within other quoted material.  

Example:  Patrick said, "Mary said, 'Look!  I'm using single quotation marks.'"

RULE 3:  Ending punctuation goes INSIDE the quotation marks.

Right:   Mary said, "The punctuation goes inside the quotation marks."

Wrong: Mary said, "The punctuation goes inside the quotation marks".

This rule even applies to single quotes:

Right:   Patrick said, "Mary said, 'The punctuation goes inside the quotation marks.'"

Wrong: Patrick said, "Mary said, 'The punctuation goes inside the quotation marks'." **

Wrong: Patrick said, "Mary said, 'The punctuation goes inside the quotation marks'".

**This is the most common single quotation mark error I see.  The punctuation goes inside all the quotes.  There are rare exceptions, which I will address later in this post.  

RULE 4:  Quotation marks are used to set off direct quotes only.

Right:   Carolyn said, "You should listen carefully."

Right: Carolyn said that you should listen carefully.

Wrong: Carolyn said that, "You should listen carefully." 

RULE 5:  The placement of question marks with quotation marks follows logic.  

Yeah, this one is less concrete, but it's clear in application.  If the quoted material is a question, the question mark goes inside.  If the material in quotation marks is a saying or not part of the question itself, the mark goes outside.  This is one of the exceptions I mentioned in RULE 3.  You will also find this "logic" rule applies to other types of punctuation with regard to quotes. 

Examples:  

Heather asked, "Did you read the QT Blog today?"

Do you believe in the saying, "Haste makes Waste"?  

Note:  In the second sentence, the quoted material is not the question.  You cannot use more than one ending punctuation mark, so you cannot put a period inside the quote and a question mark outside of it.  Most punctuation is uniform and logical.  Use common sense when you come up against an uncommon situation like the second example above.  The stronger mark wins.  And just to make it more fun, an exclamation mark will supersede the question and suffice to end the sentence.  I avoid this, because it's ...well, weird and drives critique partners nuts. It's like the Rock, Paper Scissors game of punctuation.  Exclamation mark trumps question mark. The emotion and impact of the quoted material supersedes the fact it its a question. The example below is a question, but it is also a powerful proclamation.  The exclamation point trumps the question mark. 

Example:  

Wasn't it Patrick Henry who said, "Give me liberty or give me death!"  

If you have a question outside the quoted material as well as inside, use only  one question mark inside the quoted material.

Example: 

Did he say, "Can you hear me now?"

RULE 6:  Set off quoted material with commas.  

Examples:    

Mary said, "Set off quoted material with commas."

"Set off quoted material with commas," Mary said.  

This gets more complicated when dealing with the more powerful punctuation marks like the question mark and the exclamation point.  Once again, logic comes into play.  

Right: "Did you see the sunrise this morning?" Suzette asked.  

Wrong: "Did you see the sunrise this morning," Suzette asked?

Wrong: "Did you see the sunrise this morning," Suzette asked.  

Right: "Dude.  Check out that sunrise!" Elana shouted from the beach. 

Wrong: "Dude.  Check out that sunrise," Elana shouted from the beach! 

Right: "Dude.  Check out that sunrise," Elana shouted from the beach.  

There are two correct options in the last set of examples because exclamation points are for impact, not function like the question mark.

Long (multiple paragraph) speeches in dialogue:

If a character's speech goes on for more than one paragraph, use double quotation marks to open the speech and at the beginning (but not at the end) of each new paragraph in the speech.  Close the speech with double quotation marks at the end of the final paragraph.  

Disclaimer and waiver of liability:  Okay, the heading of this paragraph is overkill, but I want to let you know that I'm aware that there are exceptions to every rule.  I've tried to give an accurate overview of the American use of quotation marks for dialogue.  My six rules for the use of quotation marks can be verified and supplemented by Strunk and White's The Elements of Style  and The Chicago Manual of Style. 

I'd love to hear from you if you have questions or just want to give me a shout. marylindsey@QueryTracker.net (link in the right sidebar). Have a splendid week.

Mary 

Mary Lindsey writes paranormal fiction for children and adults. Prior to attending University of Houston Law School, she received a B.A. in English Literature with a minor in Drama.

Mary can also be found on her website.

I Need a Reply-- STAT!

Okay, my gang of QT's...

As promised, we'll be taking a close look at the features of the QueryTracker.net site that actually involve... um... tracking queries.

First, let's quickly run through HOW to track your queries on QueryTracker.net.

The first thing you need to do is choose an agent you plan to query and add them to your query list. I've added a few of the New & Updated Agents to the query list for our imaginary manuscript, Memoirs of a QT Blogger.

So after following Elana's tips to construct the perfect query, I would send it off to my agent of choice by their preferred query method (be sure to check which methods are accepted by the agent on the agent's Overview page, which Suz discussed last week.)

The next step after sending off your query letter is to track it. This will not only help you keep track of whom you've queried and when, but will also contribute to community data that can help you interpret patterns in agent responses.

So let's track that query. First, go to the "My Query Status" tab on the agent listing (you can also access this tab by clicking on the query status symbol next to the agent's name.)


This is where you will enter data to track your query. Notice the yellow checkmark symbol by the agent's name. This indicates that the agent has been added to your query list. When you start tracking your query, this symbol will change to reflect the current status.


So, I check the listing and see that this agent takes snail mail queries. I pop my letter in the mail and come to QueryTracker.net to log it:

Using the dropdown menus, I select the date and method I used to send the query.

Now my status symbol will change to reflect the pending query.




Be sure to hit the Save Query button after entering your information!

Then comes the hardest part... waiting for a reply. :)

Luckily, our imaginary response came very quickly! It's a partial request. Yay, hypothetical US!

Now to mark our good news in the QueryTracker.net database.
Your status symbol will now change again:




Once you get your submission off to the lucky agent, you'll update the submission side of the My Query Status tab in just the same way.


Tracking a partial or full request is fun, but you should track EVERY response you receive on queries sent. Why, you ask?

Because every time you record your query responses in QueryTracker.net you are also creating data points. And the data from all the 11,000+ strong QueryTracker.net members gives you access to powerful information in the Agent Reports & Statistics tab.



So let's take a look at the stats available for queries. The full basic query report shows how many QT users have recorded sending a query to this agent, what method they used to send it, and what the responses were by percentage overall, and by method of query.

In this entry, for example, you can see that this agent receives most of her queries by email, requests to see the manuscript about 22% of the time, and overwhelmingly requests a partial or a proposal, rather than a full manuscript from the query.


There are several other reports available that can give you even more information. You can break down the agent's request rate by genre or by manuscript length. You can also track the responses to those requested partials and fulls. But perhaps the most useful information is the Query Response Time report.

Once you've chosen "Query Response Times" from the dropdown menu and clicked "Generate Report," you will see a chart like this:


The chart shows that this agent has a very quick response time for emailed queries, averaging just 6 days for a postive response and 11 days for a negative one. The response times for snail mail queries are significantly longer. This information is helpful in judging whether you should resend a query to an agent you have not heard from.

If you'd queried this agent by email and 2 months or more had passed, chances are fairly good that internet goblins are involved. But for many other agents, 2 months or more may be standard. Having this data available can help you decide when you're considering re-querying.

There are also a lot of very cool reports that are only available to premium members. Tune in next week for the details on those.

And keep on Tracking!

Editorial Tool: Read Out Loud

One of the best self-editing tips I can give is to read your manuscript out loud.  It feels silly, I know, but the benefit outweighs the awkwardness.  

Our mind often compensates for errors.  When reading, mistakes are missed because the brain anticipates patterns and we correct inconsistencies automatically.  Reading out loud forces the reader to slow down to the rate of speech, which helps identify errors.  

Read the words inside the triangle below silently. 

Did you spot the error?  Your chance of spotting the duplicate "the" is higher if you read it out loud.  This kind of mistake happens all the time in manuscripts, primarily because of cutting and pasting.  It is the type of error for which the mind compensates.

Check this out:

Aoccdrnig to a rseearch sutdy at Cmabrigde Uinervtisy, it dseno't mtaetr in waht oerdr the ltteres in a wrod are, the olny improamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae.  

Could you read that?  I had no trouble.  Amazing what our mind can do, huh?

For me, the biggest benefit to reading my manuscript out loud is spotting unnatural or rough sentences.  The rhythm and inflection in my head is different than that of the spoken word.  Things that seem natural, particularly in dialogue, often are stilted when read aloud.  

I also recommend having someone else read the manuscript to you.  Because the characters in one of my novels are teens, I had teens read it to me.  Talk about a wake-up call to bad dialogue!  Mercy.  

I like this editorial tool so much, I read almost everything I write out loud now--manuscripts, letters, emails, blog posts...  It not only helps me spot errors, it annoys my family!  Who could ask for more?  *wink*

Mary Lindsey writes paranormal fiction for children and adults. Prior to attending University of Houston Law School, she received a B.A. in English Literature with a minor in Drama.

Mary can also be found on her website.

Quick Technical Note

Just a quick technical note.  If you subscribed to the QT Blog via email using the box to your right, please re-subscribe.  The feed was pointing to the wrong place, and yours truly is dyin' of embarrassment about it.  I double-checked the code and tested it, and it now works properly.  Sorry for any inconvenience!