In Other News…

It’s my little brother’s birthday today!

Happy birthday, Fuzz-Muffin!

BAM! You’re On The Floor!

(Well, I could do without the obnoxious laugh track. Things like this were so much funnier to me before I started with the whole medical training thing. Now all I can think about is how much their medical bills are going to be.)

(Anyway. Article.)

We see fainting everywhere in fiction, from swooning damsels in distress to buffoons scraping for cheap laughs in mindless comedies. And heroes are always fighting off a loss of consciousness when they’re being tortured by evil bad dudes everywhere, and annoying sidekicks are always dropping into the nearest pile of horse puckey at the sight of blood.

So what’s going on? Is there a medical explanation?

Of course! 😀

If your brain doesn’t get enough blood flow, it’ll shut down. And this causes a person to lose consciousness. That’s called syncope. If they’re upright, they’ll fall down. (If they don’t lose consciousness, but still experience dizziness and other near-syncope-like symptoms, it’s called….near-syncope. Thought it was going to be more dramatic, didn’t you? 😀 ) True syncope is also characterized by a relatively quick recovery, with no real neurological after-effects.

So, listen. Gravity is always pulling your blood down toward the center of the earth. Your cardiovascular system is all set up to fight against this force to keep the blood circulating adequately to all parts of your body, no matter what orientation it’s in. It’s a rockin’ system.

But if something goes wrong with the cardiovascular compensation against gravity, gravity wins. And the blood gets pulled away from whatever is the highest part of the body. If it’s your brain, your brain will shut down until enough blood gets back into it.

As a side note: fainting sure isn’t fun, but it’s a pretty smart failsafe in case gravity starts winning. It gets you horizontal, on the ground, so your brain is a low enough point that gravity won’t pull too much blood away from it. Cool, huh?

So what causes the failure in the first place?

There are a lot of reasons why people faint. As a matter of fact, I dreaded getting a syncope case during my time-limited practical exam for my boards, because there was SO MUCH WORKUP to do that I’d never get to everything in time. The ultimate cause could be in the heart, or the brain, or the lungs, or an imbalance in the blood…..and it could be any number of causes within those categories. Like I said, lots of reasons.

But how about fainting in fiction? The guy who passes out instead of revealing the secret location of his hidden army while under duress? The girl who can’t stand the sight of needles? The dude that gets overrun by carnivorous spiders because his maladaptive phobia causes him to faint when he should be running away, and thus provides an opportunity for us to see exactly what said carnivorous spiders would do to our erstwhile hero if they could manage to outsmart her? The poor folks in the wedding videos?

It’s probably all from the same end cause: vasovagal syncope.

Say what now?

Vasovagal (vaso – blood vessels, vagal – having to do with the vagal nerve and parasympathetic function) syncope (fainting).

This can happen with a strong emotional shock, or with a large, sudden amount of pain.

Here’s what happens. The sympathetic and parasympathetic influences are in their tug-of-war balance, keeping heart rate, blood pressure, breathing rate, etc. all around their preferred normal baseline ranges. Suddenly, there’s pain or terror, or something that strongly stimulates the sympathetic branch of the nervous system (the fight-or-flight branch)! The sympathetic tone leaps WAY out of balance, and the tug-of-war leans STRONGLY to the fight-or-flight side.

In reaction to the increased sympathetic tone, the heart contracts HARD! (Remember, in a fight-or-flight situation, it’s a good idea to have more blood pumping through your system.)

Then, sensors in the heart that are supposed to be keeping an eye on the balance between the sympathetic and parasympathetic tone see that the sympathetic tone has completely overwhelmed the parasympathetic tone! And they freak out! They have to balance the discrepancy somehow! So they send signals to increase the parasympathetic (“vagal”) tone!

But then, the overwhelming sympathetic tone reduces to a certain extent, because it was probably a bit of an over-reaction.

Now, all you’re left with is an overwhelming parasympathetic influence, which drags things STRONGLY over to the rest-and-digest side! This means heart rate, blood pressure, etc. all drop like stones. And if your blood pressure drops enough that it can’t pump enough blood to your brain, BAM! Your brain shuts down and you’re on the floor.

Illustrate that point with a random side story!

How funny that you’d encourage me to do such a thing. It’s almost as if we were both internet-based entities being written by a single author for the purpose of increasing the accessibility of a blog post!

I’ve actually experienced vasovagal syncope. Pretty recently, as a matter of fact. In my hapkido class, I was teaching a lower belt how to do a particular combination of a joint lock and throw. And she did it really well. So well, in fact, that she threw me right off the mat. I hit my knee really hard on the floor, and it hurt like crazy.

And then, not realizing that I had just experienced a potentially triggering stimulus, I got up off the floor to show her how to position herself so she didn’t throw me off the mat the next time.

And I started feeling nauseous. And dizzy. And woozy. And a little hot. And what do you know? I actually recognized the symptoms! I felt my pulse, and sure enough, it was much slower than it should have been under the circumstances. And I remember thinking, “If I don’t lie down on the floor RIGHT NOW, I’m going to fall down on the floor.” So I lay down. Just in time.

Every time I tried to sit up, I felt the same faintness. So I stayed down until my body figured out that I was actually okay, and my autonomic nervous system sorted itself back out into its proper balance.

Okay, but this whole explanation doesn’t exactly follow for the wedding videos. I mean, the brides weren’t THAT hideous. Neither were the grooms, for that matter.

Well, there’s something else that causes a vasovagal response.

Nothing.

Literally.

If there’s nothing going on that activates your sympathetic system, your autonomic nervous system gets so bored that the sympathetics just shut down. Your heart rate falls. Your blood pressure falls. You lose tone in your blood vessels, and they dilate to their full extent. Blood falls down through your legs and away from your brain. And bam! You’re on the floor!

This happens to medical students all the time. (A medical student’s job during a surgery is usually to stand and watch. And hold the retractors that pull tissue away from where the surgeon is working. For. Hours. On. End.) One of the first things they told me during my surgery rotation was what to do if I started feeling faint. Because situations like that are very, VERY risky for the whole vasovagal syncope thing.

It also happened to my little brother a lot when we were singing in choir performances under hot lights, doing weird musical-but-non-physiological things with our breathing. It happens to people who are standing in crowds listening to politicians talk. It happens to people standing during a wedding ceremony.

But this all hinges on gravity, right? What about astronauts?

Okay, I gotta drop this in here. I actually don’t know too much about what happens in an actual zero G environment. I can guess. But, I think it’s even more interesting what happens after they get back to Earth.

After a while in zero G, astronauts’ bodies tend to forget their antigravity compensation mechanisms, because the body hasn’t used them for a while. So when they get back into a gravitational environment, they experience orthostatic hypotension for a while until the compensatory mechanisms remember how to kick back in.

Oh, how I loves me some physiology! (Does it show?)

(Anyone else wanna clock that guy at the end, or is it just me?)

Sources:

Ganong, William F. Review of Medical Physiology. 21st edition. McGraw-Hill, 2003.

McDermott, Daniel, et al. Approach to the adult patient with syncope in the emergency department. UpToDate, May 2010. http://www.uptodate.com/online/content/topic.do?topicKey=adult/6980&selectedTitle=1~150&source=search_result

Sabatine, Marc S. Pocket Medicine, 3rd edition. Lippincott Williams & Wilkins, 2008

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Things I Kinda Knew I’d Probably Say At Some Point, But Still Surprised Me When They Came Nonchalantly Out Of My Mouth

“Hey, make sure I don’t go home with the blood in my pocket!”

Milestones: The Worst One of All.

Lost my first patient (well, first as an MD) on Wednesday. Didn’t really want to talk about it, but I figured I should at least acknowledge.

We live in such fragile, temporary shelters.

I Can Haz Mat?

I took a year off between college and med school, at the urging of my super-supportive parents. So I ended up moving to Boston for a year, and volunteering at Massachusetts General Hospital while I pseudo-supported myself working as a freelance stage electrician.

One of the coolest things that I got to do at Mass General (among a sea of really cool things), was to participate in a Hazmat drill. This drill was to train the physicians, nurses, and ancillary staff on how to handle a mass-casualty situation.

Because I’m a writerly-person, I also was super-excited to participate for research purposes. And I also thought it would be great to write up the experience for my online writers’ group, so they could benefit from the information, too. And now, I can share it with you guys!

The Scenario:

A bomb with components of cyanide is set off in the Park Street T station. (Non-Beantowners: This is a high-traffic transfer point between the Red and Green lines of the Boston subway system.) Due to the highly toxic nature of cyanide, the most critically injured patients pass away before help can get there. The survivors are instructed to get themselves across Boston Common (a park in the middle of the city), and over Beacon Hill to Massachussetts General Hospital. (Walking it usually takes me around 25 mins to a half an hour.)

Preparation:

A couple of days before the drill, we were asked to send an email to the volunteer coordinator, telling them what scrub size we’d need to wear, whether we spoke any languages other than English, what age of victim we wanted to play, and whether we would be willing to act as a critical patient.

The day of the drill, around 70 volunteer victims (VV) showed up, which was awesome. We were told to bring a bathing suit or shorts and a t-shirt to wear under the scrubs we were given; the scrubs would represent our clothes during the drill, and we put strips of red tape on our swimsuits or clothes so the Hazmat team (HT) would know that they represented our skin and shouldn’t ask us to remove those. People who were wearing wedding rings and earrings were instructed to put red tape over their jewelry so they wouldn’t be asked to remove them.

We were then given sheets of paper which described how badly injured we were, our vital signs, the specifics of our injuries, and character scenarios. I had a compound radial fracture and multiple lacerations, and was assigned to show up in a wheelchair as a critical patient. I was to be in a panic because of how bad the wound on my arm looked, and convinced that I was going to die from the blood loss.

Additionally, one of the coordinators approached me and asked me if I would be comfortable playing the part of a Deaf person, since I put on my sheet that I had some experience with American Sign Language. Apparently, the coordinators like to throw stuff at the HT that they aren’t expecting, but that they might run into in a real-life scenario. (I don’t know if they had ever put a signer through the drill, but I was told that the year before they had to figure out what to do with a blind man and his seeing-eye dog. They ended up putting both of them through decontamination. Apparently the dog was really well-behaved during the process.) So I decided that I would play a profoundly Deaf person who used ASL as their primary language and was unable to read lips. And then I was instructed to make as much trouble as I could, within reason and the bounds of the drill.

Oh, did they pick the right person for that! 😀 <== evilest of evil grins.

Other people were assigned head wounds, various blast-related injuries and burns, and breathing difficulties as a result of cyanide exposure. A bunch of people spoke Spanish, and two women were assigned to a scenario in which the first woman only spoke Mandarin, and the second woman would offer to translate for the HT. A few were assigned to arrive on stretchers and in wheelchairs, but a lot of people had minor injuries and would just walk. Three people were assigned to play a family.

After we got our parts to play, it was back to the conference room for moulage. The makeup jobs were awesome, with fake blood and bandages and torn scrubs with bloody edges. I had my left arm wrapped in bloody gauze (I’m a right-handed signer), and splashes of blood and makeup all over my face and arms to represent various cuts and bruises. I also sported a small head wound (fake blood running down from my hairline) and a nosebleed. It was really a fantastic makeup team, especially for a large volume of volunteers. A girl whose primary injury was supposed to be a head wound looked like she was bleeding out of her ear, under the gauze they had wrapped her in. One woman wore a burn mask. (A lot of people walked by us as we sat in the hallway, staring at the group openmouthed, until we explained that the wounds weren’t real. I think we might have accidentally traumatized some kids, too.)

Being all bloody wasn’t enough, though…in the hallway, we were given palmfuls of goo that would glow under blacklight, and buckets of dirt to smear all over ourselves. By the time we were done and ready to go, we really did look like victims of a subway bombing.

The Drill:

By the time I was done with moulage (they did the non-critical VVs first, since in a real situation they’d probably be the first ones to make it to the hospital), the decon tent was already set up, and the drill was in full swing. I climbed into a wheelchair, inserted myself into the next group of VVs, and waited my turn.

The whole front of the hospital was cordoned off as it would have been in a real situation, with yellow CAUTION tape, crowd-control officers, and police cars. (Since the front of the hospital is also the ambulance bay and the entrance to the Emergency Department, we left room for emergency vehicles to get by.) Another cool feature of the hospital’s area-securing system is a series of hollow plastic barriers. They’re relatively easy to move, but when you fill them with a ton or two of water (which maybe takes two minutes), they turn into a really effective barrier against a possible vehicular assault on the hospital itself.

Additionally, one of the parking garages was ingeniously transformed into an outdoor treatment/overflow center. They drew heavy tarp-curtains over all of the openings, which would allow them to heat up the bottom level of the garage in case of a wintertime large-scale emergency.

The HT personnel all wore white Hazmat suits with clear faceplates, rubber galoshes, black gloves, and air filters/breathing units at the small of their backs. Over the suits, everyone wore color-coded vests with neon yellow strips that told the person’s operational role in big black letters.

The decontamination operation was set up in front of the hospital. As VVs arrived, they were assessed by triage personnel. The triagers had a selection of plastic slap-bracelets in red, yellow, and green. (These represented [green] those who have only minor injuries, and can wait some time to be treated, [yellow] those with injuries that are immediately life-threatening, and [red] those whose injuries are so severe that they are unlikely to be saved by treatment. Group yellow gets first priority.)

After that, the VVs were conducted to the decon tent.

The bright yellow, plastic tent was separated into three corridors which ran the length of the tent. Each of the two outer corridors were separated into three sections. The first section was square and empty, with a little window zippered into the side. Here, VVs were asked to remove all of their clothes, (including shoes, jewelry, etc.), place them in plastic bags, and hand them out through the little zipper window. They then proceeded to the second room, which was separated by zippered flaps (which weren’t zipped up, at least while I was there).

This section was longer than the first, and absolutely FILLED with warm, soapy water. There were spray-nozzles at ankle, knee, waist, shoulder, and head levels, and I assume a bunch on the ceiling as well. These misted a fine but firm spray (like a medium-pressure shower head), which completely drenched the VV. The VV was instructed to scrub off as best he can, running his hands through his hair and under his arms, etc., as he walks through the section. In the third section, also set off by zippered flaps and identical in most ways to the first section, the VV was handed a towel and a hospital gown to cover up with. One of the outer corridors was for men, and the other was for women.

The center section runs the length of the tent and is open at both ends. The middle of this section is taken up by a collapsible-lattice conveyor table covered with rollers. This is where the most critical patients are decontaminated by the suited HT members who stand on each side of the conveyor.

When the VVs finish with the decon tent, they are examined by a guy with a blacklight, who is looking for traces of the glowing goop we had applied earlier. If any is found, the VV is sent around to the front of the tent to repeat the decon process. When they’re contaminant-free, they’re conducted out of the way by hospital transport personnel, who are not suited up.

A couple of the VVs were asked to go through a second time, to simulate more patients.

Using this system, the team was able to decon around 100 VVs, in various states of health, in an hour.

My experience as a Deaf victim:

It seemed rather chaotic when I arrived on the scene, but that could be because I was sitting down and didn’t have my usual view of the world. Presently, a woman in a Hazmat suit came over to me and started talking to me. Remember, I was playing a Deaf character, so I started signing at her, describing the bomb in the station, my injury, and asking if I was going to die from blood loss. Obviously no one really understood. (Interestingly, though, no one ever asked around to see if anyone spoke sign language.) The woman, with the help of the guy pushing my wheelchair (who knew maybe 10-20 signs), determined whether I was having difficulty breathing, whether my arm should be considered a concern, and whether I could walk. I made a show of being in a lot of pain getting out of the wheelchair, but managed to get to my feet.

After a couple of attempts to communicate verbally (some Deaf people can read lips, but I didn’t want to make it easy on them and it’s not like it’s a comfortable form of communication for Deaf people), the woman figured out that I would only respond to gestures. Unfortunately, she didn’t realize that I had to be looking at her in order for her gestures to get through. 😀 I made sure to be ultra-distracted by the mannequin going through the center aisle of the tent while the woman was trying to get me to take off the “contaminated” scrub suit, and I could definitely see her gesturing out of the corner of my eye. I kept on asking if that “man” was going to be all right, and she would repeatedly tug at the shoulder of my scrub suit.

When I “understood” that I had to strip down, I started demanding an explanation. I explained that my arm hurt like hell, and there was no way I could get my shirt off without hurting it. And when were they going to do something about the blood? I was bleeding to death in front of her, and she wants me to take my shirt off?! The woman was incredibly patient, even though she couldn’t understand what I was saying. I eventually gave her a break, and allowed her to help me remove my scrub shirt. Apologizing profusely, which (of course) got in the way. And I wouldn’t move my “injured” arm. I even remembered to cry out and pull away when she touched it accidentally. And I made sure that I got tangled up in one of the sleeves. (I take my job as a trouble-maker seriously!)

After I had taken off the scrub suit and the little skid-socks I was wearing, she pointed me into the center section of the tent. Again, I gave her all kinds of grief; how could I go in there with my arm all bloody? It was going to hurt like hell! It already hurt like hell! She nodded understanding and made a sympathetic face to me. (It was pretty easy to figure out what I meant; to make the sign for “hurt”, you point your index fingers at each other with a modulating facial expression that tells how strong the pain is, and make the sign near the place where it hurts. Since I was only signing with one hand, it looked like I was pointing over and over to my hurt arm.) She was saying “I know, I know”, whenever I said my arm hurt and was bleeding, but each time insisted that I had to go through the decon section.

I kept this up for a minute or two, then decided to relent. I noticed that while I was turning away, she was gesturing to me again, telling me to scrub under my arms, etc. But my back was turned, and so I decided that the instructions had been lost.

I stepped through the flaps to the middle section (the floor had a little flap of tarp sticking up to act as a trough to keep the water in), and was completely drenched within three seconds. It was like walking into a wall of (thankfully warm) water. The deluge was inescapable; every time I tried to turn my face away from the spray, it was hit by another one. There was nowhere I could turn where I didn’t get a full faceful of medium-pressure water. Thankfully, the soap didn’t sting my eyes at all. It did, however, make it practically impossible to see. So I felt for the wall, and let it guide me to the other end of the tent. My hand occasionally brushed the spray nozzles, which felt like tiny plastic layer-cakes about the circumference of silver dollars.

I stepped out into the third section of the tent, absolutely drenched. Having received no gestural instructions for what to do after I had gone through the center section (even though I actually knew that I was supposed to move on through to the end), I just hung out there, trying to back things up. The victim who came through after me managed to convey to me that I was supposed to be moving on. So I did.

When I emerged, dripping and shivering a little (it was a humid and chilly summer evening, right after a major storm system had gone through), I decided to make some more trouble. I made a big show of looking back through the center section of the tent, fascinated by the decon process that was going on in there. I wanted to see how close of a look I could get without someone noticing me, but one of the suited HT guys to the left of the conveyor waved me away after I had nudged only a foot or two in.

The folks at my end of the decon tent noticed me a minute or two later, and a guy came up to me and started running a handheld blacklight over me. I started signing at him, but he didn’t notice that I wasn’t responding to his instructions; he lifted my chin while he told me to lift my chin, etc. Then a woman came up
to me, examined my arm, and put a piece of gauze over the injury. I guess it was to signify that I had received medical treatment.

Someone helped me into a wheelchair after that, and gave me a towel and a hospital gown, and a green laminated paper that I didn’t remember to read because I was busy making communication problems for people. I started signing up a storm to the guy pushing my wheelchair, demanding to know where we were going, and why. He just smiled at me and shook his head in confusion, every time I tried to say something to him. I eventually gave up, “frustrated”, and rode to the entrance of the hospital. There, a woman wrapped me in a warmed blanket, and told me that I should go through the process again to simulate another patient.

So I did.

This time, the triage guy didn’t figure out that I was Deaf. Whenever he asked me a question, I’d sign at him that I couldn’t hear. His response was to get closer and closer, and he eventually knelt right next to my wheelchair, face to face with me. I could tell that his view of my hands was completely cut off by the chin of his Hazmat suit. I was really confused by that; surely he could see that I was signing!

No matter; I was pegged as a Jane Doe with no story, examined, given a green bracelet again, and sent through the tent again. This time I didn’t make quite as much trouble; I was simulating a completely different person, after all. And the lady on my side had been so patient with me the last time. I was a little concerned since the red tape had come unstuck from my wet clothes, but they substituted the hospital gown for my “clothes” (and they’re not idiots). This time, the woman gave clearer gestural instructions, and made sure I was watching her while she gave them.

After I finished up the process, I went back to the conference room to gather my real clothes and change back into them. And wash off the residual blood. There was going to be a debriefing session a half an hour after the last VV was processed, but there were still people going through when I got done with my part. So I went to hang out with one of the crowd-control cops.

I didn’t need to do any trouble-making at the edge of the scene with the crowd-control cop. The regular denizens of the hospital area were giving him the perfect simulation. He was doing a great job directing people away from the drill, even people who needed to get past to make it to doctor’s appointments, etc. Only ambulances were let through from one direction, and only drill participants from any other. Whenever anyone approached, the CC guy would hold out his arms, palms toward the “intruder”, and motion them back. It was a surprisingly effective gesture; even people who were blustering their way through, indignant at the inconvenience, reacted to it immediately in some way or another. No one got through.

I hung out there until the last patient went through the tent. It was a little difficult to see what was going on from where I was, but I was amused to see that one of my fellow VVs had elected to collapse right after the triage process. A bunch of people in suits knelt around her, and eventually she went through the process like everyone else.

The Wrap-up:

The debriefing was really cool. It was fascinating to learn how much was going on where I couldn’t see, and how many people made this thing possible. In addition to the doctors and nurses on the Hazmat team, there were Buildings and Grounds staff, volunteer firefighters, and any number of other roles that were played away from the site of the decon tent.

Random tidbits:

-It only takes two people to set up the decon tent. Any more than that, said the head of the HT, and people just start getting in each other’s way.

-The stretchers have thin sheets stretched over the vinyl mattresses. This is not just for patient comfort; medical personnel use the sheets to lift patients from one surface to another.

-If the soap/water mixture is too thick with soap, it’ll clog up the spray-nozzles in the tent.

-The Hazmat suits contain radios. If a person engaged in one activity sees something bad happen that’s not a part of his responsibilities, he’s supposed to radio to the others to solve the problem, instead of doing it himself.

-When they went over the decon tent with a UV light, they observed that the first half of the tent was contaminated by the glowy stuff. The second half of the tent was completely clean. So, it’s pretty effective.

-If this were to happen at night, the team can set up floodlights to illuminate the whole process. The decon tent has its own lighting system inside.

-Apparently, a new feature since the last drill: the generators that warm up the water and provide power, etc, were significantly quieter this time. According to many team members, that significantly reduced feelings of uncontrolled chaos.

-There are few things weirder to see than a guy in a Hazmat suit peeling back the headpiece to take a drink of water out of a water bottle, resettling the headpiece, and jumping back into the fray.

-People stop trying to explain stuff to you if you don’t seem to understand them the first time. That lady in the first section of the tent is really the only person who even tried to explain to me what was going on. If I was a real victim, I would probably be scared to death and totally confused by the entire process.

-I might have been shuttled around in the wheelchair so much partially because I couldn’t communicate, and wouldn’t respond to verbal directions.

-Apparently, during the last drill they couldn’t heat the water. AAAAAAAAA!!! I totally lucked out.

Pictures:

http://icanhascheezburger.com/2008/09/21/funny-pictures-cat-warns-about-lolpox/

And, surprisingly, Dr. Grasshopper’s Very Own GrasshopperCam!

Observations for today

-Every time I draw blood from a hepatitis+ or HIV+ patient without sticking myself with the needle, I feel like I get a new lease on life.

-If anyone was going to make a TV show about my job, it would be really boring. There would be a lot of footage of me running up and down stairs. The same stairs. A lot.

Milestones: Te Conozco, Bacalao

Dear Fiancee Of My Dying Patient,

To be honest, this is not REALLY a milestone. Patients and family members threaten me all the time, with everything from reporting me to my superiors, to lawsuits, to actual bodily harm. Some people even threaten me as if it’s a joke, when they’re uncomfortable with a medical situation. Dealing with being threatened is normal for me. It’s practically a part of my job description.

But since this is the first time this has happened since I got the degree, I may as well mark the occasion.

Ma’am, your fiance has stage four lung cancer and end-stage AIDS. He is dying. And though we’ve told you this many times, I understand that you haven’t yet accepted it. It’s a tragic, impossible thing to have to figure out how to accept.

I know that you do not know that you’re grieving. I know that you’re trying to exert power in a situation in which you feel powerless.

When you go and speak to the chief of medicine tomorrow about my refusal to flip your fiance’s medication schedule twelve hours so he gets his morning meds at night and his night meds in the morning, I hope it helps you take another step through the stages of grief that will allow you to face the end with grace and dignity together.

I know this demand is an expression of your need to participate in your fiance’s care and have some power over a horrible situation.

But let’s be clear. You’re not going to have my job for refusing.

You are a family member, and therefore your needs are important to me ONLY if all of my patients’ needs have been adequately dealt with first. If they haven’t, there’s only so much time I’m willing to spend on you. I’m sorry if that makes you angry. But my time is limited, and it belongs to my patients.

I am more than happy to be your bad guy. I’m everybody’s bad guy. Just look in popular media. The doctor is ALWAYS the bad guy.

People never think twice about threatening the bad guy.

It. Happens. All. The. Time.

If you don’t believe me, consider this:

I have been a ward doctor for ten days.

Ma’am, I wish you the best. I’ll see you tomorrow.

And I’m very good at smiling at you.

Love,

Dr. Grasshopper

(Posted with trepidation.)

Picture from: stacie-siddha.iblogsfree.in

Exsanguinate! Exsanguinate!

Dear Dr. Grasshopper,

How much blood can a character lose before they die?

Well, it kinda depends on the size of the character, to be honest. If a very large man loses a liter of blood, it’ll have a completely different effect than if a very small woman loses a liter. So the specific amount that a character can lose varies with the character. But I’ll try to give some general guidelines so you can figure it out for your character.

First of all, let’s figure out how much blood is actually in your character.

Blood is made of plasma, and blood cells, and all kinds of good stuff. (Remind me to write a post about blood composition.) Regardless, here’s a reasonable way to figure out how much blood your character is starting out with.

WARNING! MATH AHEAD! DON’T RUN AWAY; YOU WILL JUST HAVE TO DO THE CALCULATIONS TIRED! (PS: I suck royally at math, so if I screw up, please let me know.)

(Important terminology – “Hematocrit” = the percentage of blood volume occupied by red blood cells. Typically, around 47% in men and around 42% in women. Plus or minus a few percent.)

Okay, now that that’s out of the way, we can do some calculating!

Plasma volume in L = (Body weight in kg) x 0.05

Total blood volume in L = (Plasma Volume in L ) x (100/[100-hematocrit])

(That’s a little hard to read. So let me clarify. Take 100 minus the hematocrit. Divide 100 by the number that results from that operation. Then take the number you have now, and multiply it by the plasma volume in liters.)

And, here’s an example!

Our hero, Toughguy Manley, is a 70 kg man, with a hematocrit around 47. Let’s see how much blood he has.

So,

Plasma volume in L = 70 x 0.05 = 3.5 L

Total blood volume in L = 3.5L x (100/[100-47]) = 6.6 L

(Note: I’m using 47 because that’s the usual hematocrit for a man. If we were calculating a woman, I’d use 42.)

So, Toughguy Manley will have about 6.6 liters of blood in his body, or 6600 mL.

Now that you know how it’s done, you can plug in your own character’s weight in kilograms. (Here’s a handy calculator for people who use non-metric systems of measurement.)

I’ll wait while you do some calculations.

Excellent!

Now that we know how much blood your character has, we can figure out how much she can afford to lose.

The pretentious medical term for bleeding is “hemorrhage”. (“hemo-“ = blood, “-rrhea” = flow). The way doctors classify hemorrhage is by percentage of blood volume loss.

Here’s a quick rundown of the hemorrhage classes:

Class I Hemorrhage – Loss of up to 15% of blood volume. In a healthy character, this won’t cause too much trouble. At the very most, her heart will start beating slightly faster. But that’s about it. Her blood pressure won’t change appreciably, and she probably won’t have too many symptoms in general.

Class II Hemorrhage – Loss of 15-30% of blood volume. Your character’s heart will beat faster to circulate the remaining blood faster, to make up for the fact that there’s less of it. Her blood pressure will undergo a mild to moderate decrease, and she may start to have some symptoms related to the drop in blood pressure. For example, her skin will get cold and clammy as her peripheral blood vessels narrow down, squeezing the blood out of the skin so it can supply more vital organs. She may feel light-headed, and have some changes in her mental status. If she tries to sit or stand up quickly, she may get dizzy. She won’t make as much urine, since there’s less volume passing through her kidneys for processing.

Class III Hemorrhage – More than 30% blood volume loss. The symptoms that started to show up in Class II will get worse. Her heart will beat very quickly, but it won’t be enough to keep her blood pressure up. The blood pressure will fall even more dramatically, resulting in even less perfusion of the skin and the extremities (which will make them cold to the touch), and her mental status will decline significantly.

Class IV Hemorrhage – More than 40% blood volume loss. Your character’s body will not be able to compensate for a blood loss this severe. She must either get an emergency transfusion, or she will die from hemodynamic decompensation.

So with this information, now we can figure out how much blood, to the milliliter, will leave your character’s body during your dramatic wounding-and-possibly-killing-of-character scene!

Let’s have an entertaining example!

Remember, Toughguy Manley is a 70 kg male, and he has about 6600 mL of blood. He’s just found the Seekrit Hiding Bunkur that houses the Doomsday Device of Doom (Of! DOOOOOOOM!). Suddenly, during the dramatic climax of the story, he’s shot by Best Friend McTurncoat, who was actually working for the Evil Bad Dudes all along! Now, he can’t die from this, because he has to tell Gorgeous Genius just how badly he’s fallen for her, and he has to be just loopy enough that he’ll tell Gorgeous Genius just how badly he’s fallen for her! So, let’s put him at an early Class III hemorrhage. Say, 32% blood loss.

6600 mL x 0.32 = 2112 mL, or 2.1 L

Toughguy Manley has lost a bit more than 2 liters of blood. He’s giddy, his heart is beating like crazy, his blood pressure is low, and his hands and feet and skin are cold and clammy. And he’s still losing blood. And Best Friend McTurncoat is standing over him, expressions of triumph and deep anguish fighting for dominance on his face.

It’s not looking good for Toughguy Manley.

Luckily, at that moment, Gorgeous Genius activates the Doomsday Device of Doom (Of! DOOOOOOOM!), after re-jiggering it to use only a small percentage of its capacity, and to affect only Evil Bad Dudes! (Plus, now it writes novels! And assembles bicycles! And makes three kinds of french toast!) All the Evil Bad Dudes fall over unconscious, and the day is saved! Hip, hip, hooray!

And as Gorgeous Genius saves Toughguy Manley’s life using the blood-transfusion setting on the rejiggered Doomsday Device of Doom (Of! DOOOOOOOM!), he professes his undying love for her and for her absolute bad-assery. And for physiology. Because physiology rocks.

The End.

Hey! If you want me to answer a question about using medicine in fiction, shoot me an email! doctorgrasshopper (at) gmail (dot) com. (Remember, though, that I don’t have a lot of time to research answers, so please be patient with me. Thanks!)

Picture:

http://thistosay.blogspot.com/2009/07/firefly-out-of-gas.html

References:

Ganong, William F. Review of Medical Physiology. 21st edition. McGraw-Hill, 2003.

Manning, James E. Fluid and Blood Resuscitation. Tintalli’s Emergency Medicine, Chapter 31. McGraw-Hill, 2004.

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If you use this as if it were real medical information, I will turn on my own Doomsday Device of Doom (Of! DOOOOOOOM!) (After it does my dishes, of course….)

It’s Hilarious. In An Incredibly Uncomfortable Sort Of Way.

(At least, for doctors.)

(PS: an outside hospital is….any hospital that transfers a patient to you at your hospital. Ah, patient transfers.)

Um. Holy Crap. On a STICK!

Welcome, BoingBoing readers! There’s just an acre of you fellas, ain’t there?

Looks like we’re going to need a bigger boat…..

Wow.

Hi.

(Picture from: http://www.jeanetteverster.com/2009/12/hannahs-haven/ )