Take it off!

If you’re like a lot of writers, you know EXACTLY what your character looks like.

Eye color. Hair color. The shape of his mouth. The curl of her hair.

You may even know what he’s wearing. You may even have been tempted to describe his wardrobe, down to the tiniest detail.

But here’s something you may not have considered:

What does he look like UNDERNEATH his clothes? Unless you write romance and/or erotica, you probably haven’t given this much thought.

One of the things that I’ve learned from being a doctor is that naked people will surprise the hell out of you.

Random chunks of flesh could be missing from their legs. They may be missing organs, and you can tell which ones from the pattern of their surgical scars. They could have a really out-of-character-seeming tattoo. They could be collecting their urine through a tube and into a bag hanging from a strap around their leg. They could have a sheathed knife taped to their back for easy access.

It’s unbelievable some of the things that you find. And the lengths some people go to in order to hide them from the world.

So here’s a character-building exercise for you.

Come up with one thing for each of your characters that is usually concealed by their clothing.

A scar? A weapon? A talisman? A pet?

How does it affect their behavior? Are they proud of it or ashamed of it? Do they try to hide it? How do they accomplish that? Is it obvious or very subtle? Who knows about it?

You may discover hidden depths in your character that you may never have found otherwise.

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Published in: on December 1, 2010 at 6:10 pm  Comments (13)  
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Tools for the Toolbox: Proteins!

Your choice of chicken, beef, or tofu!

No, the physiological meaning of “proteins”, not the pop-culture meaning.

Oh. Are they at least nifty?

Of course! Would I talk about them if they weren’t?

Maybe. If you wanted to talk about something else that was nifty.

Fair enough.

But they’re nifty themselves.

Well, yeah.

So, what’s nifty about them?

Besides the fact that they’re like little legos and snap-beads and erector sets and other types of kids’ building toys that thoroughly delighted me when I was little?

Um…doesn’t have to be BESIDES that…

Well, okay. I’ll start there.

Proteins are cool because they’re basically the things that cells use to DO things and MAKE things.

Need a tunnel through your cell membrane for charged particles to swim through? Use a protein!

Need an enzyme to catalyze a step in your biochemical process? Use a protein!

Need something to carry oxygen from one part of your body to another? Use a protein!

Need a scaffolding in your cell body to hold its structure and provide a transport railway system from the nucleus to the cell membrane? Use a protein!

Need a doomsday device to strike fear and terror into the hearts of the good, hardworking peasants on the greater continent of Anteuri 2?

I’ll use a protein!

Um……okay, maybe you can’t use a protein for that.

You know, you get carried away WAY too easily.

But it’s so fun to carry you with me!

Wow, there are SO many things I could say after that comment.

We’re totally getting off track.

And it’s totally your fault.

Which…if you could forgive the meta-comment…would be the case even if it was YOUR fault….

Would you just get back to the proteins?

Right.

So.

Let’s make a protein!

We’re going to start with the basic building block of a protein, the amino acid.

Oh, look! A table that shows the twenty standard amino acids that our bodies tend to use to make proteins!

How convenient!

Wow, I wonder how THAT got there?

If you look closely at the convenient table (click to embiggen), you can see that even though they all look different at the top, each amino acid basically has the same structure at the bottom. Namely, they have an amino group ( H2N- ) and an acid group ( -COOH ).

Oh! So THAT’S why they’re called amino acids!

Yup!

By the way…what’s the deal with the whole “essential amino acids” thing? I hear that phrase all the time.

There are some amino acids that our bodies can synthesize by themselves. But there are other amino acids that we just can’t…particularly: leucine, isoleucine, lysine, valine, methionine, threonine, phenylalanine, and tryptophan. So, it’s ESSENTIAL that we get these amino acids from our diet, because we can’t make them ourselves. Get it? Get it? ESSENTIAL amino acids.

Okay, got it! So, they’re building blocks.

Yeah! So, amino acids are like those attachable plastic beads I used to play with as a kid. Each type of bead was a different shape and color, but they all had identical snap-together connections that you could use to connect any bead with any other bead, and make any kind of pattern you wanted to!

She's making a DNA polymerase.

Likewise, you can string the amino acids together to make any pattern of amino acids that you want to make your protein! This is called a primary structure.

And now the true fun begins!

I’m using the bead analogy because it’s convenient. But if you look up at the table again, you’ll see that even though they attach together and string along like beads, they’re really more similar to puzzle pieces!

Or lego rings? Kinda?

What I mean to say is that each “bead” on the sequence has a puzzle piece (a “side chain”) attached to it. And the puzzle pieces fit together in different ways, because they all have different properties. For example, the positively-charged side chains will repel each other, but attract the negatively-charged side chains.

As a matter of fact, the amino acids would make a great soap opera:

Histidine, Lysine, and Arginine are sisters, all from the well-to-do Positively-Charged family of the Amino Acid estate. And they all hate each other. As a matter of fact, they’re so alike that they repel each other. But what happens when the Acid Brothers, Glutamic and Aspartic come to town? They’re both negatively-charged bad-boys…and they’re oh-so-attractive!

Tune in next week, as Lysine says: “Oh, Aspartic! I find you so attractive! But you’re attracted to Arginine! She’s so repellent!”

I’d totally watch that.

I’ll get the popcorn.

You’re supposed to be saying something that makes that….ahem…..”writing”…..up there relevant to the subject matter.

Okay, fine.

So, some amino acid side-chains are positively-charged, and some are negatively-charged, and some are neutral, and some are repelled by water. So when you let go of the ends of the string of amino acids you made….

Hilarity ensues!

Exactly! If by “hilarity” you mean “folding into higher-order structures”.

That’s exactly what I meant by “hilarity”!

So there are some very predictable patterns of hilarity that ensue. For example, proteins love to fold into a structure called an alpha helix:

Or a beta-sheet:

Shamelessly borrowed from the same folks: http://www.hcc.mnscu.edu/chem/V.27/page_id_27848.html

These are called secondary structures.

After the secondary structures are formed, the rest of the hilarity repels and attracts and pushes and pulls itself into a beautiful, complex wire-sculpture-like tertiary structure.

Like this:

Or this:

Or this:

And then, sometimes multiple proteins in their tertiary structures join together in a quaternary structure, as you can see with the four subunits of hemoglobin.

Each individual protein is a different color in this picture; you can see how they come together in their quaternary structure!

Cool, huh?

And even cooler are all the things you can do with…..

Awoooga! Awooooooooga! LONG POST ALERT!!! People in the Internet Age have short attention spans! And you’re on vacation!

Oooh, thanks for keeping an eye on that for me.

You bet!

Well, folks, I’m going to skedaddle!

Tune in next time, when Tryptophan says: “AAAAAAAAA!!! WATER!!!! GETITOFFGETITOFFGETITOFFGETITOFF!!!!!!”

and we talk about what we can do with the awesome little proteins that we made!

(And how we can use them in writing.)

(That’s what you’re really here for, right? I thought so. 😀 )

Table:

http://www.neb.com/nebecomm/tech_reference/general_data/amino_acid_structures.asp

Pictures:

http://www.growingyourbaby.com/2009/12/09/recall-edushape-snap-beads-due-to-choking-hazard/

http://www.rxlist.com/forteo-drug.htm

http://www.crystalkiss.com/interlocking-lego-rings-for-people-in-love/

http://www.org.chemie.tu-muenchen.de/people/mh/Kdp/kdp.html

http://www.di.uq.edu.au/sparqproteins

http://chemistry.umeche.maine.edu/MAT500/Proteins8.html

http://www.chemistry.wustl.edu/~courses/genchem/Tutorials/Hemoglobin/151_T3_hemoglobin.htm

The contents of this site, such as text, graphics, images, and other material contained on the Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site!

If you think you may have a medical emergency, call your doctor or 911 immediately. This blog does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by this blog, or other visitors to the Site is solely at your own risk.

The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an “as is” basis.

If you use this as if it were real medical information, I’ll denature your proteins. And you won’t even notice until the next post, when I talk about what “denaturing” means!

Published in: on October 27, 2010 at 10:52 am  Comments (8)  
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Tools for the Toolbox: _. . ._. …_ . …

In honor of the fact that I’m rotating through Neurology at the moment, I’m proud to present…

NERVES!

(In case you don’t read Morse Code and were too lazy to google it, that’s what the title says.)

So, nerves are super-cool.

Here’s a picture of one, so you can join me in basking in the coolness of nerves.

Are you basking?

What’d I tell you? Coolness personified.

Well, maybe not personified….but if you squint closely, you may find yourself glancing at your neighbor and having a shift in perception, suddenly seeing his shape described only by a network of white, filamentous strands, as if he were a sculpture of spiderwebs….

Only me?

Darn.

Well, that’s okay. I also subconsciously judge people based on how easily I could start an IV in the veins on their hands.

(The study of medicine engenders its own special flavors of crazy.)

Anyhoo. NERVES!

A nerve cell is called a neuron. That’s the cell in whose coolness we were basking, up there a minute ago.

The job of a neuron is to pass information along, in the form of an electrical signal. (The way this happens is super-cool, and warrants its own post, so stay tuned. For right now, we’ll just talk about how they’re arranged.)

There are three parts to any neuron.

The dendrites (from “dendron”, which means “tree”) are the tree-branch-like projections off of the central cell body, also known as the soma or perikaryon. The dendrites collect impulses from surrounding neurons and send them to the perikaryon. There are usually a lot of dendrites on a neuron, making it easier to collect a LOT of information.

(Dendrites are probably the coolest things in the human body, because they like to rearrange themselves like crazy, making a dynamic structure that allows us to learn and remember things, and adapt to changes and all kinds of other important things like that.)

So, a neuron receives signals through its dendrites. But what if it wants to say something to the other nerves in the area? That’s where the third part of a neuron comes in, the axon.

Axons are incredibly cool structures, too! There’s a conical process on one end of a perikaryon called the axon hillock, and that’s the staging platform that shoots off the axon, a long, cylindrical filament that keeps its diameter for practically its entire length (whereas the dendrites tend to taper off). Axons are responsible for carrying information away from the perikaryon, toward whatever it’s supposed to connect with and talk to. Wherever it is.

(Think about how far away the tip of your toe is away from the end of your spinal cord [it’s a little above the level of your iliac crests, if you remember from this post. ] A nerve axon has to run that entire distance to carry its signals! They’re LONG, man!)

Okay, a little more terminology, then I’m calling this post a wrap and going to bed. And then we’ll get to the REALLY incredibly cool stuff in the next couple of posts.

The connection where nerves can talk to each other (or to muscles or gland cells or whatever) is called a synapse. Axons can form synapses with cell bodies, dendrites, or even other axons. For clarity purposes when describing nerve connections, a neuron sending a signal toward the synapse is called “presynaptic”, and a neuron that receives the signal from the synapse is called “postsynaptic”.

Makes sense, right?

Synapses are oases of awesome in a desert where the sand is made of unabashed coolness. They might get their own post. Or a couple. We’ll see.

Anyhoo. NERVES!

Axons are covered with a nifty stretch of jointed insulation, called a myelin sheath. More about that, too. Later.

I know you can’t wait. I hardly can either.

But I’m pushing bedtime as it is.

Man, I’m a geezer already.

But that’s okay. At least you can read this at three in the morning, if you want.

Because your nerves make it possible.

NERVES!!!

Pictures:

Resources:

Junqueira, Luis Carlos; Carneiro, Jose. Basic Histology: text and atlas. 11th edition. McGraw-Hill, 2005.

The contents of this site, such as text, graphics, images, and other material contained on the Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site!

If you think you may have a medical emergency, call your doctor or 911 immediately. This blog does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by this blog, or other visitors to the Site is solely at your own risk.

The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an “as is” basis.

If you use this as if it were real medical information, I’ll bask in the cool awesomeness all by myself. Didja hear me? ALL BY MYSELF! (So there.)

Published in: on October 14, 2010 at 1:40 am  Comments (5)  
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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

The contents of this site, such as text, graphics, images, and other material contained on the Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site!

If you think you may have a medical emergency, call your doctor or 911 immediately. This blog does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by this blog, or other visitors to the Site is solely at your own risk.

The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an “as is” basis.

If you use this as if it were real medical information, I’ll sic gravity on you. Yeah, that’s right. Gravity! What now, mutha-luvah?

Published in: on August 26, 2010 at 10:47 am  Comments (22)  
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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!

Published in: on August 18, 2010 at 10:20 pm  Comments (4)  
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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.

The contents of this site, such as text, graphics, images, and other material contained on the Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site!

If you think you may have a medical emergency, call your doctor or 911 immediately. This blog does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by this blog, or other visitors to the Site is solely at your own risk.

The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an “as is” basis.

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….)

Published in: on August 7, 2010 at 10:51 am  Comments (18)  
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Tristan, Iseult, and the Octopus Trap

You know the story. A great epic love, lovers crossed by star or circumstance, a tragic ending, and SOMEONE dies of a broken heart. You’ve seen it everywhere, from romance novel on top of romance novel, to Erik (The Phantom of the Opera) to Tristan and Iseult. And some even say that Padme died of a broken heart (even though she was clearly helped along by Anakin, when he, you know, crushed her windpipe with the Force.)

Yeah, that’s just sloppy writing. When Little Ann died at the end of Where the Red Fern Grows, Wilson Rawls at least had the respect for the audience to say that she stopped eating.

Well, it’s not as sloppy as one might think…

Wait, what?

It’s not necessarily sloppy writing to say someone died from a broken heart.

You’re not about to tell me that people actually die of broken hearts.

Well…..

Seriously? Like, seriously?

Yeah, dude. I’m about to tell you that people actually die of broken hearts.

Take a gander at this Japanese octopus trap.

This is called a tako-tsubo.

What does an octopus have to do with broken hearts? I mean, the World Cup is over.

::Sigh::

I’d like to tell you a little bit about Takotsubo Cardiomyopathy (cardio = heart, myo = muscle, path = feeling/suffering), also known as Stress Cardiomyopathy…

…Or Broken Heart Syndrome.

Takotsubo was first described in case reports from Japan, but has since become more widely recognized. It’s a fascinating condition in which a strong emotional shock causes your heart to do…well, this:

Here’s a picture that shows basically what’s going on in that video.

Picture shamelessly stolen from the Wikipedia article.

We’re looking at a cross-section of the left ventricle of the heart. The ventricle on the right is relatively normal, and the ventricle on the left is suffering from Takotsubo. Basically, the apex, or tip, of the left ventricle balloons out in a way that you usually don’t see except from a heart attack. But in this condition, the coronary arteries that feed the heart are wide open.

The condition is called Takotsubo because the ventricle is said to resemble a Japanese octopus trap. The base of the ventricle, up near the atria, continues to function normally.

It’s not entirely clear exactly what causes this to happen. There’s some evidence that a significant increase in the levels of circulating catecholamines (the “fight-or-flight” hormones released by the sympathetic nervous system) may contribute to the development of the syndrome through any one of a number of proposed mechanisms.

A person suffering from Takotsubo will feel many of the symptoms of a heart attack. They’ll have chest pain or discomfort behind their sternum, they’ll get short of breath. Their electrocardiogram, the squiggly lines that show the patterns of the electrical activity in the heart, will look an awful lot like a heart attack. Enzymes that are released when heart muscle is damaged can be found in small quantities in their blood. And the person suffering from Takotsubo transiently goes into heart failure (a condition in which the heart is too weak to serve as an adequate pump for the fluid in the body.)

Interestingly, though (and most unexpected if you’re going to go from the fictional literature rather than from the medical literature), the majority of people who develop Broken Heart Syndrome survive it. The mortality rate is said to be around 8%. When a person dies from Takotsubo, it’s usually from a ventricular arrhythmia (= a dangerous change in the rhythm of the heartbeat), which is often observed during periods of heart failure. If the person survives the acute attack, it ends up being a transient condition that doesn’t seem to leave too much of a lasting impact.

Patients with Takotsubo are treated with supportive measures, basically making sure the heart gets help pumping if it needs help pumping. This can be done with drugs that encourage the heart to beat harder, or even artificial pumps that give the heart an extra bit of help with the squeezing.

So, how should I use it in a story?

First of all, make sure you actually want your character to “die of a broken heart”. I gotta say, it really got me when Little Ann crawled to the grave of Old Dan and perished there…but whenever I see that particular plot point anywhere else, it’s a major eye-roll hazard. So make sure you’re willing to take the risk. And then, please, please, PLEASE do something new, interesting and different with it. Don’t just use it to get rid of a pesky character that you don’t know how to kill.

Once you’ve committed to Takotsubo as your character’s mechanism of demise, consider selling it like the medical condition that it is (within reason, depending on the level of medical technology/healing magic in your secondary world.) Consider listing a few of the classic symptoms of Takotsubo. Have your character get short of breath, with wet sounds near the bases of the lungs. Give them a tight, squeezing feeling right behind their sternum. Then, have them die suddenly when their heart goes into a fatal arrhythmia. And make sure to weave a nice, solid, character-oriented scene around them to send them off.

Extra points if there’s an octopus in the room.

Pictures:

http://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy


References:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847940/

http://www.ncbi.nlm.nih.gov/pubmed/17706815

The contents of this site, such as text, graphics, images, and other material contained on the Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site!

If you think you may have a medical emergency, call your doctor or 911 immediately. This blog does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by this blog, or other visitors to the Site is solely at your own risk.

The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an “as is” basis.

If you use this as if it were real medical information, it’ll break my heart.

Published in: on August 2, 2010 at 8:08 am  Comments (25)  
Tags: , ,

Stories From Med School: Hyperthermia

As a fourth-year medical student, you’re supposed to know enough about what’s going on in a patient’s treatment to be able to follow along with the rest of your team, and even to contribute a few aspects to the patient’s care. As a result, a fourth-year student at my med school is often distinguished from a third-year student by the title of “Sub-Intern”, or “Sub-I”.

I did my Sub-I in internal medicine at the county hospital, and then I requested a rotation in Intensive Care in the same hospital, with one of the toughest old-guard docs the hospital had. I figured I’d learn a lot. And I did.

Anyway, this story is from my ICU month.

—–

One Tuesday at four in the morning, when I was on call with my team, a patient came onto our service in really, really bad shape. He was a young guy (younger than me, which still gives me a touch of existential crisis when it happens), in his teens.

He had been running away from the cops with a stash of cocaine, about eight ounces in a plastic bag. He realized that he was going to get caught, so he decided to get rid of the evidence.

By swallowing it.

And eight ounces of cocaine entered his system. He was unconscious within minutes.

Here’s what cocaine does to you. It cranks up the thermostat in every system in your body. Your heart rate goes through the roof (which is why you can get heart attacks from cocaine use), your blood pressure goes through the roof, your breathing ramps up, et cetera. Your temperature also skyrockets.

When we assessed our friend, his temperature had reached 106 degrees. That’s well into brain-damage territory. If we didn’t bring his temperature down, and fast, he’d die. And if he didn’t die, he’d likely come out of this in a permanent coma.

I’ve never seen my team move so fast.

So, we started an IV of refrigerated saline, and set the drips as fast as they would go. We packed him in ice, and covered him with a cooling blanket that would draw even more heat from him.

If you need to cool someone down, the best places to put the cooling sources are in superficial (close to the skin) areas with high blood flow. In practical terms, that means neck, armpits, and groin.

But that apparently wasn’t even enough. The cocaine was still raging through his system, telling it to RAMP UP! RAMP UP! RAMP UP!

We had to bring his temperature down even faster , and it had to happen SOON! The only other thing we could do was to blow cool air on him in addition to the other measures.

Which meant we needed a floor fan. And as the junior member of the team, it was up to me to obtain one.

In retrospect, the team might have just needed me out of the way; the fan wouldn’t help THAT much. But I didn’t realize it at the time. At the time, it seemed like the most important task in the UNIVERSE!

—–

Let me tell you something about the county hospital. It’s a huge old building with maybe ten floor fans in total. They are all located at the nursing stations.

In August in that part of the country, floor fans become a desperately sought-after commodity, and are fiercely guarded by the nurses. Understandably. That hospital is not the friendliest working environment, temperature-wise, and nurses spend their entire day running around.

But if you need a floor fan in August…especially if you’re a medical student…you need to either run across a really, really understanding nurse…or you need to risk pissing one off.

I did not have time to find a really, really understanding nurse. There was a kid dying in the ICU. And a floor fan would help.

Cue Mission: Impossible music.

I ran through each ward on each floor of the hospital at top speed, taking stairs between floors two at a time. Patients and nurses eyed me curiously as I flew past. A doctor running in a hospital usually means an emergency. But a med student running at four in the morning? Who knew what that meant!

Finally, I located a precious fan on the fourth floor, cooling off the momentarily empty 4 East nursing station.

I then called an elevator.

And made a mad dash.

Three things happened at once.

1) I unplugged the fan and hefted it against my shoulder.
2) The night nurse appeared from a patient’s room.
3) The elevator dinged down the hall.

We both started to run. And we both started to yell.

“Where are you taking that! Come back here! What are you doing?” She didn’t know why I was taking the fan. She just knew that the nursing station would be practically unliveable for the rest of the night without it. Like I said, who can blame her?

“I’m the Sub-I on the ICU team!” Oh, there was no way I was stopping! Patient care trumps nursing comfort, and Sub-I safety! “My pager number is 123-4567! This is for a patient! I’ll bring it back! I promise!”

The elevator doors started to close. The night nurse was right behind me.

I dashed in, just in time for the doors to close behind me and right before the nurse could catch the elevator. I punched the button for the ICU floor so the nurse would not be able to call back the elevator.

I’d made it.

I ran back to the ICU as fast as I could, and we set up the fan. And we worked. And we worked.

—–

The kid was in the ICU until the end of my rotation. On the last day of the rotation, he woke up a bit.

“Hello,” we said.

“Hello,” he carefully said back.

“How are you?”

“Fine.”

Success! We had saved enough of his brain function that he had at least retained enough processing power for a simple conversation! We grinned at each other like idiots.

I left the ICU service the next day, so I have no idea how much function he recovered. But he survived to see his family again. So I call that a win.

And the floor fan was there, helping him stay cool, until I left the service.

—–

On the last day, I took the fan back up to the nurses’ station on 4 East, and plugged it back in.

The nurses all exchanged looks. They knew who I was. And I was all alone, the baby gazelle on the Serengeti of the county hospital wards.

And I slunk out of there as fast as I could.

—–

Bonus round! Which branch of the autonomic nervous system predominated in every single person in that story? Especially the teen?

Sympathy. And…parasympathy?

Ever wonder how our body knows how to do things and when to do them? There’s an incredibly complex signaling system in our bodies, working ALL THE TIME, without us having to do anything about it. Isn’t that cool?

Well…

Before you answer, I should inform you. It’s cool. It’s really cool.

If you say so.

I do.

Today I want to talk about the autonomic nervous system. “Autonomic” can be broken down into the roots auto = self, and nomos = arrangement or law. So, it’s the branch of the nervous system that is responsible for self-regulation. And when we’re talking about self-regulation, we’re talking about regulation of all kinds of bodily functions: from how quickly you breathe, to how much you salivate, to how big the pupils of your eyes are.

The autonomic nervous system is divided into two opposing forces: the sympathetic influence, and the parasympathetic influence. Both forces are acting upon every bodily system at all times. It’s like playing tug-of-war between two evenly-matched sides. There’s a balance point between the two opposing forces, and a dynamic system that keeps the balance point in place.

You can see an example of this kind of dynamic equilibrium in the first 25 seconds of this video:

So, what do the sympathetic and parasympathetic systems actually do?

I’ll break it down for you.

The sympathetic system is the “fight or flight” system. I like to remember it as, “everything you want to be doing while you’re running away from a lion.”

(well….hopefully more successfully…..)

So, what would be helpful when you’re running away from a lion?

You want your muscles to work really, really well. So you’re going to make sure they get a really good oxygen supply. You’ll dilate your muscular blood vessels, and your heart will beat faster and stronger to make sure enough oxygen is getting to your muscle cells. You’ll also breathe harder and deeper, making sure you have a lot of oxygen in your blood for maximum delivery.

What else? Well, you’ll want to see really well while you’re running away. So your pupils will dilate to a bigger size to let more light in.

And you’ll also want to inhibit a couple of parasympathetic functions, which… well, you’ll see why in a minute.

The parasympathetic system is responsible for the “rest and digest” functions.

Basically, it’s “everything that your body needs to do…unless you’re running away from a lion!”

The parasympathetic system lowers your heart rate and blood pressure. It slows down your breathing. It constricts your pupils and narrows your blood vessels to direct blood flow from your muscles to other important organ systems. It lets your eyes make tears.

The parasympathetic system increases salivation, which helps in the digestion process. It also increases the movement of the digestive tract, allowing you to digest food and excrete waste.

(Helpful tip: Avoid excreting waste while running away from a lion.)

Usually, these systems find an equilibrium point and stick with it, dynamically pulling against each other to maintain it. And they also react to stimuli, changing the equilibrium point as necessary to adapt to daily needs.

Let’s talk about heart rate as an example. A normal heart will contract about 60-100 times per minute. This represents the physiological balance between the sympathetic and parasympathetic influences. At rest, (such as when you’re sleeping), the influence of the parasympathetic function will increase, and your heart rate will slow. When you’re exercising, the influence of the sympathetic function will increase, and your heart rate will speed up.

Another example: your eyes aren’t completely dilated or completely constricted at any one time; they usually hang out around a particular size (that changes slightly according to age). They use the sympathetic and parasympathetic systems to adapt the diameter of the pupil to the amount of light the eye is receiving.

Then, when the particular condition that’s pulling the system in one direction (say, toward the sympathetic side of things) disappears, the other system (the parasympathetic side, in this case) will exert enough influence to bring the systems back into their favorite physiological set point.

How is that not cool?

Your operational definitions are problematic.

It’s still not cool enough? Fine. I hear sex sells.

Fun with autonomics!

The sympathetic and parasympathetic systems are both involved in sexual activity. The parasympathetic system is responsible for arousal, and the sympathetic system takes care of things such as male ejaculation. The mnemonic to remember which does which? “Point and Shoot”. See, doctors are funny!

“Funny”… “Cool”… “Fun”…. You see, this is what I’m talking about. I’m getting you a dictionary for your birthday.

::Sigh:: Another one?

The other ones clearly haven’t helped.

Okay, fine. It’s not cool and doctors aren’t funny. But I still think it’s pretty awesome. So there.

Oh, Dr. G. We really need to get you a life.

It’s going to have to wait till after residency.

Published in: on July 20, 2010 at 1:48 am  Comments (22)  
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Tools for the Toolbox: Cancer

I’m a little uneasy about the whole idea of writing a post about using cancer as a fictional tool, because it’s such a devastating disease to patients and family members. But it is an important disease type, and I see it used everywhere in stories. Basically, whenever someone wants to deliver an emotional wallop. So…I’m going to give you some info on it.

But remember, cancer sucks. There’s nothing about cancer that doesn’t suck. And chances are, everyone in your audience will either know someone with cancer or have it themselves. So when you write about cancer, as with all diseases, try to remember that these are the things that destroy lives and tear families apart. Please write with a conscience.

And please take a moment to send some good vibes to anyone who is suffering from cancer, and to their families and friends. They could really use it.

And now, to the fictional world. As I’m sure you’ve seen in any number of stories, this collection of diseases can make a very useful tool for plot and/or character development.

Cancer is a general term to describe a type of disease: the runaway growth of a cell line. (This is also called a “neoplasm”, which means “new growth”.) Cancer can happen in practically any cell of the body. It’s a huge collection of diseases.

On the fiction end of things, cancer is a remarkably versatile disease type. So you can use it for many different situations, with practically any character.

What is it?

Cells have a mechanism for replicating themselves, dividing into daughter cells.

As you might imagine, there are a lot of brakes in place, so that cells divide only on the proper schedule. Because if the brakes are broken, the cells keep dividing and dividing. . . and you get unregulated, runaway growth.

Here’s a good visual for the kind of exponential growth we’re talking about (though the video shows quickly-dividing bacteria, and the cells we’re talking about divide much more slowly.)

You can imagine that even something as small as a mammalian cell could start taking up some room if there were enough of them in one area. And this is what a tumor is: a collection of uncontrollably-dividing cells.

If it’s a cancer of blood cells: the cells don’t stay together to form a mass, but they still divide uncontrollably, taking over the bloodstream by sheer numbers and making the fluid equivalent of a “tumor”.

Who gets it?

Anyone.

Old, young. Black, white. Male, female. Educated, uneducated. Anyone who has replicating cells can potentially get cancer. That’s you. That’s everyone you know. That’s everyone you’ll ever meet. Heck, it’s also everyone you’ll never meet!

However, certain types of cancer are more common in certain populations. For example, breast cancer is more common in women then men (although men can also get it). Prostate cancer is exclusively found in men, since women don’t have prostates. Male smokers are 23 times more likely to develop cancer (and not just lung cancer, by the way) than non-smokers. (I don’t have the specific statistic for female smokers, but I’d bet an arm and a leg that it’s similar. And I kinda need both of my arms and legs. Just saying.)

The NIH cancer-info site has a section on statistics about who’s getting cancer in various populations. It’s a good place to go looking: National Institutes of Health: National Cancer Institute

But to be honest, if you need one of your characters to have cancer, you can give them cancer. No matter who they are. I’m not going to call foul.

Why do you get it?

If the DNA of a cell (the blueprints that tell a cell how to act) becomes damaged in such a way that causes the brake mechanisms to fail, the cell may become cancerous. This damage can happen in many ways.

— A person can be born with genes that cause a cell line to become cancerous, such as in familial adenomatous polyposis.

— A person’s environment can cause enough damage that their cells become cancerous, such as with UV exposure and melanoma (a runaway growth of the pigment-containing cells in the skin.) There are also some environmental factors such as the human papillomavirus (HPV) that appear to cause cancer.

— A person can put substances in their body that damage the genes in their cells in a way that causes cancerous growth patterns, such as with smoking and various types of cancer including lung cancer.

— A person can have a genetic predisposition to developing a cancer, but will only develop the cancer if they are also exposed to an environmental factor or toxin.

The way your character gets cancer will probably depend on who your character is, how old, if anyone in their family has had cancer, and what they are exposed to either through their work or their living environment. It’s good to turn to the books to see if any known diseases fit your character type. Again, the National Institute of Health is a good place for this kind of selection research. It has sections on Cancers by Body Location/System, Childhood Cancers, Adolescent and Young Adult Cancers, and Women’s Cancers. It also has a wealth of other information. Go thou and research!

What are typical symptoms of cancer?

You can pretty much figure out what symptoms your character will have based on the function of the organ that has the tumor, and the function of any nearby organ that might be squeezed by a mass of growing cells. Also think about squeezing off a blood supply to a nearby organ, blocking lymphatic drainage, or squeezing the nerves in the area.

If it’s a tumor in the intestines, your character will likely eventually have trouble defecating due to blockage. If it’s a tumor blocking the common bile duct, your character will have symptoms that result from the blockage of the flow of bile and the resultant back-up through the liver: their stool will be gray/white and their urine will be brown, they could have pain on the upper right side of their abdomen (and classically, the pain could radiate to their back), and their skin could turn yellow (jaundice).

Beyond that, there are some classic, non-specific symptoms that many cancers share. Since the uncontrolled cell growth steals a lot of the groceries that the body would rather use to fuel its non-cancerous cells, a person could experience an unexpected and unintended weight loss and fatigue. Cancer cells can release chemicals into the body that generate unexplained fevers as well.

It occurs to me that at this point I should say: Please keep in mind that these symptoms don’t automatically mean you have cancer. They can show up with other diseases, too. If you have a symptom you’re worried about, talk to your doctor about it. It’s his job to sort stuff like that out.

When do you get it?

It’s most common in older populations. According to the American Cancer Society, 77% of all cancers are diagnosed in people age 55 and older.

But that doesn’t mean older people are the only ones who get it. You can give any one of your characters cancer, no matter what their age is.

However, do your research. Some types of cancer are more common in certain age groups. So, pick your organ of choice and look in a pathology text or on the NIH website to see if there’s any particular cancer type known to be likely in your character’s age group.

Where do you get it?

Cancer can happen in any organ. There are some organs that are more likely to develop cancers than others. For example, the heart and eyes are far less likely to develop a neoplasm (although it does still happen).

Here are two graphs showing the most common cancer deaths by year and type of cancer, separated by gender. (Please note that it’s the deaths from cancer that this graph shows, not how common the cancers themselves are. But it might give you a general idea about which organs like to create deadly cancers.)

How fast does it grow? How fast does it spread?

It depends on the type. Some cancers, such as Basal Cell Carcinoma, grow very slowly and are less likely to metastasize (spread to other parts of the body). And some, like melanoma, can grow very fast and spread to every organ system in a person’s body, long before the first symptom presents. It really depends on the type of cancer and where it shows up in the body. Research, research, research. (Sensing a pattern here?)

So, how can you use cancer in fiction?

Pretty much any way you want to, within reason. It’s a good disease type if you need something that develops slowly over years, and isn’t noticed until it’s too late. It’s a good disease type if you need a character to slowly waste away. It’s a good disease type if you need something that could have been cured early, but was missed and so became incurable.

The limits of cancer are pretty much the limits of your imagination. If you want to use a real disease: pick an organ, dig into a pathology text or the NIH and American Cancer Society websites (links in the “Sources” section), and see what’s available.

If you want to invent a cancer. . . well, you can. Pretty easily. Since it’s a mutation away from normal cell function, cancer acts the way cancer feels like acting. As with any other plot point, (1) do your research; (2) your audience will believe the story you tell as long as you justify it; and (3) keep your embellishments quiet and plausible.

Side note: Every once in a while, I see someone’s genius protagonist come up with “a cure for cancer”. It just strikes me as silly. Finding “a cure for cancer” would involve finding a cure for every single individual type of cancer. (Shout-out to medical researchers, by the way, who are devoting their lives to finding cures for every single individual type of cancer!) But please don’t be that writer. Thanks.

Okay, that’s probably enough for now. There’s clearly more to say, but this post is a long one already. Sorry for the choppy read, too.

Sources:

http://www.cancer.gov (National Institute of Health)

http://www.cancer.org/downloads/STT/500809web.pdf

http://www.cancer.org (American Cancer Society)

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Published in: on June 30, 2010 at 9:03 am  Comments (6)  
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