Author Question: Can Onset of Paralysis be Delayed after a Fall?

Kaylee Asks:

In a book I am working on the main character falls off of a one-story wall injuring his back. Could he be paralyzed? If so, would it be possible for paralysis to set in an hour or two later? Would he be able to remain conscious and still walk for about an hour? He is a spy, mid 20’s, strong, and loves to run.

Jordyn Says:

In my experience, I’ve never seen a delay in onset of paralysis. Usually, it is immediate. I’ve not personally seen people with devastating paralysis from a fall from this height. Broken legs/arms, lacerations, and concussions . . . sure. Could a spinal cord injury happen? Of course there are always outliers. If you did write this, it would help believability if the character fell directly onto their head (called an axial loading injury) or onto another hard object (like a rock or something with a hard edge) to increase the chance of a complex fracture causing paralysis.

I did some hunting regarding spinal bones specifically. This article says three meters (which equates to about 10 feet or one story) can cause spinal fracture, but just because you break the bones doesn’t necessarily mean paralysis. A person with a stable fracture of their back can be up and walking around. I’ve seen this plenty of times.

I  did find one article where a woman did have delayed onset of paralysis of four days, but if you read through the article she had a significant mechanism of injury and died as a result of complications of her injuries.

Best of luck with this story!

 

Author Question: Is There a Drug that could Mimic Death?

Toni Asks:

I’m writing a contemporary retelling of Snow White. I was wondering if you have any suggestions on how the stepmom could intend to poison her but is not successful. Instead, maybe just paralyzes her or slows her respiratory system down to where it seems she’s dead. Any suggestions?

Jordyn Says:

I brainstormed this with a co-worker pharmacist and these are our thoughts.

There isn’t a current paralyzing agent that will work for this scenario. A couple of problems with paralyzing agents is that they never just slow down respirations— they knock them out totally. Plus, in the absence of a sedative, the person is very much awake and panicked because they can’t breathe. Giving this drug alone could not mimic death and would rapidly cause death from hypoxia unless medical intervention was given post haste.

The drug we came up with for you is called Donnatal and can be given as an elixer. It has four medications: Hyoscyamine, Atropine, Scopolamine, and Phenobarbital. The hyoscyamine actually helps with intestional disroders like irritable bowel syndrome. It is the other three components that will help with your scenario.

The atropine and the scopolamine both act to dilate pupils and could mimic fixed and dilated pupils that you get upon death.

Phenobarbital is a barbiturate and can be used to treat anxiety and seizures. Overdosing on phenobarb will cause slow and shallow breathing.

Here is a patient teaching sheet for further information.

Hope this helps and best of luck with your story!

Author Question: How Long Before a Teen Diabetic Gets Sick Without Insulin?

Megan Asks:

I’m so glad I found your website. I would love it if you would answer this on your blog. Thanks for reading and I look forward to your answer.

My YA manuscript has scenes with two sixteen-year-old teenage boys on a  twelve hour adventure race in the mountains. One of the boys has Type 1 diabetes. He consistently tests his glucose and knows what to eat/drink and he has an insulin pump. All is going well until his insulin pump malfunctions and he realizes he has left his back-up insulin in a cave they had sheltered in earlier in the story.

My specific medical question: What would happen to him if he has to wait approx. one to two hours for the other boy to retrieve his insulin and return to him? What symptoms would he show? And, after taking the insulin (1 – 2 hours past his regular schedule), would he be able to function well enough to walk to the finish line area without further medical assistance?

Jordyn Says:

Hi Megan!

Thanks for sending me your question.

I don’t think your character would be affected dramatically by a one to two hour delay in getting his insulin.

Insulin works to transport sugar from the outside of your cells to the inside. In the absence of insulin, his blood sugar will start to rise but how fast it rises depends on a lot of factors. For instance, what is he eating and drinking? How vigorous is he exercising? Considering he is stopping to rest and wait for his friend will help.

The rise in blood sugar is problematic, but is actually not the most concerning issue. What usually causes the emergency is a build up of acids in the blood due to the body’s inability to use the sugar inside the cells. Because the body still needs energy to run, it begins to break down fat for energy leading to a rise in ketones in the blood— hence the name diabetic ketoacidosis (or DKA).

If he were to continue to exert himself, I could see a situation where this process could be hastened, but though he might not feel awesome— I don’t think he would be incapacitated. Also, if he’s not eating or drinking, his blood sugar could also get too low depending on what type of insulin his pump was delivering.

I found this article that gives some tips on what the patient might be feeling. In my experience, I haven’t seen anyone using the blood based ketone testing— just urine test strips.

Some sites say DKA can develop in one to two hours. That might be true, but I would be doubtful a patient would be incapacitated in that time frame. They may not be feeling great, but can function. How severe DKA is really depends on how acidic the blood is when they seek treatment. Some people have ketones in their urine, would be considered in DKA, but their blood is not that acidic. People like this can usually be rehydrated with fluids in the ER, an insulin correction given, and sent home.

The more acidic the blood— that determines the course for a pediatric DKA patient. We measure this by the pH of the blood via a blood gas. Diabetics who have very acidic blood generally end up in the ICU for many reasons I won’t outline here.

Hope this helps.

Author Question: Frozen Body

Susan Asks:

I just stumbled on your site while doing a search, and I wonder if you can answer this question. The victim in my latest book has been pushed through a hole in an ice-covered lake. She drowns, and her body slips under the ice. Her body is not found for two days. Would the body literally be frozen, to the point that it would have to be thawed before an autopsy could be conducted? Or would it just be really, really cold?

Jordyn Says:

Hi Susan! Thanks for sending me our question.

My opinion is that the body would not freeze and would not need to be thawed for autopsy.

In researching this— it appears that water underneath an ice sheath on a frozen lake (though still really cold) is not at 32 degrees F but could be as warm as 40 degrees F. Since fish are cold-blooded and will take on the temperature of their environment and their tissue doesn’t freeze– then I don’t believe a deceased human’s would either.

Best of luck with your story!

Author Question: Transplanting an Infant with a Congenital Heart Defect

Erin Asks:

I stumbled across your blog earlier this week and you have no idea how incredibly excited I was to have made the discovery. I’ve been devouring your recent blog posts and I am so impressed with the details of your answers. You are amazing!

I recently finished the first draft of a novel, tentatively titled The Blood Farm. It is a story about what happens to society when we begin to view one another as commodities.

I have tried to do my due-diligence in researching medical practices, specifically organ transplants, but I’m not confident in all the details.

Here is my question:

In the scene, an unborn baby is diagnosed with multiple genetic defects (including hypoplastic left heart syndrome) that have caused her organs not to form correctly. She is scheduled to undergo a heart and double-lung transplant following birth. The mother goes into pre-term labor and the baby’s outlook is dire.

What would the procedure be for prepping this baby for transplant surgery?

Jordyn Says:

Hi Erin! Thanks for all the compliments regarding my blog. I’m so glad you have found it to be a useful resource.

First of all, for the blog readers, a simple explanation of hypoplastic left heart syndrome (HLHS) is that the baby is born with an underdeveloped left ventricle. The left ventricle is the primary part of the heart that propels blood out to the body and is larger in size than the right ventricle. If the heart’s strongest chamber is weak, it’s easy to see how this can be problematic for life. Also, this is generally not the only thing wrong with the heart when there is this congenital heart defect.

There are two approaches to the management of Hypoplastic Left Heart Syndrome. One is a three-staged operation over the child’s first few years of life and the other is transplant, but the first surgery will still be required to save the baby’s life even if going for transplant.

First thing to know about HLHS is that it is a ductal dependent lesion which means that the way the baby’s heart formed in utero is required post birth. When a baby is born— two holes in the heart close— one (the PDA) pretty early. We need to keep the PDA open for these infants so a drug called Prostaglandin E is given as a continuous IV infusion to keep this hole from closing.

Most often, babies with this condition are known prior to birth so once they are born they could be intubated depending on their work of breathing and oxygen levels. These infants have lower than normal oxygen levels and don’t have normal oxygen levels until after their third surgery, but they are always started on Prostaglandin.

The plot you propose regarding a heart transplant for a newborn infant is very tricky. It will take months to find a heart for this baby. The earliest a doctor friend of mine had heard about transplanting infant’s like this was at three months of age. As I mentioned, there is a three-stage operation that can also be done with survival rates at about 70%. From what I can tell from this article this matches the transplantation survival rate. However, the ethical argument, due to the limited availability of donated infant hearts, is that the three staged operation should be used in these infants to save those limited infant hearts for children with other conditions for which there is no other treatment.

Babies born with HLHS will not leave the hospital until their first surgery is done.

So, all this to say, I’m not sure HLHS would be the best condition to give this baby.

You might want to consider some of the hypertrophic cardiomyopathies. This pamphlet would be a good place to start.

Author Question: Transplanting an Infant with a Congenital Heart Defect  Click to Tweet.

Can You Fake an Ultrasound in Real Time?

Gerard Asks:

I came across your blog as I was googling my question. This week, I was watching Grey’s Anatomy (Season 14, episode 18) in which an unscrupulous (or maybe it he was just a fraud?) doctor was giving false diagnoses for breast cancer through ultrasound—I think to sell treatment?

Knowing a little about computers, I wondered how that could be possible. Can an ultrasound store the millions of images or 3d imaging from another patient to be “played” on another patient? Of course, I wrecked the show for my wife by questioning the episode she was enjoying.

So, in case I’m all wet in my assumptions, is it possible to fake an ultrasound in real time?

Jordyn Says:

Hi Gerard! Thanks for submitting your question to me. The perfect person to answer your question is Redwood’s resident medical expert, Shannon Moore Redmon.

Shannon Says:

Today’s ultrasound technology does offer the ability to record video clips that an extremely unethical doctor could replay while pretending to scan a patient with a probe. Most patients would not know the difference between normal breast tissue compared to a malignant mass and the shape of the entire breast isn’t really a factor on the ultrasound screen, since we’re only scanning a small section at a time.

With that said, the hoax displayed in the Grey’s Anatomy episode – Hold Back The River, would be difficult to achieve in real medical life.

Gold Standard

First, ultrasound is not the Gold Standard for detecting breast cancer. That role belongs to mammography (x-rays of the breast). Highly trained technologists position and complete several different mammography views. Ultrasound simply supports suspicious lesions first detected on these images. Doctors use the scan to provide more information and ultrasound should never be used alone to detect malignancy. I hope most patients would not simply take a doctor’s word based on an ultrasound alone when determining whether they have breast cancer or not.

When a mass is identified on a mammogram and followed up with ultrasound, these images or video clips do not give a complete diagnosis of cancer. We can suspect cancer by the appearance of the mass we see, but the only way to know for sure if the mass is malignant, is through a biopsy. Stereotactic breast biopsies are often performed at imaging centers or hospitals. A large needle is used to take samples of the mass and then send them off for pathology testing. Those results tell if a mass is cancerous or not. If the patient is not a candidate for stereotactic breast biopsy, then the mass can be removed in surgery and sent to pathology for testing.

Appearance

When a sonographer finds a suspicious mass on ultrasound, we look for several factors in the appearance. Is it solid or fluid filled? Does is have smooth borders or finger-like spiculations extending into normal tissue? Does a shadow present posterior to the mass? The mass shown during the episode did not meet the specified criteria for malignancy. Let’s break the moment down:

The doctor shows the female character a mass on the screen. There was no shadowing posterior. The borders were smooth and looked like the normal tissue adjacent to it. The area the physician suggested was solid but had a Cooper’s ligament running through the tissue which is typical for a normal lobe of the breast. I’ve included an ultrasound image of a true malignant mass, so you can see for yourself what a true breast cancer might look like on ultrasound. I think you’ll find the video clip played in the scene looked nothing like the true cancer below.

 

 

 

Exam Inaccuracies

During the scene, a swishing heartbeat noise can be heard in the room. Grey’s Anatomy seems to think that when an ultrasound is being used, every machine creates this noise. Let me assure you, that’s unrealistic.

The noise heard in the background is created by a Doppler sample of a vascular structure, such as an unborn baby’s heartbeat or blood flowing through an artery. Neither of these were being scanned during our breast exam.

When no Doppler is activated on the screen, this sound cannot be heard. But yet, we have the heartbeat noise once again. I wish someone at Grey’s Anatomy would update their sound effects team.

After the blond female doctor goes back to Seattle Grace, she has her doctor friend scan her breast to make sure there is no cancer. The doctor who performs the scan and supposed to be knowledgeable enough to detect breast cancer, is holding the wrong probe. She should be holding a linear transducer used in high frequency imaging and provides a rectangular footprint on the screen. Instead, her probe is curved and used for abdominal and pelvic scanning because of the lower frequency range.

Another flaw in the episode is how all these doctors are experts at performing scans in every area of the body. In real life, trained, registered sonographers and technologist work in these modalities. They would be the ones to execute the imaging. Then a radiologist would read the exam and communicate with the surgeon or other physicians. But once again on TV, we see the Grey’s Anatomy doctors performing all the imaging exams. No sonographers or technologists around anywhere. So unrealistic and a little insulting.

I think it is time for the Grey’s Anatomy team to hold back more than the river— they need to hold back on performing any more ultrasounds until they consult a living breathing registered Sonographer.

********************************************************************************************
Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.

Author Question: Treatment of Teen Suicide Victim (2/2)

Today, we’re continuing our discussion of the medical treatment of a fifteen-year-old male suicide victim who slit his wrists at school. You can find Part I of the discussion here. In this post, we’ll focus on more of the mental health aspects over the medical treatment.

Pink Asks:

Upon examining a patient, and if sexual abuse is suspected, what is the hospital protocol? How do the hospital staff work with police and the victim’s family?

Jordyn Says:

If outward physical exam of the skin shows injuries concerning for sexual abuse, this can be handled several ways. In order to answer this best, I’d need to know what kind of hospital your patient/character is at in order to give advice as to how that community would likely respond but I’ll give thoughts as to how my institution would handle it—which is a large, urban pediatric medical center. A rural hospital would likely handle it much differently.

One thing I want to say is that no sexual assault exam would be done without the patient’s consent (or parental consent—a court can order if needed)—so this would not be done on an unconscious person. What you can see from the outside would be the limit. For instance, in girls and women no internal vaginal exam.

There might be an extreme outlying caveat to an internal exam if the patient were near death, concern for loss of evidence, or other victims were at risk, but it would have to be VERY PRESSING circumstance and likely the courts/law enforcement would be involved in order to move forward.

Regarding the suicide attempt, the next thing to keep in mind is that the patient’s medical needs are always addressed first. In fact, the patient must be “medically cleared” by a physician before they can participate in a mental health evaluation.

If there is a concern for sexual abuse, we would first contact social work through our hospital to develop a game plan. If a sexual assault exam needs to be done, we have health care professionals that are very experienced in doing these with kids/teens and we want the most experienced professional to do the exam and collect any evidence. Social work will do a couple of things if they think the concerns are valid. One, report it to the state (Department of Children and Family Services—something along those lines depending on the state) and second, report it to the police if they believe a crime has occurred. The incident is reported to the police jurisdiction where the crime took place and not the location of the hospital where the patient is receiving care.

As an example, if a woman is raped in Anchorage, AK, flies to Seattle and seeks treatment there, the hospital in Seattle is going to have to call Anchorage, AK police to report the crime. Local police can help determine the appropriate jurisdiction if it’s not clear.

The timing of the sexual assault is important in collecting evidence. If a person was just raped, we’d be very anxious to encourage the person to have a sexual assault exam done ASAP. If they are reporting something that happened more than three days prior (it’s 72 hr for us)—it’s not as pressing that an exam should be done immediately but plans can be made with the patient and family for follow-up exam and care.

Larger police departments typically have victim advocates that can help families through processes like this, but it is up to them to call that person in. Contrast this with a more rural hospital that may “hotline” the concern for abuse to the state, call the police, and depend on state social workers to determine the course of action.

Pink:

Are patients who attempt suicide always sent to a mental health facility for treatment? I know patients speak with a crisis counselor, but what if the attempt wasn’t caused by being under the influence of drugs, or a mental illness, but due to a desperate situation (domestic violence)?

Jordyn:

The most important determination about whether or not someone will receive psychiatric care is whether or not they are a current danger to themselves (and/or others) and how likely are they to act on it. This is determined by a mental health professional and not the medical staff. The reason for the attempt doesn’t necessarily differentiate potential lethality—it’s what the patient is thinking about in their mind and how at risk they are to act on it.

I think you’re trying to make a distinction that a desperate situation caused by domestic violence leading to a person’s suicide attempt would be seen as less lethal and it wouldn’t. If a person is trying to kill themselves because their home situation is driving them to do that—that is very significant and taken as seriously as someone who swallows pills, or slits their writs, or is having a psychiatric break. Someone attempting suicide due to domestic violence will likely have other co-existing mental health issues like anxiety and depression.

This is a very serious topic and definitely worthy of fiction to help foster discussion of suicide. Good luck with this novel.