Medical plotlines/characters/realism critique

sozme

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Feb 24, 2013
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Hello, I just wanted to offer my services to anyone interested in critique of their medical plot-lines, characters, or synopses. Obviously this being SF/F and not medical thriller-oriented, I'm sure you would have more questions about minor details or old school field surgery (fantasy). Nonetheless, it is what I have to offer.

Background - I am a 4th year M.D. student in the USA currently in the process of interviewing for residency in internal medicine.
 
Not sure if you are inviting questions or offering a paid consulting service... but I do have a question along these lines, so if you intended the latter kindly ignore me :)

I have a character that needs to get knifed from behind... and I want him to be in bad shape, but able to walk around for a while and eventually find help. Do you have a suggestion as to specifically where I should have him get stabbed so that he wouldn't be immediately disabled / bleed out within minutes? And in a medieval setting, what's the recovery time for a wound like that? Thanks in advance!
 
I have a character who has just been shot in the knee and has lost a lot of blood. He passed out after he was attacked. The doctor in charge of his care suspects he also has brain damage, would it be unusual for her to put the character in an induced coma while they investigate?
 
Obviously this being SF/F and not medical thriller-oriented
Not necessarily :)

I'd like to pose a question in two parts if you don't mind.
A) If you found someone who appeared to be asleep with no signs of trauma or obvious medical condition, how would you treat them if it became apparent they could not be woken using normal methods?
B) If that person did not receive any form of medical attention, how long could the they remain in such a state before damage occurred?
 
I have a character that needs to get knifed from behind... and I want him to be in bad shape, but able to walk around for a while and eventually find help. Do you have a suggestion as to specifically where I should have him get stabbed so that he wouldn't be immediately disabled / bleed out within minutes? And in a medieval setting, what's the recovery time for a wound like that? Thanks in advance!

Not really any specific location I can recommend. If you get a flank stab wound, the easier ways to die quick are when you penetrate retroperitoneal structures i.e. kidney. Retroperitoneal space - Wikipedia, the free encyclopedia

The recovery time would depend on a lot of things, but any penetrating trauma in those days that didn't cause you to bleed out, people often died of infection. So the character would have to have good wound care.

Maybe the character could get stabbed by someone behind him, but the person stabs them in the front (i.e. pulls them and jams the knife into their abdomen). In that case, right lower quadrant is probably the safest place to get stabbed without being eviscerated.
 
I have a character who has just been shot in the knee and has lost a lot of blood. He passed out after he was attacked. The doctor in charge of his care suspects he also has brain damage, would it be unusual for her to put the character in an induced coma while they investigate?
They would be deeply sedated if the person presented to the hospital with altered mental status. Folks with significant neurologic impairment cannot protect their airway, and are intubated, which requires sedation and paralysis (in many cases). So the person in your scenario with a suspected severe traumatic brain injury from falling and hitting his head (guessign thats what happened after he was shot) would likely be sedated with a drug called propofol (for descriptive purposes, its a vial of milk-white liquid that is delivered through an IV) and in the intensive care unit on a ventilator.
 
A) If you found someone who appeared to be asleep with no signs of trauma or obvious medical condition, how would you treat them if it became apparent they could not be woken using normal methods?
Depends where they are found... this is actually not an unusual occurrence in patients staying in the hospital.

Usually you try to arouse them with noxious stimuli, i.e shouting, sternal rub, axillary pinch, etc. If they don't respond with anything (limb movement, faint vocalization, whatever), then they'd need more thorough neurologic exam including pupillary and corneal reflex, look in the back of their eyes (funduscopic exam), and then just thorough general physical exam. Basically you would look for signs of papilledema (sign of increased intracranial pressure) or posturing: Abnormal posturing - Wikipedia, the free encyclopedia

You would also want a full set of vital signs. Any nonresponsive or mentally altered patient will also have a point-of-care glucose (d-stick) performed, since hypoglycemic coma is relatively common cause of this phenomenon.

If they are unresponsive and vitals are abnormal you would respond to whats abnormal. If they are desaturating, you would bag-valve mask ventilate them, and possible intubate them. If they have a fever, you would CT scan them and do a lumbar puncture. If they have low blood sugar, you would give them an ampule of D50 +/- thiamine (for a homeless alcoholic found laying in the gutter). Many people like this end up getting brain imaging in the form of a non-contrast CT scan. If there was concern for a non-convulsive seizure, the person would get an EEG.

And then there are a bunch of other things and nuances. If you have written this scene, it would be easier to give you advice in the form of a direct critique of the piece. There is really no one single set of steps involved in evaluating every person with undifferentiated altered mental status. You rely a lot on clinical suspicion which is determined by who the person is, where they are found down, their medical history, etc. For example, a teenager found by his parents unresponsive in his room would make me strongly think of something like drug overdose vs. 3 month old baby where I would think of some inborn error of metabolism vs. 80 year old lady in nursing home which would make me think of something like hyponatremia or stroke. Epidemiology and what's most likely in a given demographic play a big role in determining the workup.


B) If that person did not receive any form of medical attention, how long could the they remain in such a state before damage occurred?
Depends entirely on the cause. In general, very few things that cause someone to become completely unresponsive will resolve without intervention.
 
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Not really any specific location I can recommend. If you get a flank stab wound, the easier ways to die quick are when you penetrate retroperitoneal structures i.e. kidney. Retroperitoneal space - Wikipedia, the free encyclopedia

The recovery time would depend on a lot of things, but any penetrating trauma in those days that didn't cause you to bleed out, people often died of infection. So the character would have to have good wound care.

Maybe the character could get stabbed by someone behind him, but the person stabs them in the front (i.e. pulls them and jams the knife into their abdomen). In that case, right lower quadrant is probably the safest place to get stabbed without being eviscerated.

Thanks!!
 
Aside from potential phantom pain later on, and the risk of developing a fat embolism, what are some of the risks associated with emergency or accidental amputation, if blood loss was taken out of the equation?
 
I can't write battles - I've never been involved with one, which makes all my descriptions second hand. So I'm seeing my present one from the interior of the infirmary tent with one of my main characters, a princess with no medical training, having volunteered to help out, while her dragon does stretcher bearer duties.

At the beginning of the battle patients are triaged, with the ones most likely to survive (and the most important officers) being worked on by trained healers while the bad risks go to the princess and her enthusiastic but ignorant and clumsy helpers, many of whom throw up and have to be led out of the tent as more danger than they are use in the first half hour.

But the trieurs have some medical training, so are called to help out in the 'high survival' (still not exactly MASH) region, leaving the princess to sort and choose, and I would like to put the dialogue as the head of the tri explains to her how to make the choices.

Weaponry is muzzle loaders, musket and canon, bows, largely compound but some longbows and crossbows, and bladed weapons. Armour is disappearing, but helmets and breast and back are still common. Microorganism theory of infection is known, but not generally accepted yet. I assume gut shots would generally be a condemnation, and certain liver, kidney and head shots, while massive blood loss or heart would never make it as far as the tent?
 
Aside from potential phantom pain later on, and the risk of developing a fat embolism, what are some of the risks associated with emergency or accidental amputation, if blood loss was taken out of the equation?
If we are talking lower extremity amputation, there are a number of problems. Usually these are associated with open, dirty/contaminated wounds, and that's a huge problem in a setting with no antibiotics. Infection can take the form of osteomyelitis or residual graft infection and is a source of chronic postoperative pain.
Most stump pain is pretty significant, but tends to fade after about 3 weeks.
Stump hematoma is a kind of rare but not so rare problem, the risk of which is compounded in the modern era by the use of anticoagulants (owing to amputee's high risk of venous thromboembolism).
You mentioned fat embolism, but thromboembolism in general is an issue for anyone with LE amputation because they will remain immobilized for long periods of time in recovery.
In studies, Many people with below-knee ampuations go on to suffer from myocardial infarction (something like 3%) and kidney disease. I don't know how useful those things would be for your story though.

I'll PM you a paper from a surgical journal entitled: The Role of Amputation in the Management of Battlefield Casualties: A History of Two Millennia
This may spark some ideas.
 
I can't write battles - I've never been involved with one, which makes all my descriptions second hand. So I'm seeing my present one from the interior of the infirmary tent with one of my main characters, a princess with no medical training, having volunteered to help out, while her dragon does stretcher bearer duties.

At the beginning of the battle patients are triaged, with the ones most likely to survive (and the most important officers) being worked on by trained healers while the bad risks go to the princess and her enthusiastic but ignorant and clumsy helpers, many of whom throw up and have to be led out of the tent as more danger than they are use in the first half hour.

But the trieurs have some medical training, so are called to help out in the 'high survival' (still not exactly MASH) region, leaving the princess to sort and choose, and I would like to put the dialogue as the head of the tri explains to her how to make the choices.

Weaponry is muzzle loaders, musket and canon, bows, largely compound but some longbows and crossbows, and bladed weapons. Armour is disappearing, but helmets and breast and back are still common. Microorganism theory of infection is known, but not generally accepted yet. I assume gut shots would generally be a condemnation, and certain liver, kidney and head shots, while massive blood loss or heart would never make it as far as the tent?
This resource may help you:

A manual of military surgery, by S.D. Gross, MD, 1861
 
In general, very few things that cause someone to become completely unresponsive will resolve without intervention.
The public understanding of "unresponsive" is not necessarily the same as that quantified by a medical professional. Lay reporting of unconsciousness does not always correspond to a GCS of 3, for example. So, the most common cause in the general public is too much alcohol, often on a Friday night. Unresponsive to the man in the street but can prodice a grunt with a sternal rub or a loud shout. Gets better on its own with a bit of luck and a bad hangover. Post-ictal state is another fairly common one which usually resolves spontaneously.
 
Interesting.

I have been researching how to set broken bones in the Middle Ages and come across some remarkably effective cures for some conditions. I hope you're not a scholar of those kind of remedies.

Although, I am partial to a leech, or ten... :D

pH
 

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