It's Probably Sepsis

Occasional writing, occasional thoughts, occasional pictures of flowers, occasional discussions of why I love sepsis

[aqlm]

Laryngeal Injury

There was a recent question about what someone with laryngeal injury would sound like and how that injury might occur. There are numerous excellent medical resources on this so I want to distill it down for a story writing audience.

 The larynx refers to a section of the anatomy rather than a single discrete item. It contains cartilage, muscles, and the vocal cords/folds. The most notable piece of cartilage is the epiglottis, which covers the larynx to prevent food and liquid from going into the respiratory tract while swallowing. The vocal cords control sound generation and the muscles of the larynx control airflow.

 Vocal cords primarily control pitch, volume, and limited phonation during speech. There are certain phonemes or word sounds produced in the larynx but most of the ones used in English are created in other parts of the respiratory tract, usually in the mouth.

 Injury:

 Just like every other organ, there are number ways of injuring the larynx. Blunt force trauma from the outside, irritation by a medical device, a penetrating injury from a blade, or damage from surgery are all possible ways of temporarily or permanently damaging the structures in the larynx. Some important things to think about when you’re writing your laryngeal injury:

 -          Someone with a laryngeal injury will have a breathy, raspy, and/or quiet voice caused by limitation of airflow. This may not be evident unless the person is tired or has been speaking for some time. The person is unlikely slur words and will be understandable.

 -          If you just want someone to have difficulty speaking, don’t use a laryngeal injury. The person will have issues with speaking but they’re in serious danger of suffocating due to lack of airflow.

 Most laryngeal injuries come from blunt trauma, such as smashing the neck on a steering wheel after a car accident. Those injuries can shatter the cartilage, collapsing the airway, or cause bleeding and swelling in the tissues of the larynx, also closing the airway. The good news is this is an excuse for an emergency tracheotomy. The bad news is the movies have lied to you about the effectiveness of pens in a pinch.

 -          Paralysis of the vocal cord is not just a speech problem. It’s a breathing problem. The vocal cords help with regulation of airflow. If they are damaged, people will have trouble breathing. It is also likely whatever caused the paralysis interferes with the function of the epiglottis. Prepare for lots of choking on food or even saliva if someone has bilateral paralysis.

 -          Endotracheal tubes used in artificial ventilation go through the larynx and irritate the structures inside. Long-term intubation through the mouth leads to damage to the vocal cords, either temporarily or permanently. This is one of the many reasons people who will be on a ventilator for a long time receive a tracheostomy: this will preserve vocal cord function for when the person is able to breathe on their own again.

 Story idea: someone who has been in the ICU for over a week is recently taken off the ventilator. This person has difficulty speaking not only because their respiratory muscles are weak but also because their vocal cords are damaged. Lots of whispered, tiring conversations. They’re not going to be speaking for very long or very loudly.

 -          Unilateral paralysis of the vocal cord can be achieved by cutting one of the recurrent laryngeal nerves, a delicate structure that is damaged during throat surgeries. It is also possible to damage just this nerve with a sharp blade. Being stabbed in the throat to cause cord paralysis is not a remarkable story technique because it’s more likely the person will be stabbed in the throat and bleed out due to nicking the carotid or jugular.

[aqlm]

Boozy Bacteria - Using Whiskey as a Disinfectant?

[aqlm]

Can a non-surgeon perform emergency surgery if a surgeon is on the phone?

I encountered this question recently in the context of writing an ER fanfiction. The writer wanted to know if a non-surgeon, in this case an emergency room doctor, could perform the surgery outside the hospital with a surgeon on the phone. I’m going to skip the technical limitations of doing a surgery anywhere outside of the hospital and instead discuss why virtually no nonsurgical doctors are qualified to perform surgery even in a hospital.

 In brief, most non-surgeons have not done any sort of surgery since their third year of medical school and would not be qualified to stitch up a patient let alone open up a patient. The best thing these doctors could do would be to use their life support training to stop bleeding, perform CPR, extinguish a fire, etc. and get that person to the hospital as soon as possible.

 In their third year of medical school, med students do a four to eight-week surgical rotation. They will see a variety of surgeries, with students in big academic centers seeing more cool stuff, but their role is mostly passive. Most medical students will do nothing more than hold tools (especially retractors, which is a running joke), sew incisions, meet patients, and write the occasional note. One of my friends removed a lung under minimal supervision but she was in the minority.

 After that year, many doctors will never see the inside of an operating room again unless they are getting surgery themselves. A psychiatrist or diagnostic radiologist may never do a physical exam, let alone an invasive procedure. Family medicine and internal medicine doctors may do nothing more complicated than putting in IVs or giving shots. Pathologists may not be around a live patient from the day they leave medical school. These people know the basics of anatomy and may recall some elements of their surgical exposure but most of them would not feel comfortable with a scalpel in their hands. The surgeon on the phone with them would need to remind them of the anatomy as well as the surgical procedure itself. From experience I can tell you how quickly you forget things you aren’t using even if six months ago you remembered them perfectly.

  As a side note, many surgeons will not feel comfortable operating out of their surgical specialties. An OB/GYN who can whip through five C-sections a day would feel very uncomfortable doing a cardiac bypass. An orthopedic surgeon is amazing at knee replacements would not feel comfortable removing the liver. There is a lot of specialization in medicine.

[aqlm]

Clear Dreams and Nightmares Part 2

My work is up on AO3. A bit of a taste: “Lady Kima,” shouted the gnome. 

She sighed and sagged within her armor. “Lady Kima, care to join us for a verse or three? Or does Bahamut forbid the singing of folk tunes?”

“Folk tunes,” sputtered Vex'ahlia. “Seriously? ‘The Trees of Westmarch’ is a folk tune. ‘Go Forth Young Elf’ is a folk tune. This is ridiculous portrayal of exaggerated sexual prowess. You should be ashamed to sing it in front of her!“

Scanlon pouted. “Aww, Vex. It’s all in good fun.”

Kima held up both hands to cease their squabbling. “Your defense is appreciated, Vex'ahlia, but not needed.” She pivoted towards Scanlon. “Bahamut’s laws are vague on the subject of the singing of bawdy tales. I rarely indulge as my duties seldom include nights drinking in taverns.”

“If you traveled with us further, Lady Kima, we could fix that,” replied Percy, looking up from his polishing cloth. “By my estimate, a good third of our adventures have been spent being drunk in some tav-oof.” The ranger reached over and whacked him in the stomach hard enough for the breath to get knocked out of him. “Hey! It’s true!” http://archiveofourown.org/works/11899989/chapters/27055287

[aqlm]

Appropriation isn’t okay even if you’re a minority

LGBTA writers: Stop misrepresenting us in fiction! We deserve accurate treatment and full, rich roles.

Also LGBTA writers: Here's this racial minority tradition I've ripped off to make my story cooler and more authentic.

[aqlm]

Clear Dreams and Nightmares

A piece of fanfiction from the Critical Role series The nascent powers of a fledgling god may vex even the stoutest of mortals, but they are dancing lights and vague shadows in the presence of the most awesome of dieties, Bahamut. Those who wear the Dragon’s sigil, who speak His name with pride, who worship Him with their deeds and valor, who count themselves among those honored chosen know how to bring Bahamut’s power to bear. They craft wards and armor, cast spells and draw runes, and surround themselves with His protection to keep the prying, insidious mind of Vecna from tearing them apart. 

Safe within the keep of Allura Vyrsoren, the Lady Kima, esteemed champion of Bahamut and warrior of His light, slumbers fitfully.  Before she allowed herself to rest, she repeated her enchantments and consecrated once more the hallowed ground upon which the home was built. She carved His form into the doorway and performed her evening meditation, then climbed into her bed. Vecna, his threat ever-growing, would find every passage into that home – magical, ethereal, or physical – barred by the colossal might of Bahamut. 

There are no wards, however, that will keep nightmares from tangling around the posts of the bed, sliding across the ornate wooden bedframe, and curling themselves into the recesses of Kima’s sleep. Such dreams are of her own making. No god need lend his aid. 

They come when her mind is already disquiet and her legendary resolve diminished by waking burdens. There is no shame in nightmares, she has been taught. Those whose lives have been in safety and comfort rarely see things that would return to trouble them, unbidden, in the night. A soldier who has trudged through the hells and witnessed the wickedness of man has made memories of valor. Few sleep easy who have seen what they have seen and done what they have done.  Reliving a horror survived is a mark of triumph, not weakness. She resents them, nonetheless. 

Kima finds herself in the torture halls of the Cruel King, her body destroyed and violated by a man who thought to break her. She watches again the men and women she led forth murdered in front of her eyes. On the worst nights, she watches her love in the throes of the Feebleminded spell, all trace of intellect and personality erased in a single act of betrayal. She would prefer to relive those months in darkness and agony, she reflects when awake, than a single second of that powerless grief. 

Kima does not wake up screaming. She does not sweat and thrash. She does not roll over and bury herself into the sleeping shoulder of Allura – the mage must rest, else her power is scantly restored. On most nights, Kima’s eyes flicker open and she recenters herself by observing the familiar stonework above the bed. She counts the inlaid pieces of tile and finds the blue piece of marble she chipped with a mighty and accidental swing of her weapon. She recalls Allura’s scolding and the happy penance Kima gladly performed that night after the incident. Though the room was restored in a flash of Allura’s magic, this piece resisted all mending. It became a focus of comfort, the memory and the familiarity allowing her to sleep once more. 

If that does not suffice, she slips out of bed and proceeds into the small chapel dedicated to Bahamut’s worship. She will meditate and hope that stills the mind. If not, she will hone her sword’s ever-keen edge and recite The 27 Precepts of The Dragon. Usually by the end of the tenth, that on the nature of justice in an unjust world, she will be prepared to fall back to sleep. Should all 27 leave her lips and she find herself awake and uneasy, she will take the final step of putting on Bahamut’s armor and attempting to sleep in a small bed she keeps in her own quarters. It would be an uncomfortable sleep, but she knew from experience nightmares would have no hold on her. 

Except she was already wearing her armor. She had not bothered with any of the usual techniques before bed. She had not even gone to Lady Allura’s bedchamber. Kima was preparing for an awesome war against an unthinkable foe. Wearing anything less than her armor would be foolish – they could be asked to go at a moment’s time. That was the explanation she gave Allura, at least, and the mage did not dissent. She respected her Lady’s judgment. If there was a reason Kima would absent herself from their shared space, Allura would respect it. So what if the other reason was that Kima knew the nightmares would find easy purchase on a greatly disturbed mind? T

hey came, as predicted, an amalgamation of the horrors beneath the duergar city spliced together with the defiling of Allura’s mind. In this one, Kima was bound and watched in mute horror as the torturer took the hooks from Kima’s flesh and raked them, one by one, across the mage’s body. Kima’s ears filled with the screams of mercy and pain, mixed with a begging wish for her love to rescue her. Kima’s will was bound with tight iron and she could neither release the object of her desire or speak words of comfort. Within the depths of the dream, she found Bahamut’s truth and forced herself awake. 

A bead of sweat trickled down Kima’s brow and she sat upward from the bed in her quarters. The candlelight told her just an hour had passed since she settled in for her uneasy sleep. It had seemed longer. It always did. She swung her feet around and got up, straightening the metal breastplate from where it dug familiarly into her neck. There would be no rest for now, it would seem. 

[doctortay-deactivated20210629]

Do you write M/M and/or F/F fic?

Hello to all my fellow slash writers!! 

As many of you know, I am in the process of revising my doctoral dissertation in to a book for publication, and I need your help!

As soon as I made the decision to write my dissertation about slash, I wanted to survey fic writers to learn more about our collective experiences, but the realities and time restrictions of graduate school didn’t allow me to do so. Fortunately, my publisher is very excited to include the experiences and insights of slash writers in the next version of this project, and that is where y’all come in! 

If you’re so inclined, please complete my Writing Slash FanFiction survey  to share your thoughts and feelings about why and how you write slash fic. 

This survey is specifically for slash fic writers of any and all fandoms. For the purposes of this project, I am defining a slash ship as any M/M or F/F relationship. The ships can be canon (e.g., Clexa from The 100) or non-canon (e.g., Sterek from Teen Wolf). New and veteran fan writers of all ages, gender identities, and sexual orientations are welcome and encouraged to complete the survey. There are 17 questions, and you can write as much or as little as you like. Please, however, answer every question. At the end of the survey, you have the option to provide your Tumblr or email address in order to be entered in the three raffles I will be holding to thank the survey participants. I will be raffling off three copies of Fascination/Frustration, a Fandom Surprise Pack, and two 2,000 word fic prompt fills!  Thank you very much for your time and support of this project and please, do not hesitate to contact me with any questions or comments! You can email me at [email protected] or contact me via Tumblr.

Also, please signal boost and reblog - the more the merrier!

[aqlm]

How to make a sick character

The magnificent @scriptmedic an excellent purveyor of medical advice and has inspired me to think more about writing illness. I direct you to her e-book that is so good and so bite-sized. Moving on.

 Writing a sick character shouldn’t just be choosing a fun disease and looking at the Wikipedia page for how it’s treated. You, the excellent writer, want to create a portrait of a sick person that is accurate and involved. We’ve all read stories of beautiful people who have cancer and we’ve all seen Grey’s Anatomy or its ilk. So why not think about illness in the same way a doctor does for a change?

Here are things I keep in mind before I walk into a patient’s room as a medical student.

Signs and symptoms

People don’t show up at the doctor’s office and state, “I have cancer!” If they do, they have typically spent too much time alone in the dark with Dr. Google. Most often they’re going to show up with a sign or symptom of a problem and ask what the hell’s going on. A sign is something objective that the doctor can observe – a rash or an abnormal blood test. A symptom is something the patient reports but the doctor cannot independently verify, like fatigue or elbow pain. Not all diagnoses require signs, FYI. There are no consistent objective signs of migraines but their symptoms are successfully treated all the time.

Is your patient showing up with one big scary sign or a cluster of vague symptoms? Did somebody else notice it or did they notice it themselves? Was something detected during a routine scan at work or during a yearly medical screening? Is the person sick or is this symptom or sign occurring while the person otherwise feels fine? 

 Cause

Infection, cancer, and heart attacks are all common and instantly recognizable but don’t begin to approach all the wonderful ways our bodies can go awry. Don’t overlook the roles of metabolic problems, toxicities from prescription medications, degenerative diseases, autoimmune diseases, and many others. Infection an easy go to because it’s an obvious way to take somebody from completely healthy to suddenly ill but it’s certainly not the only tactic. The person who ends up in the hospital with an adrenal crisis secondary to an undiagnosed pituitary problem is going to be impressively ill in a new and interesting way.

 Onset

Is this a new symptom (acute), one that’s been happening for a few weeks (subacute), or one that’s been happening for a few months or longer (chronic)? Is this a completely new illness or is this someone who has been sick for a while and is suddenly worse? Did person think they had one disease but it turned out to be a totally different disease?

If it is a new symptom, was the person perfectly healthy beforehand or was the person sick but didn’t know it? In many cases, our bodies can compensate remarkably for things that are slowly going wrong. Someone who is severely anemic due to a slow internal bleed can do well with a hematocrit that would send the average person to the hospital for transfusion. If that anemic person gets a cold, the body stops being able to compensate and the anemic person becomes very ill.

 Diagnosis

Many diseases are diagnosed clinically, that is, without the doctor ordering any tests and relying on patient report. Other problems need supporting documentation in the form of bloodwork, cultures, diagnostic imaging, or psychological testing. Some diseases can be diagnosed by family doctors and other require a specialist. Occasionally we have no idea what something is and throw treatments at it in the hopes something will stick.

Different tests take different lengths of time to schedule, perform, and be read. You can get the results of an HbA1c, which helps test for diabetes, back in minutes but it will take weeks to grow out certain types of bacteria. You may not be able to schedule your biopsy for months but you can probably get an x-ray today. Will insurance cover these things? Do you need to go to one of the few hospitals in your state or country who can do this test?

 Treatment

This is not just a matter of curable versus incurable. There curable diseases where the treatments are so expensive most people can’t afford them or so invasive most people don’t want them. There incurable diseases that can be successfully maintained for decades on end - think diabetes or depression, but also some forms of cancer and even HIV.

If there is a treatment that is a chemical, is it a pill, injection, implant, or infusion? Are there side effects, cost concerns, or drug interactions? If there’s a surgical cure, what are the side effects of the surgery? Does the person have to live near hospital to be treated or is this something that can be managed by a local doctor? Are there alternative or controversial treatments?  If there is a treatment, does the treatment make the person more likely to have other diseases? This is important with chemotherapy but also with treating anything needing immune suppression. Somebody who is being successfully treated for rheumatoid arthritis may be more likely to get infections because their immune systems are so crushed.

Course

Is this a curable disease, fatal disease, or chronic? Does this need medication to be cured or will it go away on its own regardless? Will it leave a lingering problem or will there be no trace once it has passed? (Shout out to NCIS for referencing Tony’s getting the plague when discussing scarred lung tissue). Will it be a disease that unpredictably gets better and worse (relapsing/remitting)? Will it be disease that constantly gets worse (degenerative)?

Remember some diseases appear to kill quickly because they are only detected when the person is very ill already. One of the reasons for the terrible prognosis of ovarian cancer is its tendency to be detected only once it has metastasized and is symptomatic. The cancer itself is not necessarily terrible but the lack of reliable screening and early detection means a woman diagnosed with ovarian cancer usually has cancer throughout her abdomen as opposed to an isolated tumor. Also remember it is possible to die *with* cancer instead of *from* cancer. Men with prostate cancer tend to die *with* it - something other than the cancer kills them.

 Ending thoughts

I look forward to meeting more people in fiction who are sick with things that I see every day. No, not cancer or strep throat but congestive heart failure, nasal polyps, and osteoarthritis of the knees. Good luck and happy writing

[aqlm]

Dendrobium sp. unknown (possibly macrophyllum) - Dendrobium orchid

Chicago Botanic Garden, June, 2015

Took new friends to see the flowers. We haven’t had a summer trip since then; school has been so busy.

[aqlm]

Chemotherapy side effects: It’s more than just barfing and wigs

Inspired by @scriptmedic, thoughts on medical writing from a medical student. 

If your character has cancer and is getting chemotherapy, chances are you’ve written a thin woman in a headscarf who has to keep a bucket near her at all times. While this isn’t necessarily incorrect, it is incomplete and arguably less interesting than real life.

When writing about chemo side effects remember the following:

Different cancers are treated with different chemotherapy drugs

Different chemotherapy drugs have different side effects

People get several “rounds” of chemo several weeks apart, so side effects will wax and wane

Side effects can occur shortly after treatment or several weeks after treatment

Patients can feel fine the first 24 hours after chemo

Most nausea/vomiting resolves in the first week and can be helped with Zofran (tm) 

Some symptoms may not appear for days, weeks, or years (!)

Here are side effects that lend themselves to more interesting stories.

Infertility. Have your character struggle with this. Does she want to undergo the invasive process of harvesting eggs? He is too sick to put off treatment so he can store his sperm.

Sensory disturbances. Temporary or permanent hearing loss, peripheral neuropathy (pins and needles), changes in taste and smell. 

Hand/foot swelling. This can range from uncomfortable to debilitating. Your character may start dropping things or find walking almost impossible because of pain.

Irreversible heart damage. This can be a huge setback. Your character is doing great on chemo, tumor markers are going down, and boom, testing shows cardiac damage. Now the treatment needs to be changed to something that may be less effective.

Mouth sores. These can generalize to sores anywhere in the mucosa (esophagus, nose). Even drinking water is painful.

Increased chance of later cancers. Chemo damages cells and damaged cells can lead to cancer. Your character celebrated 10 years free of lymphoma and ends up with bladder cancer.

Look up your cancer’s treatment protocol on https://www.cancer.gov/ and discover which side effects are right for your cancer. 

[aqlm]

Rose, unknown type

07/2015, NY Botanical Garden

Arguably the best flower picture I will ever take, aided by a patient hand who held the flower steady.

[aqlm]

Brief thoughts on cancer

The relative fruit size (grape, nectarine, cantaloupe) or sporting size (golf ball, softball, football) of your tumor is not the main determination of your survival. Where it goes, how it grows, and what it does to the rest of your body are just as important.

Unexplained weight loss is a great thing until it causes muscle wasting.

The best screening for ovarian cancer is “Don’t”. 

[aqlm]

“Her lungs sound like garbage.”

The neurointensivist was displeased with our mutual patient’s pulmonary function. 

[aqlm]

Echinops ritro - Globe Thistle

New York Botanical Garden, 07/2015

Out with my parents, eating fancy cheeses, and forcing them to stop every foot to take a picture.