The Mythical Shot of Adrenaline

Recently, I read a great thriller by a well-known author, who had a wee little error in his medical facts, but one that took me out of the story at a key moment: As the injured and sleep-deprived protagonist desperately seeks to save his daughter from a horrific serial killer (yeah, redundant, but this guy was super-twisted), he asks a doctor to give him a shot of adrenaline. Said doctor complies.

Unfortunately, that scenario sets off the MD BS-detector (and I don’t mean Bachelor of Science).

Adrenaline

A “shot of adrenaline” does exist, as in the epi-pen prescribed for those with an anaphylactic reaction (lethal allergy) to bee stings or peanuts. The intramuscular injection prevents the most deadly effects, including closure of the airways (bronchospasm) and low blood pressure (vasodilation). However, the injection lasts no more than fifteen minutes, and that only because of gradual release from the muscle. Once in the bloodstream, adrenaline lasts less than a minute.

The rationale is not unreasonable, when we exercise, or are terrified, or are terrified because someone suggested we exercise, we secrete adrenaline. It increases breathing, heart rate and blood flow, and releases sugar into the bloodstream (energy to burn, so to speak). But a shot into a muscle for gradual absorption is not the same as your body dripping it into your blood stream. Not to mention, adrenaline is only one of many hormones of exercise.

And then there’s the down-side–heart attack from constricting the coronary vessels, cardiac arrest from arrhythmia, stroke from extremely elevated blood pressure, etc.

So, while a well-timed injection of adrenaline can save the life of an anaphylaxis or cardiac arrest patient, an unnecessary shot of adrenaline is more likely to be lethal than to give your hero energy to chase the bad guy.

As an aside, the whole “adrenaline vs epinephrine” argument is interesting, though perhaps only to geeky wordophiles. The hormone was identified in an extract from the top of the kidney. In Greek derivation, on (ad) the kidney (renal). Unfortunately, the company that marketed the drug trademarked the name Adrenalin (without the ‘e’) in the US. So, while the rest of the world uses the term adrenaline, in the US we use the Latin version epi (on) nephron (kidney) = “epinephrine.”

Not a big deal, until a US doctor in Europe tries to help in an emergency and skips over a vial of adrenaline in search of epinephrine (or vice versa, of course).

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Needed: A Poison

Question from a reader: I need a fatal poison for a 105-lb. woman that begins acting in 20-30 minutes and the victim dies shortly thereafter – within an hour. Just after ingesting the poison in an alcoholic drink, the victim needs to be physically able to walk or stagger to a nearby subway stop, take a 5-10 minute ride to Grand Central, and then get on a commuter train. She’s found dying on the train after it leaves the station. Cyanide and Strychnine both seem to work, but the newer prescription medications don’t. I’m a rank amateur at this. Would you be able to suggest a suitable poison?

Cyanide would do it (remember the Tylenol murders?). Speed of onset is dose-dependent. The victim would feel “general weakness, giddiness, headaches, vertigo, confusion, and perceived difficulty in breathing. At the first stages of unconsciousness, breathing is often sufficient or even rapid, although the state of the person progresses towards a deep coma, sometimes accompanied by pulmonary edema [fluid in the lungs], and finally cardiac arrest. A cherry red skin color that changes to dark may be present …”

Basically, cyanide causes the body to be unable to use oxygen. There may be plenty around, but the cells can’t use it. This is a reasonably good reference if you want more info Cyanide Poisoning.

Note that sugar inactivates some of the cyanide so maybe don’t mix it in a daiquiri…and it smells like almonds, so something like amaretto would mask it nicely.

Strychnine would be less appropriate for your story as the victims are in a lot of pain and have muscular contractions that would be visible and garner attention on the train. Also, the onset is probably too fast.

Arsenic would be too slow for your purposes here.

Digitalis (digoxin) toxicity is another option, but it’s onset is a couple of hours so she’d need to be at the bar for a while before she heads out. If you want more info about that, let me know.

To Touch a Corpse

I have a question about body temperature and death. Would the skin be cold when feeling for a pulse after 4 hours, on a summer afternoon but after a heavy rainstorm. Would the rain be enough to cool the skin or would it still be warm to the touch? Thanks so much!

What an interesting question. Not something I know off-hand, but here’s what I found…

Old ‘rules of thumb’:

• body temperature falls by 1.5 degrees F (<1 degree C) per hour;
• time since death (in hours) = fall in body temperature from 37 degrees C + 3
• skin feels cold 2-4 hours post mortem indoors (6-8 hours in protected areas)

Read more: http://www.forensicmed.co.uk/pathology/post-mortem-interval/

So you are used to a body feeling like it’s 37C (98.6F). After four hours, falling at 1.5 degrees per hour, it would be 92 degrees. Of course if the ambient temperature is higher than that, it won’t fall, but that’s mighty hot even in the summer. And rain would cool the skin even faster, the rainwater is significantly cooler and conducts heat easily from the body to the surrounding air.

So yes, I believe the skin would be cool to the touch.

Intubation Essentials

“Before he could respond, George was called away to assist with an emergency endotracheal intubation because he was stronger than the other nurses and they needed help restraining a combative patient intoxicated on an unknown cocktail of pharmacologic agents.

After an injection of a muscle relaxant, they forced a tube down the patient’s windpipe, and they monitored him closely because an overdose could lead to respiratory paralysis and asphyxiation.”

This text was sent recently, with a request to comment, which suggested a need to better explain endotracheal intubation.

First, the term,

• endo = in
• trachea = windpipe
• intubate = insert a tube into the airway (or really other orifices (orifi?) like a urethra, but we won’t go there…)

Second, why would we want to do such a thing?  There are two main reasons, (1) the patient cannot breathe for themselves and we need to put them on a ventilator – this could be from something going wrong in their head (trauma, stroke, drugs), or intentional (general anesthesia for surgery) or (2) to protect a patient’s airway, for example a stroke patient whose gag reflex is impaired. Without airway protection, stomach contents might end up in their lungs.

Third, how is this accomplished? If you’ve ever had something “go down the wrong pipe,” you know we don’t willingly let a tube go through our vocal cords and into our windpipe. The gag reflex is there for a reason, and generally pretty effective. If the patient is already unconscious, often we can proceed with little or no medication, but for the majority, we first almost always have an IV, then we give at least two drugs: one to put the brain to sleep (propofol, pentothal=thiopental, ketamine, others) then a second drug to paralyze the muscles so the vocal cords don’t slam shut when we touch them (succinylcholine or any of a number of “non-depolarizing muscle relaxants”). The downside of these drugs? The patient will definitely stop breathing, so if we can’t breathe for them for some reason…you get the picture.

Within a minute or two, we can easily open the patient’s mouth, insert a laryngoscope (metal blade pictured below), lift the patient’s lower jaw to allow direct visualization of their vocal cords (upside-down ‘V’ in image on right),

Laryngoscope inserted into mouth and lifted to view vocal cords (nearly vertical thin line midway). From Anesthesia Key https://aneskey.com

and slip in a breathing tube.  (Image from Anesthesia Key https://aneskey.com)

In reference to the text above, we don’t do this on a combative patient, until they’ve become non-combative, with medications. So the nurse might hold the patient down for IV placement, or for an intramuscular injection of a sedative, but not for the intubation itself.

Though “emergency endotracheal intubation” is not wrong, it’s not what we say.  Just “emergency intubation” will do, or “They need to intubate.”

We don’t give the muscle relaxant until the patient is asleep, otherwise they’re awake and paralyzed – not much more terrifying in my imagination. And we don’t “force” a tube into an airway.

Lastly, we don’t then monitor for respiratory paralysis and asphyxiation at this point. He’s already intubated and will be placed on a ventilator. We CAUSED respiratory paralysis with our muscle relaxant – though it is likely short-lived. And he can’t asphyxiate unless we really screw up – turn off the ventilator, override all the safety mechanisms and figure out a way to hook up something other than oxygen, etc.

So if you want a character to be intubated, or to perform an intubation, these are the steps. You can learn much from the internet, but I’m also happy to read it over…

 

Thrillerfest 2017

It was my second Thrillerfest, the annual meeting of the International Thriller Writers, and what a thrill (sorry, that was awful). I started with MasterCraftFest with the amazing Grant Blackwood (co-author of Clancy and Cussler novels, plus his own Briggs Tanner series). I look forward to seeing his comments on my pages. The eight-hour session was terrific…lots of notes!

Wednesday and Thursday’s Craftfest was for learning. David Holtzman gave an informative, and terrifying, talk on Hacking for Hackers – wow, we’re all in terrible danger, not just from viruses and worms, but RATs and zombie drones, and even cute-sounding activities like smurfing and snarfing. Back up your computers, people!

Thursday afternoon’s Pitchfest was a good time for beta blockers as hundreds of aspiring writers (including me) tried to convince Agents and Editors to take a look at our work. Getting that eighty-thousand word novel into an elevator-pitch is no small feat. Good thing the Grand Hyatt New York has really slow elevators.

Sandra Brown, Lee Child, David Morrell, Nelson DeMille, RL Stine, Heather Graham…all at one table! (okay 2)

Friday and Saturday’s Thrillerfest was geared more to the fans, with informative panels, and signing sessions for the way-cool Matchup anthology, where 11 pairs of opposite sex thriller writers had their main series’ characters work together. Nearly all were in attendance (the authors, not the characters)…can’t wait to read it.

The week was capped off by an awards banquet honoring Lee Child, complete with Lee Child m&m’s. Daniel Palmer and Brad Parks pulled a Weird Al Yankovic and changed the words to Beatles songs – “Tiny Jack Reacher”, “Eight Blurbs a Week”. It’s recorded here. Start at 47:04 for the song. It’s pretty hilarious.

 

 

It was a tremendous and exhausting week. I highly recommend it, whether you’re writing, or just reading, thrillers. Now I have to get to my incredibly long GoodReads list!

 

J.L. Delozier, MD – physician-novelist

A new name has joined the ranks of physician-authors like Michael Crichton, Tess Gerritsen, Michael Palmer, Abraham Verghese…the Google list is much longer than I realized. And it just grew with the addition of Dr. Jennifer Delozier. A Family Practice physician from Pennsylvania, she has an unusual job – non-military, government physician who is deployed to weather disasters. Most days she works as a physician at a VA clinic, but when the likes of Hurricane Katrina, Ike, or Gustav threaten lives, Dr. Delozier is there, putting her life on hold to care for those in the path of danger.

During deployments, the shelter provided for the medical team is always sturdy in construction, if lacking in amenities. One such site is the setting for her new novel, Storm Shelter. Imagine hurricane-force winds outside, but a murderer inside. As conditions worsen both inside and out, how would you respond? As she has seen in real disaster situations, some apparently “good” people decompensate and perform egregious acts. While some presumed “bad” people behave heroically.

A writer since childhood, Jennifer had to back-burner her passion during the rigors of medical training. It was the needs of a friend that finally compelled her to put pen to page. While her friend wrote the screenplay he’d long planned, she worked on her first novel. Both were honed through weekly critique sessions, to great success – Type and Cross is nominated for Best First Novel at Thrillerfest next month.

Her second novel, to be released June 28^th, is a prequel. Storm Shelter’s focus is her nightmare-plagued, tequila-swilling psychologist-for-hire protagonist’s backstory. Jennifer says it will appeal to those who love plot-driven, anxiety-provoking, adrenaline-pumping stories…and who doesn’t?

She’s already begun work on the third in this trilogy, the as-yet untitled sequel to Type and Cross. After that, she plans a stand-alone, and has more than twenty other stories swirling in her brain, anxious to see the light of day – everything from children’s books to sci-fi. So whatever section of the bookstore you prefer, you’ll likely see J.L. Delozier on a spine. Enjoy!

 

 

 

An Interview with a Physician-Novelist

Melodie Winawer, MD is a physician, scientist, teacher, wife, mother, and now published novelist. Her debut novel, The Scribe of Siena, comes out on Tuesday. So, besides necessary book promotion (like agreeing to this interview), how is she spending the last pre-release days? Reveling in her success? Relaxing with friends? Well, sort of, if relaxing with friends includes making clarée in the traditional manner of medieval Italy. Oh, and let’s not forget about a full clinical load of neurology patients, anxiously awaiting word on an NIH grant application to fund research on the genetics of epilepsy, and planning a Mother’s Day celebration for her own proud mom. Whew! Humbled yet?

A full life doesn’t begin to describe Dr. Winawer’s. And this week she tops it off with the publication of her first novel, a five-year plus labor of love. Enamored with history since childhood, four-year-old Melodie shocked her Jewish parents by announcing her intent to become a nun. “The impulse to the contemplative life wasn’t about religion though, it was something else.” She imagined a life of quiet solitude, illuminating medieval manuscripts – which, by the way, is not reading by flashlight under the covers, nor doodling in the margins, but decorating a hand-written manuscript with miniature illustrations using radiant colors and real gold and silver. Not exactly where she ended up.

She’s come to realize part of her fascination with the past is the pace of medieval life. Modern conveniences, while eliminating time-consuming tasks, also eliminated some of the pleasures of everyday life – of spending time working with and for the ones we love. Immersing herself in the world of fourteenth century Siena, she has spent days preparing and serving historically accurate meals, making almond milk from scratch, squeezing grapes by hand, and steeping wine in spices that make me grateful for Wikipedia (galangal, anyone? – good thing she lives in New York with specialty groceries…and has Amazon Prime).

Multi-lingual and a voracious reader of historical fiction (including eight (VIII) retellings of the Arthurian legend and Mary Renault’s complete works), Melodie came upon the mysterious decline of Siena after the Plague of 1348, while nearby Florence recovered, and flourished.  “A trip to modern day Siena, with the same population since the 1300s, and where residents still engage in medieval rituals with great seriousness, is like a kind of time travel.”

And what does a good scientist do with a mystery? “I try to look up the answer. If I don’t find an answer, I look harder, I ask colleagues with expertise. If no one knows the answer, or better, if there is disagreement, or even controversy about the answer, that’s when I know I’ve found my next research project.” In science, the next step is to design and conduct a study, and publish the results. In fiction, Melodie revels in the freedom to create characters and situations true to history, but from her imagination. She hopes to transport her readers to that time through a complex story that includes world-building, engaging characters, and a compelling plot.

And her imagination takes the reader on an immersive trip through Siena of today and six centuries ago. The Scribe of Siena is the story of Beatrice Trovato, an unusually empathetic neurosurgeon (more unrealistic than time travel to an anesthesiologist – just kidding). As her work begins to suffer from this overpowering connection to her patients, her beloved brother passes away unexpectedly, and she travels to his home in Siena to settle his estate. There, she becomes engrossed in his incomplete research on a 650-year-old conspiracy to destroy the city. The journal of Gabriele Accorsi, the man at the heart of the plot, transports her to the year 1347, just before the Black Plague. She falls in love with both the time and the man as they attempt to save the city. Despite its inconveniences and dangers, Beatrice is captivated by the surprising sweetness of medieval life and, reminiscent of Diana Gabaldon’s Claire Randall, Beatrice must decide in which century she belongs.

“The Scribe of Siena is the captivating story of a brilliant woman’s passionate but dangerous affair with a time and place, testing the strength of fate and the bonds of love.”

Her advice to aspiring writers? “Write what you love, or what you must write. Ignore whether it’s what people will want to read.” She also shared advice from her 9-year-old daughter, and aspiring author: “You can only write the way you write.” Learn from other writers, study their craft, but write your own words, in your own style.

What is she reading now? Feast of Sorrow: A Novel of Ancient Rome, by Crystal King – about the man who inspired the world’s oldest cookbook and the ambition that led to his destruction. And The Gods Who Walk Among Us, by Max Eastern – “a witty, quirky, noir mystery set in New York City.”

I look forward to reading “The Scribe of Siena,” but since I prefer to read an author’s works in order, I have to get through her 28 scientific publications and numerous book chapters first.