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),

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…

 

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Thrillerfest 2017

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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.

Thrillerfest Panel

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.

Lee Child m&ms

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, JLDelozier.jpegTess 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.

DStormShelter_CVR_SMLuring 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 28th, 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 oscribe of sienan 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.

Progressive blindness in a character

I have this guy slowly going blind but I don’t say why. It’s sfighting-blindnesset in the second half of the 19th c, mostly during the civil war but then we pick up with him again later when he’s gone completely blind. Any insight would be appreciated.

If things are darkening in the center, it can be macular degeneration. Generally strikes older people. They don’t go completely blind as peripheral vision is retained, but they can’t see anything they actually look at, so reading is extremely difficult, as is recognizing faces, driving, or functioning independently. We still don’t have great treatments for this disease.

Cataracts are another possibility, and the most common cause of blindness worldwide. This is clouding of the lens and may be visible to others. The clouding develops slowly, causing faded colors, blurry vision, halos around light, and trouble seeing at night.  Cataracts can be caused by eye trauma, but are most commonly due to aging, especially in those who drink alcohol, smoke, and/or have prolonged exposure to sunlight without eye protection. Treatment of cataracts has existed for centuries, but in the 19th Century it was very uncommon, and frequently lethal to operate on the eye.

Glaucoma damages the optic nerve resulting in vision loss. Most forms are caused by high pressure within the eye and it’s more common in those with migraines, high blood pressure and obesity. There’s also a familial component. It may develop slowly or rapidly and with or without pain. They may see halos around lights, have nausea and vomiting, and a pupil that doesn’t react to light. The vision loss is generally permanent, but can be prevented, though not in the 19th Century. The first surgical treatment was in 1856, and drug treatment in 1875.

Diabetic retinopathy is another relatively common cause of blindness. It starts with swelling around blood vessels in the back of the eye causing blurred vision, then progresses to formation of extra blood vessels that burst and bleed and further blur vision. All this can be prevented, or at least slowed, with good care and frequent examinations, but after 20 years of diabetes, 80% of patients will be affected to some degree.

For your character, glaucoma may be the best bet. But if you want him to still be able to get around, and just be unable to read or something, then macular degeneration might be a better choice… Good luck!

Infection? Cancer? Both? Poor patient

A number of years ago, a friend was misdiagnosed with cat scratch disease when what she had turned out to be Hodgkin lymphoma. I may be able to use this in a story. Here’s the odd question: What would happen if a person had both illnesses at the same time? I would think the symptoms, which have similarities, would be worse, making the patient seek treatment sooner. Am I correct? Would the diagnosis be more difficult or not?

First, as physicians we are taught a variant of Occam’s Razor – to look for the fewest possible causes that account for all the symptoms. And, ‘when you hear hoofbeats, think horse, not zebra.’ So, if faced with symptoms that could be equally explained by two different diseases, we would generally favor the more common one, and not a combination of the two.

capture

That said, here is a little info on the two diseases:

Cat Scratch Disease3745112b0cdace5741892ad5c3f6202e

(aka Cat Scratch Fever (but not the album)) is caused by a bacteria and is most common in children. Symptoms begin about 1-2 weeks after a cat scratch or bite, so often the patient has forgotten about the inciting event. Kittens, outdoor cats, and those without flea protection are most likely to harbor the bug. The infection usually resolves on its own in about a month, though rarely can progress to involve the eyes, heart or even brain.

Immunocompromised patients (HIV, certain cancers) are at particular risk for complications including a vascular skin lesion and liver or spleen problems. Diagnosis is challenging. There is a particular stain for use on a lymph node biopsy, but its not perfect. Culturing the bacterium can take several weeks. Another test (PCR) is quicker but only about 50% accurate.

Hodgkin’s Lymphoma

is a white blood cell cancer. About half of cases are caused by a virus (EBV). Most common in 20-40 year olds, patients require chemotherapy, radiation therapy, and sometimes a stem cell transplant. Survival in the US is quite good (>85% at 5 years). The diagnosis is made with a lymph node biopsy showing the cancerous cells.

So if someone had both diseases, their symptoms might be worse, or they might not, depending on how advanced the lymphoma is. At some point they can no longer mount an immune response to the Cat Scratch bacteria and they would miss out on some symptoms. Interestingly, if the patient were in that situation, the Cat Scratch disease could cause liver and spleen problems (cysts), while swelling of those organs is common in Hodgkin’s.

The differential diagnosis (list of possible causative diseases) of enlarged lymph nodes of several weeks’ duration is extensive. Coupled with additional symptoms as noted above, and a concerning medical history, the physician would likely order a biopsy, as well as scans of the body to look for additional abnormalities. Several lab studies would also be checked.

The short answer is, YES, the diagnosis would be more difficult. The biopsy would show Hodgkin’s and that should explain all the symptoms. Unless there was a recent history of a cat scratch or bite, they might not look for it. Whether the cancerous cells could fight the Cat Scratch bacteria is tough to predict, and once they started chemo it could potentially get worse.

I could find no case reports in the literature of a patient with both diseases…but that’s what fiction’s for, right??

My pregnant patient needs an emergency

So I am writing this scene in which my heroine has preeclampsia and faints from a traumatic situation while in labor. She is rushed to the hospital.
The doctor tells the father the umbilical cord prolapsed and that they need to take the babies because it’s risky and he could lose both babies and mom.
Since she is passed out, would they need to give her something anesthetic?
I need both mommy and babies to survive in the end. Can you give me some advice as to what happens?
Interesting!

First, a little about preeclampsia, formerly known as toxemia, and still known

preeclampsia2-edit2

from Preeclampsia Foundation

as one of the leading causes of maternal mortality. It’s a hypertensive disorder of pregnancy, coupled with some other signs or symptoms (protein in the urine, swelling all over, headache that won’t go away, visual changes, etc).

We don’t really know the cause, but there are some risk factors, and multiple gestation (like twins) is one. As is first baby so your scenario is great. If you want to make your heroine a morbidly obese diabetic you’ll really be golden (just kidding).
Depending on how severe the high blood pressure and other symptoms, and how far along she is in her pregnancy, she might be kept in the hospital until delivery. If her blood pressure is difficult to control, or other symptoms progress, that alone is reason to take the babies early (you don’t need to add cord prolapse – see below). We try to get babies to 37 weeks, if not, 34 weeks is another safe endpoint. Earlier than that we try to keep moms safely pregnant for 48 hours to give steroids, which help the babies’ lungs mature.
Umbilical cord prolapse is much less common. It can’t happen until the water breaks and the cervix is dilated at least as wide as the cord (couple centimeters), and in twins would only risk the one whose cord is hanging out. Recognized immediately, the presenting part (head or butt of the baby) can usually be pushed up to avoid squishing the cord. We roll mom straight to the OR with a nurse riding on the stretcher keeping the baby from strangling itself. The nurse remains under the drapes while we induce general anesthesia and deliver the baby by C-section.  If cord prolapse were to happen when your character is at home, the baby is really unlikely to survive.
So you really don’t need the prolapse, or the fainting for that matter. Preeclampsia is so named becomes it is the symptoms that occur before (“pre”) eclampsia – which is seizures. If a mom is brought in by ambulance having seized, and we’re pretty sure it’s from preeclampsia, and the baby is far enough along, we’ll do an emergency c-
section right then.
Either way she would still need anesthesia. If she just passed out from being surprised or bad news or whatever, it would only last seconds to a minute or so. Longer than that would have to be from something else (or faked).
So, if you want drama, here’s my suggestion…she has a seizure at home and doesn’t really wake up (your EMT can call it a post-ictal state when he calls it in, just to sound cool). Her blood pressure is high, and maybe she’d been having a headache all day. When they arrive in the ER they go straight to Labor and Delivery. The doctors check her BP and find protein in her urine so they go straight to the OR. She’s still quite groggy and Dad is freaking out. She is anesthetized for the emergency surgery, and they can’t be sure she’s going to wake up b/c she might have had a stroke (most common cause of death in preeclampsia).  You could even have her wake slowly from the anesthesia to draw out the anxiety…or maybe they even do a CT scan of her brain which ends up normal and then they just have to wait (up to several hours).
In case a pregnant woman happens upon this article…preeclampsia occurs in only about 3-5% of pregnancies in America – three times that in the developing world – and most cases are mild. So have no fear. Go on and reproduce. Just get your blood pressure checked occasionally, and go to the hospital if it’s sky high.
Other questions???