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???

Pregnancy in Fiction

I’ve read a couple of novels recently that took fiction to a whole new level with regard to pregnancy and delivery. In one, a “neonatal nurse” flipped a breach baby during delivery, in another, a 6-week pregnant woman had an audible fetal heart rate, a traditional abdominal ultrasound, and had difficulty with her pants becoming tight and her bra no longer fitting. So I thought perhaps some ground rules were in order…

First, pregnancy is caused by…yeah, I’m skipping this part. One of my romance-writer friends can fill that in. But…I will say that the youngest pregnant patient I’ve cared for was 12 years old, though hers was not consensual sex. Anyone through puberty has the capability to become pregnant/cause pregnancy.

Pregnancy is logged in weeks from the last menstrual period, with 40 weeks being “fully cooked.” In fact, most women become pregnant mid-cycle, so they are only pregnant for 38 weeks. During those first few weeks of pregnancy, lots happens to the mother-to-be. She may feel out of breath as her brain resets the target amount of carbon dioxide in her body. Her breasts begin to grow, slowly. She feels exhausted, maybe emotional, nauseous (man, what we put up with for our kids!).

At this point, the only way to really assess the baby is with a trans-vaginal ultrasound – a probe advanced to the cervix, with which an image of the lima bean is visible. A single pixel blinks on and off…that’s the heartbeat, and it’s visible at about 5 weeks, but it can’t be heard quite yet.

The first trimester (approximately 13 weeks) is the worst for nausea, and the most

scan0001

10 week ultrasound

important for fetal development and avoidance of exposure to drugs and chemicals. With an ultrasound probe pressed hard against the lower abdomen, the heart beat can first be heard around 12 weeks. So if you want the mom and dad to smile lovingly at each other at the sound of their baby’s heart…make sure she’s at least that far along.

The second trimester is when things become apparent to others. First-time moms feel the baby move for the first time (“quickening”) around 18-20 weeks. Repeat moms recognize the fluttering a little earlier. The baby bump starts to appear (different from just over-eating and becoming overweight). The height of the fundus (top of the uterus, measured from the pubis) in centimeters, should be about the same as the number of weeks pregnant (assuming a single baby). Healthy moms visit their ob about every 4-6 weeks at this point, with and ultrasound around 16 weeks to look for major structural problems in the fetus.

Viability (where the baby has a chance to survive outside the womb) occurs between 23 and 24 weeks, so just over half-baked, but these babies require major resuscitation and advanced care. If your character is delivering a 24-week baby in the woods, it won’t survive. Most babies achieve lung maturity around 34 weeks, so that’s about the age a baby born in the woods could very reasonably survive.

Since 2000, we almost never deliver breech babies vaginally, unless it’s the 2nd twin. We might try to flip a breech baby before labor, but the success rate isn’t great, and there can be complications.

Unless there are problems, like high blood pressure, diabetes, a huge baby, etc, we don’t induce labor or perform an elective Cesarean until 39 weeks gestation. This is also relatively new. Turns out baby lungs do better if we wait those extra few days. In fact, if we do an elective Cesarean at 36 weeks and 6 days our obstetricians have to defend the move…as if we know with certainty the exact day the baby was conceived. Rarely do we allow a woman to go past 41 weeks either.

Lots more info about pregnancy and delivery. Bring on the questions!

 

Bruising

I have a character who is beaten up.  How long does it take for the bruising to show?
bandaged-smiley-face-100x100
I envision her having a black eye, a busted lip, a broken arm and perhaps a broken rib or two.  I think her arm will have broken as a result of being slammed against the edge of a brick wall, and I assume there will be a major bruise at the point of impact.  I want to describe the state of her arm when the police examine it about 1 1/2 – 2 hours after the fact.

Bruising is blood under the skin. That won’t necessarily happen from a broken limb, depending on the mechanism of the break. She would have a road rash type picture from the roughness of the brick wall (though long sleeves might minimize that), and may develop a bruise from that crush, though 2h is a little quick. The appearance of the arm itself would depend again on how exactly you imagine her breaking it. It can look normal, or have a lump, or best might be for it to have an obvious deformity, a bend where there shouldn’t be one.  That’s called a “displaced fracture.”  If you want to get gory you could have a piece of bone sticking out of the skin, that’s an OPEN fracture and would bleed. Though by 1.5-2h the bleeding should be stopped.

A bone will only break if there are forces opposite to its length, like slamming it against the corner of a brick wall so part of it wraps around the corner, if you know what I mean. Or twisting it. Just slamming someone against a wall wouldn’t break it, unless they had their arms out to break the fall maybe.

Broken ribs CAN bruise, since they’re so close to the skin, assuming your victim isn’t obese, but again it’s not that quick.  As an aside, depending on the mechanism of breaking a rib, a portion of it could poke into the lung and cause a “pneumothorax” (air in the chest, but not in the lung). That causes chest pain, breathing difficulty, and can be a major emergency, or not, depending on what you want to happen with your poor soul.

 

Why do so many women feel guilty for getting epidurals?

This post is unrelated to writing, but I couldn’t resist when this headline came through…”Why do so many women feel guilty for getting epidurals?” It gave no real answer regarding epidural-induced guilt, only mentioned there was a push in the UK to have women use midwives, which they credit with reducing the epidural rate from 69% to 59% over a 10-year period. Which revives the interesting argument of “natural” childbirth and the impression forced on many women that they are somehow less if they request an epidural for their delivery.

Labor is natural, so the argument goes, and the pain of labor is ordained by God (Genesis 3:16 “in sorrow thou shalt bring forth children” – so we can blame Eve). However, kidney stones, so MY argument goes, are just as natural, if not specifically mentioned in the Bible. And who would argue that someone who suffers a kidney stone should go without pain relief? What about an abscessed tooth? Or an amputated digit? Just because thousands have lost digits over the millenia, no one would argue you should grin and bear it like Adam.

I have a theory, grounded in absolutely no facts, about the modern perception of pain. In the thousands of years women had babies without analgesia, they suffered pain frequently…headaches, broken limbs, saber-tooth tiger bites…so their innate mechanisms were honed to internalize (or externalize) their pain in such a way they remained functional. Now we take Tylenol/Motrin/Advil for the slightest ache. Perhaps, my theory goes, our brains have lost the ability to ignore pain, our natural endorphin mechanism no longer kicks in.

Despite being an obstetric anesthesiologist, I marveled at the intensity of my own labor pain with baby #1. (“Marveled” may not be the right word, but let’s go with it.) Believe it or not my labor nurse, apparently unaware of my career, told me an epidural would cause a cesarean delivery. I was shocked, appalled, outraged. Well aware of the risks, and cesarean delivery is not one of them by the way, I went around Nurse Ratched and called my friendly neighborhood anesthesiologist directly.  When I received said epidural (at 8 frickin’ centimeters dilation), I realized what an incredibly wonderful thing I do for a living. Baby #2 came too fast, so I did get the full-tilt blessing of natural childbirth. And for #3? Epidural when she decided not to come out after less than an hour of labor like her impatient big brother.

And the moral from my experience both as a laboring mother, and as an obstetric anesthesiologist with twenty years’ experience? It’s YOUR delivery. Do whatever you want. Epidural, no epidural, breathing, no breathing…okay, not that last one – BREATHE!  It is my considered opinion that some women must have fewer nerve endings in their cervix/uterus. Occasionally someone will come in saying they’ve had minor back pain for hours, and are 9cm dilated. Others come in screaming “F— the birth plan, I want my epidural!” at 2cm. It is not all toughness, willpower and intestinal fortitude. And it is no one’s business what any woman chooses for her labor. Grin and bear it, say every swear word under the sun while shrieking the virtues of vasectomy to your spouse, or relax and enjoy (assuming you have an awesome, attentive anesthesia provider). Either way, you’ll have an amazing gift afterward.

 

 

Allied Health Personnel: Who are they?

EMTs vs paramedicsstethoscope-294378_1280

Optometrists vs ophthalmologists

Anesthetists vs anesthesiologists

In your novel, which term should you use when?

Emergency Medical Services (EMS)

The most common providers riding ambulances, fire trucks, etc are EMTs (Emergency Medical Technicians). They complete about 150 hours of training and can provide CPR, oxygen, glucose for diabetics, but they can’t start IV’s or give many medications. Paramedics, on the other hand, complete 10x the hours of education and can administer medications, start IVs, manage airways, and more. So if your victim needs a breathing tube, an IV, or major resuscitation, be sure you call the main provider a paramedic and not an EMT.

Extenders

NPs (nurse practitioners) are nurses with additional graduate school training. Many subspecialize in critical care, pediatrics, etc. CRNA (certified registered nurse anesthetists) practice anesthesia, generally under the supervision of a physician anesthesiologist. Nurse midwives practice usually with an obstetrician medical director.

PAs (physician assistant) are not necessarily nurses first, but must have some direct patient care experience to gain acceptance. They generally work under the authority of a physician, and many subspecialize.

There are many other physician extenders:

Optometrists check general eye health and prescribe glasses, ophthalmologists are physicians who also prescribe medications and perform surgery.

Midwives can do prenatal checks and deliver babies, but an obstetrician is required for cesarean delivery.  Interestingly, there are two different kinds of midwives with very different skill sets.

Any questions about physicians, extenders or allied health personnel skill sets?

 

Head Injury and Medically Induced Coma

Question:

My victim was deliberately run over by a mountain biker. Skull fracture, internal injuries broken bones. Would the victim be put into a medically induced coma and what drugs are used. How do doctors determine when to bring someone out of a coma?

Answer:

The short answer is…maybe (if necessary to control intracranial pressure (ICP)), propofol or pentobarbital, and it depends (probably ICP coming under control).  (helpful, right?) Scroll to the bottom for the short summary, or read on to understand what’s going on.

Traumatic brain injury (TBI) might occur with a skull fracture, with outcome ranging from complete recovery to death, and everything in between. Best if they are managed at a Trauma Center or at least a hospital with neurosurgical services.

Patients with TBI frequently have other injuries that complicate care, but here I’ll focus on TBI itself.

Prehospital

Glasgow Coma Scale (GCS): This would be performed early on and is a measure of brain function. It includes three areas:

  • Eye opening (spontaneous (4) down to none (1))
  • Best verbal response (not looking for a great pun, but oriented (5) down to no response (1))
  • Best motor response (obeys commands (6) down to no movement (1))
    • Yes, teenagers can still get a 6. They just have to squeeze your hand…but preferably not pull your finger.

GCS 15 is max; 13 is mild brain injury, <9 is severe. This is something the paramedics would report over the radio to the receiving hospital.

If the score is <9, the victim would be intubated (breathing tube in the windpipe) and the paramedic would be squeezing a breathing bag. They would also place an IV (intravenous) catheter and give fluids to maintain blood pressure. The GCS would be determined every few minutes to look for deterioration.

Emergency Room

They would follow the Advanced Trauma Life Support (ATLS) protocol (ask if you want more info), and scan the head (CT scan) to assess the brain. The big fear is “elevated ICP.”icp

Intracranial pressure (ICP) is the pressure inside the cranium (skull). In adults, the skull is solid, with just a few holes (e.g., eyes, and where the spinal cord departs for points south). Inside that solid skull is the brain, blood vessels, and another fluid (CSF: cerebrospinal fluid).

When something else takes up space (e.g. blood that has escaped), the skull can’t swell. Instead, the pressure inside the skull rises which can (1) reduce blood flow and (2) cause the brain to get squeezed toward the hole for the spinal cord. Unfortunately, the part of the brain most likely to get squished (herniate) through the hole is in charge of the most basic life functions (like breathing). So herniation is quite lethal. Incidentally, we look at pupils because the nerves that control them are in that same area.

So…if the CT showed a “hematoma” or blood collection, beneath the skull, it would likely be surgically drained immediately. For a skull fracture, as in your case, surgical treatment would depend on whether it was open (scalp open as well) and how deeply depressed the skull was.

So you could get away without surgery if you want. But they would at least have “minor” surgery with the placement of a pressure catheter into the brain to monitor ICP. The patient would be on a ventilator with a breathing tube, and would be receiving medications to maintain his blood pressure and try to minimize his ICP. He would be sedated, potentially to the point of a medically induced coma.

Medically Induced Coma

(you thought I’d never get there)

When nothing else works, the brain might be put to sleep. The goal is to minimize the oxygen needs of the brain, and thus the need for blood flow. Either pentobarbital or propofol would be used. The latter had become more popular, then a “new” disorder cropped up called “propofol infusion syndrome” which can be lethal and has reduced enthusiasm for long term use of the drug.

These patients have continuous EEG monitoring (electrodes on the head) to make sure we are sufficiently depressing their brain activity.

When to wake them up depends on why they were placed in the coma in the first place, but usually it’s based on the ICP, so when the ICP stays down, it’s time to stop the sedation and see how the patient wakes up.

Summary

Of course much more could be said. From a fiction standpoint, realism would come from the initial evaluation, the GCS, intubation and ventilation. A CT scan with results, the choice to induce a coma, with plenty of discussion from the physician to the family about the low likelihood of a return to prior functioning, but that it wasn’t time yet to talk about withdrawing care. Then a GRADUAL awakening when the sedation is discontinued – much faster with propofol than with pentobarbital. By the way, more realism, the propofol is a white milky liquid going into their IV.

Also plenty of opportunity for additional tension with complications like infections, other injuries, discussion of a “DNR” (Do Not Resuscitate) since the outcome if the victim’s heart stops is truly dismal. Oh the possibilities….

Let me know if you’d like more information about any of this!