Maternal Death in the 1800s

In western North Carolina, mid-1800’s, a young Cherokee woman gives birth (her first) to a healthy baby boy with a Cherokee mid-wife in attendance, but dies in the process.  What might be a reason for her death?  Not that I intend to incorporate medical details in the story, but I’d like to have enough verisimilitude to be realistic.

Then, as now, the most common would be postpartum hemorrhage, hypertensive disorder (preeclampsia/toxemia), embolism and infection. The most dramatic for your story would be hemorrhage. After the baby delivers, the uterus doesn’t contract for various reasons and she bleeds to death. You can decide how long you want her to survive. If you want her to cuddle the baby knowing she’ll die…or lose consciousness much sooner.

Postpartum hemorrhage (PPH) is one of the top five causes of maternal mortality. Worldwide it’s responsible for about 1/4 of those deaths. In the US, it’s closer to 10% and a simple hemorrhage shouldn’t be fatal unless the woman delivers in an area without resources (small hospital without a well-supplied blood bank, at home, etc).

A failure of the uterus to contract down is the most common cause of PPH, whether because it’s “tired” like any muscle after an extremely long labor, high dose pitocin, an overly large uterus (triplets, etc), or from other reasons is hard to know afterward. Other causes would be a tear in the cervix or vaginal wall that can be tough to see clearly to sew up.

The scarier causes are when the blood stops clotting for some reason. Then the only solution is to replace clotting factors. This happens with an “Abruption” when the placenta separates before it’s supposed to, like in a car accident from the rapid deceleration, but also happens unexpectedly sometimes. In this case, blood alone isn’t enough. We need “cryoprecipitate” and/or plasma to replace the missing factors. At a big hospital like mine, we get it, though it can take agonizingly long when your patient is bleeding. In a small hospital, or if the woman has a rare blood type, or has had a transfusion before and has antibodies against many types of blood, then it can be impossible to save her. This is where home births terrify me. If the woman bleeds, and they bring her in without an IV, trying to place one in a patient who’s already lost a lot of blood is a problem, and we’re way behind on fluids and getting blood available, and crossing our fingers she won’t react to the O-negative we always have on hand for pregnant women.

There are other causes of hemorrhage. Recently we’re seeing a lot of women who have had multiple cesarean deliveries and their placenta grows into the scar and won’t detach. They might bleed to death without a hysterectomy, which is difficult to perform on a recently pregnant uterus. Even at my institution, with top-notch gynecologists, they often ask the gyn-oncologists to help because the anatomy is just so different.

Suffice it to say, having a baby may be natural, but it’s not entirely benign and was the leading cause of death for women of child-bearing years for millennia.  That said, I don’t want to scare anyone, just have a good doctor and consider delivering in a place that can handle whatever comes up (preferably with obstetricians, pediatricians and anesthesiologists in-house, even if you choose a natural delivery without pitocin or pain meds).

Medieval Trauma Medicine

I need medical information for a historical novel set in medieval times. The male

from Cole H and Lang T. (2003) “The Treating of Prince Henry’s Arrow Wound, 1403” in
Journal of the Society of Archer Antiquaries, 46, 95-101.

main character is shot with a barbed arrow somewhere on the left side of his torso. After a harsh fight for survival and harrowing convalescence, he survives with lingering discomfort/mild disability. Would he be able to function somehow, right after the injury? He is very tough and would be hell-bent upon completing his mission.

After a period of time (how long could he last without help?), help would take the form of a very experienced military surgeon, with skills on the level of the Roman army surgeons/ combat medics of antiquity.

What kind of wound (placement, depth, looks…) would fit this scenario? What is a likely timeline with regard to the wounded MC´s deterioration, crisis, and recovery?
If he develops a high fever and/ or an unconscious state, will he hallucinate? Dream? Remember anything? Talk understandably? Just mutter or ramble? Etc.

Anatomy

A left torso wound with a barbed arrow could hit spleen (probably not survivable due to blood loss), or rib (fracture, very painful; +/- puncture lung), or if it happened to go between the ribs, it could hit lung (or heart if he’s really unlucky).

The lung is inside an o/w empty sack called the pleura. If the pleura is breached and air

from Medical News Today

gets into it (inside the chest but outside the lung; called a pneumothorax (air in chest)) then the lung can have difficulty expanding. It’s painful, esp with breathing in, and would get worse over time (hours maybe?). If it’s bad enough, and the air can get in but not back out (like a flap valve), then it can put pressure on the heart and kill your hero (tension pneumothorax), so you don’t want that. There are specific signs (enlarged neck vein on that side, the chest sounds hollow when tapped) and the treatment is to put in a tube (or reed) to drain the air. I found a reference to evacuating pus from the chest cavity from that time.

A barbed arrow is less likely to embed in bone apparently (wikipedia), so if it’s barbed and goes through the chest wall it could maybe just stay in the pleural cavity (outside the lung), then it’s removal and a stitch to prevent air from being sucked into the hole would be it (except the risk of infection of course). If it stays for a while, I would guess the lung would rub against it and become damaged, which again causes air in the space, chest pain and difficulty breathing. The treatment is the same, but the lung tissue might take a while to heal. As far as the wound reopening, I think the risk would be small as the hole would be small and generally not terribly bloody if it doesn’t hit a major blood vessel. Unless of course it gets infected and there is pus in the lung space.

Injury

So as a guess, he’s out in the field, gets struck by the arrow, needs to complete his mission. Wouldn’t lose consciousness. Maybe he has a  knife and cuts off most of the shaft so he’s less likely to move it…I suppose he could try unsuccessfully to remove it, but likely better to leave it in place. He should do something so his clothes don’t catch on the remaining shaft and move the arrow as he travels. He’d certainly be able to move. He’d be in pain, esp with breathing in so he’d probably “splint” – take shallow, faster breaths. It shouldn’t make him wheeze unless he also has asthma. Coughing would be REALLY painful. He might keep his left arm down (bent at the elbow maybe) to protect his rib cage on that side.

If you want it to be more hit or miss, but allow him to finish his task first, probably an infection is the best option. The drainage and irrigation described in the reference would certainly be painful, and likely result in some permanent lung damage. Really though, a healthy person can live just fine with only one lung… if you want him to have decreased function, you might have to give him another wound.  OR, he could get so sick from the infection (septic shock) that his heart takes a hit and never fully recovers. During the sepsis/major infection he would have a high fever, sweats, high heart rate, fast breathing, probably hallucinations and maybe combativeness, until he falls unconscious. He would sleep a lot. Give him cool baths.

Treatment

Regarding ointments, I found this:

• Black ointment “is good for festering wounds, it cools and refreshes, soothes and heals and it stimulates the formation of pus (Leersum 1912: 21).”
• Populos ointment was used “in cases of extreme heat caused by high fever (Daems 1967: 191).”  [I couldn’t find any more about this and be careful googling it :-)]

You can get some smells from Medieval Medicine to treat Wounds. “Wounds were cleaned and vinegar was widely used as a cleansing agent as it was believed that it would kill disease. Mint was also used in treating venom and wounds. Myrrh was used as an antiseptic on wounds. Yarrow, or Achillea was used to treat headaches and wounds, especially battle wounds.”

 

Murder by Nicotine

Question: I’m writing a short story and I want the wife, who smokes e-cigs, to poison her husband by putting liquid nicotine in some spicy food ( I read that it tastes peppery). How long would it take for the first symptoms to appear, and how long until death?

Ohhh, cruel.

The onset of nicotine is very rapid (minutes), and lasts hours, with the symptoms dependent on the dose. Usually it begins with vomiting, diarrhea, a rapid heart rate, high blood pressure, and a tremor of the extremities.

Higher concentrations cause loss of consciousness, seizures (usually with loss of bowel/bladder control), and the victim stops breathing followed soon after by cardiac arrest.

And this is a drug some choose to abuse.

Sadly, ingestion of liquid nicotine has become a means of suicide, but also several deaths from accidental ingestion have been reported, especially in children. Google images shows many vials decorated in ways that might be inviting to children. I’ve not handled a bottle, but I hope they have a child-safe cap.

The vials purchased can have a variable concentration, even differing significantly from what it says on the label. In the US, liquid nicotine comes in a wide range of strengths. Even wider in foreign countries.

And just for completeness, e-cigarettes are designed to vaporize the liquid in small amounts, to be inhaled. Some choose to disassemble the e-cigarette, and drip the liquid directly on the hot coils, providing a stronger hit of flavor, and of nicotine. The pre-filled cartridges contain about 1 ml liquid, but interestingly, not all contain nicotine.

So how about the bumbling wife tries to kill hubby with e-cig liquid but uses one that has no nicotine…and they live happily ever after.

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).

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…