Cautery Basics

Posted on August 18, 2011 by arizela

A question hit my inbox recently regarding cautery.

If you’ve never heard the term before, cautery (aka cauterization) means the intentional burning or scarring of tissue as a means to:

  1. Stop blood loss and seal blood vessels
  2. Sever tissue (for instance during a female sterilization procedure where the tubes allowing the egg to travel to the uterus are severed with electrocautery)
  3. To remove growths (like moles, warts, etc.)

Basically, the purpose of cautery is to destroy tissue. The burns produced are typically second degree (blisters), but if handled clumsily can easily become third degree burns that go clear through the skin.

Surgical cautery is often used in modern settings to seal a single stubborn blood vessel, to carefully pare off or to destroy unwanted tissue as in the case of cancerous cells, moles, or lesions caused by viruses, or to surgically separate tissues with minimal blood loss. The two types of cautery used for modern surgical intervention include electrocautery which uses an electrical instrument (see photo) to generate the burns or chemical cautery which involves the application of acids, freezing chemicals, or other chemical substances that produce a chemical or frost burn.

The old fashioned form of cautery was a little… less refined. A (typically iron) implement was heated to glowing red hot and pressed against or into an open wound, typically deeper wounds like arrow or bullet hole. In most cases, the person would have been better served to apply pressure to stop bleeding and then keep the wound clean with boiled water.

The other historical use for cautery is to seal a field amputation. Amputation is the removal of a whole or partial limb, typically arms, legs, feet, or toes (or more rarely, castration). Prior to modern micro-surgical technique (and especially in battle-field situations where time was limited and patient numbers were overwhelming) amputations were performed by applying a tourniquet above the cut line to prevent massive bleeding, cutting through the tissue to the bone, sawing through the bone, and cutting through the remaining tissue. As you can imagine, this was a very blood procedure. The risks of infection were astronomical, but the risks of bleeding to death when the tourniquet was removed were even higher. Rather than allow their patients to die from blood loss, field surgeons performed cautery to seal the end of the amputation. Keep in mind this was also before the use of anesthesia became widespread. Ye-ouch!

So when is cautery appropriate?

Basically the only times when cautery is really a good idea* is when you’re in a well controlled situation (operating room, hospital ER) or when the risks of not performing cautery outweigh the huge risks of second and third degree burns.

There are a few other instances when a writer might consider the benefits of cautery, though. Historically cautery has been used to brand people (as tribal markings, disfigurement, self-mutilation, or marks of ownership in cases of slavery), as a torture method, or as a means of obscuring distinguishing features (birthmark, scars).

What is cautery like?

The first thing the people who aren’t the one being cauterized will probably notice is the smell. If you’ve never smelled burning human flesh (and often hair)… well, let’s just say you don’t forget it. There will be a small amount of smoke if the cautery involves heat, and possible a chemical smell if a chemical cauterization agent is used.

The person getting this treatment will probably not notice much other than the burning AGONY OH MY GOD THE GOGGLES, THEY DO NOTHING! Screaming. Lots of screaming.

Aftercare

After the fact, treatment consists of keeping it clean (preferably with water boiled for 20 minutes or so), keeping it covered with a clean dressing, and try not to use it more than necessary so the tissue can heal. Don’t poke it or pick at it. Watch for signs of infection – spreading redness, pus, blackening tissue that sloughs off, foul odors.

One small caveat – I noticed that the Wikipedia page lists prevention of infection as one of the reasons for cautery, which always kind of struck me as dumb, considering the fact that you are basically scalding the skin and creating an ideal environment (moist, warm, full of the food of dying tissue) for bacteria to grow. Turns out that cautery done in the old days caused as much infection as it prevented (if not more), so I did not include that in my list of reasons why, though it has reportedly been one of the justifications for this procedure. (edit: I actually submitted a correction to the Wikipedia page, with reference and the page now lists prevention of infection as a historical rational that has no modern day merit)

*Which is not to say that characters can’t have good intentions and still do something incredibly stupid *evil grin*

Posted in infection, Treatments, wounds | Tagged , , , , | 17 Comments

Poisonous Hemlock vs. My Hemlock Fence

Posted on August 5, 2011 by arizela

So I’m building a fence. Like any reasonably savvy consumer, I did a little Google-fu magic and figured out exactly what I wanted, then called around town and scheduled a half-dozen people to come out from different companies to give me quotes. As with any industry, in the fence business you get the occasional idiot.

The Lowes guy had already rang several of my alarm bells by the time we got around to this gem (allow me to paraphrase):

“You don’t want to use hemlock rails if you’ve got dogs in the house. Dogs can chew on the fence and hemlock is poisonous. Go with chemically treated  pine.”

Now, for a lay person who has no medical knowledge and who isn’t supposed to be a knowledgeable lumber sales professional, this might be an understandable mistake. Poisonous hemlock (Conium maculatum) is a flowering plant with parsnip-like roots that is poisonous to humans and animals when ingested because of a powerful paralytic agent. This plant was reportedly used in the execution of Socrates by progressive paralysis that eventually stopped his ability to breath. It looks like this:

 

Another group of plants from the parsley family go by the name water hemlock, and these are commonly considered the most poisonous plants in North America. These plants produce a much higher rate of fatality than Conium, but deaths occur due to unrelenting seizures rather than paralysis.

Hemlock lumber is harvested from the Tsuga tree, a Japanese evergreen variety which has a similar odor to that of the poisonous hemlock, and thus the name. The two are about as related as a rattle snake is to a lemur, though. Hemlock wood is not poisonous. (Chemically treated pine, on the other hand, often contains formaldehyde and arsenic to prevent rot and insect damage, and use with animals that chew wood is discouraged.)

While the mix up is perfectly understandable for someone without specialized knowledge, a lumber salesman ought to have known better, and so should a writer who works with the poisonous plants named hemlock as part of a story.

Just in case you were thinking about using that age-old poison Conium (which has also been used by physicians and apothecaries for treatment seizures and as a sedative, but the potential for overdose is very high), here’s a quick list of symptoms of poisonous hemlock toxicity:

  • nausea or vomiting
  • rapid (early) or very slow(late) heart beat
  • belly pain
  • trembling
  • progressive paralysis (starts in the feet and moves upwards)
  • respiratory paralysis
  • coma
  • death

Water hemlock produces a different set of symptoms:

  • Nausea and vomiting
  • belly pain
  • production of excess saliva (drooling, frequent swallowing)
  • change in heart rate (fast or slow)
  • change in blood pressure (high or low)
  • arrhythmia (irregular heart beat)
  • heart failure
  • extreme hyperextension (as with tetanus, see picture below)
  • convulsions
  • seizures (progressing to status epilepticus or seizures that do not stop, which lead to death)
  • violent movements of the arms and legs

painting of a man suffering from tetanus toxicity

On an administrative note:

Hello readers! It’s been about nine months since my last round of sporadic postings, but I’m hoping to get back on track with this blog, because I love to do it. The contact information in the Ask Your Questions page is still valid.

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This blog is written for the purpose of informing writers for realism in fiction. It is not intended to diagnose, treat, advise, or assist real people who have real problems. If you have a problem not related to fiction, please see a physician!

Posted in Poison | Tagged , | 1 Comment

The Scars of the Past

Posted on November 24, 2010 by arizela

One of the matters you may wish to consider in any world-building you do are scars, both physical and psychological, and both on a personal level and on the level of your society.

You can milk a scar or a collection of scars for a lot of characterization. Did the person have a disfiguring childhood disease? Were they beaten or flogged as punishment for something? Did that very sedate, almost passive character have a violent youth?

Keep in mind that how the scars were gotten and how the character *says* they were gotten aren’t always the same thing. That wound from the great battle might really have been obtained from falling off his dad’s horse when he was 5. Even more interesting from the point of a reader are the mysterious scars – the ones your point of view character notices and wonders about but doesn’t ask about.

Scars can form anytime there’s a break in the skin – from a paper cut to major damage. For the first 4-6 weeks after the injury, the scar will probably appear red and raised. The scar can then turn a sort of bluish-purple color, particularly if the scar is on a body surface that is prone to decreased blood flow or that is over a joint or flexible area of the body (like the knee). It can take up to a year (sometimes longer, depending on the individual) for a scar to look “old” or have its final appearance. Most old scars are white-silver and either flat or containing keloids.

Keloids are abnormal “lumps” that form during scar formation and are more likely to form on people of African descent or with dark skin tone. Keloids can grow massively large, taking over entire structures of the body and rendering them useless, particularly if formed on the hands, feet, or ears. Keloids can be painful, itchy, and continue to grow for months or years. Unlike normal scars, keloids do not get smaller or lighter with age.

Diseases like measles, chicken pox, and smallpox can leave survivors covered in patchy, white scars. Leprosy, despite being curable with modern treatment, can be horribly disfiguring to individuals who do not have access to treatment, culminating in gangrene and loss of limbs, blindness, and more. In a pre-modern society that is often struck by diseases and plagues, at least some of the people your characters interact with (if not your characters themselves) will likely show evidence of those same diseases.

Another type of scar to consider are the scars left on your society by plagues and diseases. Particularly in a world that lacks modern medical practices, plagues and diseases can cut a swath through a culture, changing the behaviors of the people within it.

Military camps were also prone to certain outbreaks and soldiers more often suffered and died from bacteria than from the enemy’s weapons. Typhus, particularly decimated more than one army in the field. Typhus is a disease that struck armies because hygiene was often poor. The deadlier form is more common in cold weather and is caused by a bacteria called Rickettsia typhi. It causes headaches, joint pain, light sensitivity, high fever, rash, cough, delirium, and stupor. Without modern treatment, 10-60% of those infected with typhus died, and the disease spread like wildfire through close camps, including armies, crowded transport ships, and jails. It was historically called “gaol fever” because of its rapid spread through prisons.

Cultural practices and superstitions may spring up around particularly deadly plagues. Songs and legends may develop, not unlike the children’s songs that are thought to be about the Black Death. Historically the special treatment and blessing of food in religious rituals was part observance and part an attempt to ward off illness. Common superstitions, religious practices, and unconscious cultural behaviors often arise as a response to disease events.

Cultures may also react strongly to anyone who shows signs of illness. Historically, lepers have been ostracized or even killed, along with their families. Those afflicted with leprosy were considered cursed, and superstition played a large role in the cultural treatment of these individuals. Leper colonies were common  during the Middle Ages in Europe and India. Slave ships carrying “cargo” known to be ill with plague-like symptoms have been sunk rather than allowing their passengers to infect the port towns on the other side, and the corpses of infected people have even been catapulted over the walls of besieged towns as a primitive form of germ warfare.

Diseases have shaped the face of our world. They can add a lot of depth if you remember them when shaping yours.

Posted in Plague, Rare Diseases | Leave a comment

Birth Complications – Shoulder Dystocia

Posted on September 3, 2010 by arizela

Maternal and fetal complications during the birth of a baby are some of the most feared problems in medicine, for a lot of reasons. The truth is, most complications that are severely detrimental to mother and/or baby are rare. You can see my post Special Topic: Death in Childbirth for more information.

Perhaps one of the most feared by modern obstetric practitioners is the complication called shoulder dystocia.

Shoulder dystocia occurs in about 1% of all modern human births. It happens because one (or rarely, both) of baby’s shoulders gets stuck behind the bones of mom’s pelvis.

This is a dangerous situation for mother and baby, as umbilical cord may be compressed if it is wrapped around the neck, preventing baby from getting adequate oxygen. Further, both mom and baby may experience exhaustion, trauma (including uterine rupture), and death if this situation is unresolved.

During a normal, vaginal birth, whomever is helping mom birth the baby should apply a gentle downward pressure on the baby’s head to help deliver the shoulders during a contraction – either immediately after the head is born or on the next contraction if baby’s nose and mouth can be suctioned while the body is still in the birth canal. This gentle downward pressure should be sufficient to help baby’s shoulder disengage from the pelvis and baby should slide out quickly (catch!). If baby stays stuck despite gentle downward pressure on the head, shoulder dystocia may be the problem.

Fortunately, shoulder dystocia is not a death sentence. There are a number of “maneuvers” that can help get that kiddo out. Whoever is helping with this dramatic type of delivery has a few options. The best option and least invasive option is just to get the mom up on hands and knees. This changes the angle that baby is approaching the pelvic outlet a bit and also creates more room for baby to turn. Unfortunately, in modern births this is often unable to be performed due to the use of epidural anesthesia. Further, a lot of modern doctors are simply “uncomfortable” attempting to delivery baby in an unfamiliar position (poor them, right?) so a number of other, physician-guided maneuvers have been invented.

Another option, particularly for women who are unable to go into the hands and knees position, is called the McRoberts Maneuver (see comments), and involves pressing the legs up toward the chest while the mother is in a semi-flat position on her back. This also widens the pelvic outlet. At the same time or separately, an assistant can use the heel of his or her hand to press down firmly on the baby’s stuck shoulder, just above the mother’s pubis – the ridge of cartilage that connects the pelvic bones in the front – using the same sort of position someone might use to perform CPR compressions on the chest (generally with only one hand though).

If that doesn’t work, your doc or cabby gets to go where at least one man has gone before. Inserting at least two fingers behind the baby’s stuck shoulder and applying firm, gentle pressure to rotate the shoulder away from the pubic bone can allow passage of the baby. Be careful here not to put rotational force on the baby’s head, though. This maneuver may require pressing the baby back up into the birth canal a little bit (between contractions) to give enough room to move the shoulder.

If there isn’t enough room for fingers in the canal, an episiotomy can be performed – this involves cutting the perineum (the skin and muscle between the vagina and the rectum). The cut generally extends about halfway between the two, although larger cuts and tears sometimes occur. Episiotomy will not help the shoulder dystocia itself, but it will allow doc more room to play, so to speak. If at all possible, this should be done using sterile instruments only – the risk of post-partum infection to mom otherwise is enormous.

If all else fails, a trained physician may attempt to utilize some last-ditch efforts, like intentionally breaking the baby’s shoulder or arm or using a Cesarean cut to give him or herself a chance to reach into the womb, rotate the baby, and allow the birth. The most risky maneuver involves attempting to push the baby’s head back into the birth canal to delivery via C-section. In developing countries, physicians who have very limited resources sometimes cut the mother’s pubic cartilage under local anesthesia rather than performing a Cesarean cut. The first few options on the page should take care of ~90% of shoulder dystocias, though. Keep in mind that this is a pretty rare occurrence to start with, and the last ditch efforts should be fairly rare.

That said, modern births do occur outside the statistical norms in a lot of ways. Almost 30% of births in the United States are performed by surgical removal of the fetus, but shoulder dystocias still occur at about the same rate in vaginal births because they are difficult to predict, despite a number of decades of measuring pelvises and guessing baby-weights. Women considered to be more at risk for shoulder dystocias include those of short stature and who have gestational or other forms of diabetes. Large babies >9lb are also at increased risk, but it is practically impossible to predict which women and which babies will be affected. Even given the risk factors for this condition, vaginal birth results in a much lower rate of complications for both mom and baby than routine surgical delivery.

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Remember, information at Muse Medicine is for fiction writers ONLY and should not be construed as medical advice or applied to real people. Please seek a licensed physician for questions regarding your personal, real-life situation.

Posted in Pregnancy/Birth | Tagged , | 2 Comments

Epidemics, Pandemics, and African HIV

Posted on August 23, 2010 by arizela

I have run into a few people lately who were fairly certain that the population in Africa was going to be shrinking any day now because of the HIV epidemic that is sweeping through sub-Saharan Africa.  While it’s true that there is an epidemic of HIV infections in that region of the country, and it is also true that HIV infections there tend to be less treated and more people tend to die at earlier ages from the infections, the populations in those countries are going to continue to grow rapidly over the coming decades for a couple of reasons.

One reason is the average woman in most sub-Saharan African countries produces 6 or more off-spring in the course of her life. That’s three children for every adult in the equation 1 + 1 = 6 is bound to cause an increase in population, even given the much higher rates of infant and toddler mortality and the growing AIDS crisis.

The other reason, and the reason more relevant to this discussion is the nature of the word “epidemic” – which really only means a contagious disease that spreads widely and rapidly through a population. Unfortunately, “widely” and “rapidly” aren’t very specific terms.

The Centers for Disease Control determines the “epidemic threshold” for various diseases by looking at how many people die from a particular disease over a particular period of time and comparing that statistic to historical rates of death from the same disease over the same period of time. In other words, it’s a lot of math and most people aren’t going to realize when that threshold has been met. Seasonal flu epidemics occur relatively often in the US, for instance, and the general public is rarely even aware of the situation, because to be an epidemic, a disease only has to spread to a statistically higher number of people than it usually does, and that can still be a fairly small number on the country-wide or global scale.

The incidence (occurence) of HIV infection among the population in sub-Saharan Africa (white part of the map) is staggering when compared to incidence in other parts of the world, but it is not sweeping through the entire population like a firebrand.

When you consider that there are only around 33.4 million cases of HIV infection in the world (and we’re nearing 7 billion people world-wide), and that almost two-thirds of these cases are found in the lower portion of Africa, you can see that HIV infection most certainly is an epidemic, but when you look at it on a percentage of the population scale, the numbers are a little less dooming.

It is estimated that 5-6% of the adult population is currently infected in sub-Saharan Africa. That means that 94-95% of the population does not have HIV at this time. New infections are still happening, but not at a rate that is in danger of sweeping the region anytime soon.

Keep in mind, even in your fiction, that MOST epidemics and pandemics (which are just epidemics that strike more than one continent on epidemic proportion) are not going to cause a large percentage of the population to die out. There have been some notable exceptions to this rule – particularly the flu pandemic in 1918, which killed 40-100 million people within one year (statistics weren’t kept closely during this period and estimates of human casualties vary widely). That is still only about 5% of the world’s population, and that flu reached just about every corner of the globe.

All that said, don’t let me dissuade you from sympathizing with Africa’s current plight. There are countries within Africa who are currently experiencing infection rates as high as 23-25% of the adult population – Botswana and Swaziland are in the lead. There is undoubtedly mass human suffering related to HIV infection in the African region at this time, and efforts to educate, reduce spread, and treat infected individuals are on-going through The World Health Organization and literally hundreds of initiatives from around the world.

Despite the continuing crisis, those efforts are working. In 2009, data from the World Health Organization indicated a 17% decline in new HIV infections compared to the previous 8 years.

Posted in infection | Leave a comment