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by Murder

  Many people survive for days lost in blizzards or in the mountains during the winter. Others don't make it through the first twelve hours. Your victim could do either, depending on what you want.

  Does Alcohol Intake Prevent Death from Freezing?

  Q: Does this make sense medically? A man falls through the ice of a frozen lake at night. He is unable to get himself out but has a bottle of brandy in his pocket, which he sips through the night and survives until he is rescued the next morning. Would the alcohol help him survive? Would it act like antifreeze?

  A: Sorry, but your character is doomed, and his actions would only hasten his demise. Let me explain.

  Our skin serves as our radiator. In hot weather the capillaries in the skin dilate, blood flow through the skin increases, and heat is lost to the atmosphere. That is why many people look flushed when they are warm. The evaporation of sweat consumes some of the heat since turning a liquid into a gas (evaporation) requires energy, and it is the body heat that supplies this energy. Thus, heat is lost. People suffering from heat prostration or heatstroke are bathed with water and fanned with a towel or whatever is available.

  This promotes evaporation and heat loss from the overheated body of the victim.

  Cold is the exact opposite. The body attempts to hold its heat. Blood is diverted away from the skin so that less heat is lost through "the radiator." That is why people look paler when they are cold. When exposed to extremes of cold, the best way to protect yourself from freezing is to cover up, stay out of the wind (moving air absorbs more of the heat), and create warmer ambient air by building an ice cave or burrow of some kind. This traps the body's heat in the "cocoon," and thus less is lost. In water this isn't possible. Similar to a cold wind, the movement of the water or the victim's movements within the water would greatly increase heat loss. During World War II the survival of pilots shot down in the North Atlantic could be measured in minutes.

  Now to the brandy issue.

  Alcohol dilates the vessels in the skin, which increases blood flow and thus heat loss. Some people become flushed after alcohol consumption. This seems to be especially true with red wine, but it happens with any alcohol. In a cold environment this is the exact opposite of what is desired. The old image of the Saint Bernard with a cask of brandy hanging from his neck is bad medicine. Alcohol hastens heat loss, and thus death from freezing.

  Alcohol does not act as antifreeze in the human bloodstream.

  In your scenario the man would be up to his neck in frigid water and would likely thrash around in an attempt to stay afloat. The icy water would rapidly dissipate his body heat, and he would become hypothermic (low body temperature) in a matter of ten to twenty minutes, maybe less. If he drank the brandy or was intoxicated before he took the plunge, this time would be shortened considerably. Symptoms of hypothermia include fatigue, weakness, lethargy, and confusion. His strength and coordination would diminish and his survival struggles weaken, and he would drown.

  You may remember the dramatic news video of the young woman being rescued from an icy Potomac River. When she was

  thrown a line, she was too weak to grip it and sank beneath the water. Fortunately, a heroic man jumped in and saved her. Unless your character had such a hero handy, he would succumb to the cold and drown.

  Could your guy survive? Not likely, but there is an old Emergency Department adage that says, "You can't kill a drunk." That is why when you read about a drunk driver hitting a carload of people, it's always the family that dies, never the drunk. Sometimes life doesn't make sense.

  Could Someone Survive in a Roadway Tunnel Where a Forest Fire Raged at Both Ends?

  Q: This is going to sound like an odd question, but what would happen to a character trapped in a roadway tunnel that cuts through a hillside while a forest fire raged on either end? Would he survive? Would he get burned?

  A: Survival would depend on the length and size of the tunnel, whether the fire raged at both ends, whether there was a vent that was away from the fire so that fresh air could be obtained, and other factors. The two dangers would be cooking from the heat and suffocation from the fire consuming the oxygen. If your victim had underlying heart or lung disease, his survival time would be shortened.

  The bigger the tunnel, the more air he would have and the farther away from the fire he could stay. If the fire blazed at both ends of the tunnel, it would rapidly consume all the oxygen from the air in the tunnel, and he would suffocate unless a source of fresh air was available—either natural or via some form of breathing apparatus. If it burned only at one end or if a vent was present that was away from the flames, these sources of fresh air would increase his chance of survival. Also, this situation might give him an escape route.

  In a short tunnel surrounded by fire, the victim would likely suffocate and cook.

  Forest fire fighters carry protective blankets to crawl under and bottled air to breathe just in case the fire overruns them. In most cases this gives them enough protection to survive long enough for the fire to move on. The same could be true for your character. If the tunnel insulated him from the heat and if a source of fresh air was available, he might survive long enough for the fire to move on. Otherwise, he wouldn't.

  What Happens When Someone Is Struck by Lightning?

  Q: In my story I have a character who is struck by lightning but survives. What kind of injuries might he suffer? What long-term problems would follow?

  A: Lightning strikes come in four varieties.

  1. Direct strike: The lightning hits the victim directly. This is the most serious type and is more likely if the victim is holding a metal object such as a golf club or umbrella.

  2. Flashover. The lightning travels over the outside of the body. This is more likely if the victim is wearing wet clothing or is covered with sweat.

  3. Side flash: The current "splashes" from a nearby building, tree, or other person and then spreads to the victim.

  4. Stride potential: The lightning strikes the ground near the victim, who has one foot closer to the strike than the other. This sets up a potential electrical difference between the legs called a "stride potential." The current enters through one leg, spreads through the body, and exits via the other leg.

  When dealing with lightning, which is a direct current, the numbers involved are huge. The voltage varies from 3 million to 200 million volts, and the amperes range from 2,000 to 3,000. Quite a jolt. Fortunately, the current is very brief, averaging from 1 to 100 milliseconds (thousandths of a second).

  The injuries that result are primarily due to the massive electrical current and the body's conversion of the electrical energy to heat. The electrical shock can literally stop the heart or cause dangerous and deadly changes in heart rhythm. The heat can burn and char the skin, scorch the clothing, and fuse or melt metal objects in the victim's pockets, buttons on his shirt, belt buckles, and fillings in his teeth.

  All the tissues of the body are susceptible to injury. The skin may be charred and even display entry and exit burns. The heart muscle may be damaged and scarred. The liver, kidneys, bone marrow, and muscles may suffer permanent injuries. The brain and spinal cord may be damaged, and residual weakness in an arm or leg is not uncommon. Loss of memory and psychiatric difficulties may follow.

  One interesting sign of lightning strikes that rarely occurs are Lichtenberg Figures (Figure 6), which were first described by German physicist Georg Christoph Lichtenberg in 1777. This is a painless red fernlike or arboresque pattern over the back, shoulders, buttocks, or legs. It tends to fade over a couple of days, leaving behind no scars or discolorations. It is uncommon but fascinating.

  Treatment depends on the severity of the injuries. The first order of business is to reestablish breathing and heart rhythm if either or both are absent. Steroids are given to lessen swelling and inflammation in the body's organs. Burns are treated in the usual fashion with cleaning and dressing as indicated. Blood tests would assess the degree of liver, kidney, and muscle damage
. When muscles are injured in this fashion, the muscle cells may die or rupture. If so, they release their internal myoglobin and other proteins into the bloodstream. These proteins can severely damage the kidneys because the kidneys attempt to filter them from the blood. Flush-

  ing the kidneys with a large amount of IV fluids may prevent kidney failure.

  Recovery can be complete, with no residual problems, or the victim may have permanent liver, kidney, cardiac, psychiatric, or neurologic problems. Luck and rapid, effective treatment are important here.

  Can a Person Stranded at Sea Survive by Drinking His Own Urine?

  Q: If someone was stranded in the desert or on a life raft in the open sea, could he survive by drinking his own urine. Is it dangerous or toxic? Or is it okay?

  A: Any port in a storm, so to speak.

  Yes, this would help—at first. Urine is simply water with impurities that have been filtered from the blood by the kidneys. In the type of exposure you describe, dehydration is the major problem. Any source of water would be beneficial. However, the concentration of impurities in the urine would increase as dehydration progressed, and very quickly the urine would supply more toxins than water. Drinking it would then be counterproductive.

  In reality by the time a person considered drinking his own urine, he would already be severely dehydrated, his urine would be very concentrated, and consuming it would be of little benefit.

  DOCTORS, HOSPITALS, AND PARAMEDICAL PERSONNEL

  Can X-Ray Films Be Copied?

  Q: Can an X ray be photocopied or otherwise duplicated?

  A: Yes. X rays are often copied by use of a special copier designed for this purpose. Most hospital radiology departments have such capability, and it takes only a few minutes. Also, nowadays many hospitals acquire and store the images in a digital format. These can be duplicated, printed, altered, e-mailed, and all the other things one can do with digital data.

  How Do Doctors Handle Emergencies and Concussions?

  Q: In an emergent medical situation, what initial questions might a doctor ask? And if he suspects the person might have sustained a concussion or a more serious head injury, what specific questions might he ask?

  A: The initial questions are similar regardless of what the emergent situation is. The key is to get as much information as possible in the shortest time and with the fewest questions. In true emergencies time is often the enemy, and the physician doesn't have the

  luxury of taking a long history from the patient. I always taught my students that in such situations you can get most of the information you absolutely need with the following three questions:

  1. What's wrong or what happened? We call this the "chief complaint." Seventy percent of the time the diagnosis can be narrowed to a very few choices with the answer to this question. A complaint of chest pain leads you in one direction or line of thinking, nausea in another, and headache in yet another.

  2. Have you ever been hospitalized or treated for anything in the past, and if so, for what? We call this the "past medical history." The answer tells the M.D. about the medical problems that the person has experienced in the past and gives him the necessary background to evaluate the current problem. Many of the patient's past illnesses will have an effect on his current illness or injury, and, indeed, many of these past illnesses may still be active medical problems. Heart disease and diabetes would fall into this category since they don't go away but, rather, tend to progress.

  3. Do you take any medications or have any allergies? This tells the M.D. what the active medical problems are, such as high blood pressure, diabetes, heart disease, hepatitis, and so forth, and how they are being treated or managed. This information also guides the M.D.'s treatment so he can avoid drug interactions and the use of known allergic drugs.

  These are the general questions a physician asks of any patient in an emergency situation. If the victim is not conscious, much of this information can be obtained from relatives, friends, another M.D. who knows the patient, or medical records. MedicAlert bracelets are also helpful.

  After this basic data is obtained, more pointed questions are

  asked to fill in the areas of concern. For a patient with a head injury, the following questions are essential:

  Do you have a headache? Is it localized or general?

  Do you have blurred or abnormal vision?

  Are you experiencing dizziness or poor balance?

  Have you been nauseous or vomiting?

  Do you have any soreness or stiffness in the neck?

  Do you feel any weakness? Is it generalized or only in one side, arm, or leg?

  Are your eyes sensitive to light?

  Do any of these symptoms worsen with a change in position or movement?

  Then, of course, a complete physical and neurologic exam is performed. Based on the answers and the findings on the exam, lab work, X rays, and other tests would be obtained as indicated.

  How Do Hospitals Ration the Blood Supply in Major Natural Disasters?

  Q: I have an odd question for you. Let's say the big one hit Los Angeles tomorrow, devastating the city. I imagine the blood supply would be depleted rather quickly. How aggressive would doctors be about getting blood donors? Would doctors at temporary M.A.S.H.-like medical facilities solicit healthy people off the street to give blood? Would they be able to screen this blood quickly for AIDS?

  A: Every hospital has an emergency or disaster plan that deals with catastrophes such as an earthquake. That said, whenever a

  major event such as you describe occurs, these plans may be overtaxed and become quickly inadequate.

  M.A.S.H.-like field hospitals would crop up out of necessity, and the blood supply would be rapidly consumed. The Red Cross and other organizations would transport blood, and volunteer donors would be called in. The Red Cross keeps a list of clean donors that they regularly call on when needed; blood would be obtained from them. Yes, people off the street might be used. So far, so good. Labs would be set up to supplement those of the local hospitals to type and match the blood and screen it for AIDS and hepatitis.

  Screening for hepatitis and AIDS cannot be done quickly. Several hours and up to a day or two would be required. As the injured rolled in, it would be necessary for these considerations to take a backseat. After all, would you rather bleed to death or risk the very small possibility of contracting hepatitis or AIDS?

  At some point all this would not be enough, and unmatched (type specific) and untested blood would have to be used to save some lives. Type-specific blood is the same type that the patient has, but it does not have full cross-matching of all possible incompatibilities. It takes only a few minutes and very little equipment to determine if blood is O-negative, for example, but it is more involved to actually test the donor blood against that of the recipient for true compatibility. This increases the possibility of a reaction, but this situation exemplifies the old adage: "Any port in a storm."

  What Is Artificial Blood?

  Q: While on a safari in Africa, one of my characters is attacked and severely injured by a crocodile. His leg is mauled, and he nearly bleeds to death before he is evacuated to a hospital. I've read recently about artificial blood and may want to incorporate it in my story. What is artificial blood? Is it available? Are there any problems?

  A: Artificial blood has been the subject of research for three decades. The concerns regarding AIDS and hepatitis, the erratic availability and difficulty in storing and transporting real blood, and the need for blood in remote areas such as war zones has driven this research.

  First a word about what artificial blood is and isn't. It is a product that supplies molecules capable of carrying oxygen from the lungs to the tissues and bringing carbon dioxide back to the lungs to be expelled. The normal IV fluids given to patients in shock or those suffering from blood loss are basically water with some electrolytes (sodium, potassium, and so forth) and sugar, and they have no ability to carry oxygen, which is the immediate concern in shock
situations. Artificial blood is designed to fill this need.

  However, artificial blood is not real blood. It does not contain vitamins, nutrients, hormones, antibodies, platelets (small blood cells involved in clotting), or any of the proteins involved in the clotting of blood. If given injudiciously or in large amounts, it will dilute these needed clotting factors and lead to a worsening of the bleeding, which would be counterproductive. Artificial blood is used as a bridge to stabilize the victim long enough to get him to a proper medical facility, where definitive treatment can be rendered and real blood given.

  Early attempts at developing artificial blood revolved around extracting the hemoglobin molecule and modifying it so that it could be given without giving the entire red blood cell (RBC), which must be stored and refrigerated. Hemoglobin is the molecule within the RBCs that binds, carries, and releases oxygen and carbon dioxide. Unfortunately, the hemoglobin molecule when removed from the RBCs is very toxic and causes an increase in mortality. A report in the November 17, 1999, issue of the Journal of the American Medical Association showed that such a product, called HemaAssist (Baxter Healthcare), when used in trauma patients led to a mortality rate of 46 percent as compared to a rate of only 17

  percent in those who received the typical IV fluids. It was back to the drawing board.

  Several other products are under development and being tested at this time. One of the most promising is called Hemopure, which is produced by the Biopure Corporation in Cambridge, Massachusetts. It was recently approved for use in South Africa but as yet is not available in the United States. Hemopure is based on hemoglobin extracted from the RBCs of cow blood. Unlike whole blood, it doesn't need to be refrigerated and has a shelf life of two years (42 days is usual for properly refrigerated blood). Its administration is simple: Start an IV and drip it in.

  In your story it would be perfectly reasonable for the medical personnel on your safari to have available Hemopure or any similar product your imagination might create. This is fiction, after all. As long as artificial blood has some factual basis, which it does, you can make up your own brand name.