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by Murder

  Your crocodile victim would be removed from the croc's mouth; his wounds would be treated with local compression and tourniquets to control the bleeding; he would be given intravenous fluids (probably D5LR—5 percent dextrose in lactated Ringer's solution) and a couple of bottles of Hemopure (or Product XYZ); and transported to a hospital facility. There, he would receive real blood and undergo surgery to repair his injuries. The artificial blood would be the bridge that allows him to survive.

  What Is Blood Doping, and How Does It Work?

  Q: I'm writing a story in which a young track star uses the process of blood doping to gain an unfair advantage in an upcoming meet. How is blood doping done? Are there any complications?

  A: Athletic performance and endurance are dependent on the ability of the body to supply oxygen and nutrients to working muscles and remove toxic by-products from them. This requires a conditioned cardiovascular system, an adequate supply of glycogen and other energy sources from the liver and muscles, and blood rich in hemoglobin, the molecule in red blood cells (RBCs) that carries the oxygen from the lungs to the muscles. The more hemoglobin in the blood, the better it transports oxygen.

  The natural way to increase the RBCs and hemoglobin is to live or train at an altitude where the thinner air stimulates the bone marrow to produce more RBCs. People in Denver, Colorado, tend to have a greater concentration of RBCs and hemoglobin in their blood than those who live at sea level. An athlete who moves to the mountains to train would see results after a few weeks.

  Blood doping is a method of doing this artificially. It is basically the removal of blood, separating and storing the RBCs, and giving the plasma back. After three or four weeks the body has replaced the removed RBCs. Then, at a later date, the stored RBCs are given. This immediately increases the concentration of RBCs (and hemoglobin) in the blood, which improves oxygen delivery capacity and thus athletic performance. Marathoners, cyclists, and other endurance athletes can use this procedure to gain an unfair advantage.

  Complications are rare if the process is handled appropriately. Transfusion reactions do not occur since the person is receiving his own blood. However, if the blood is mishandled, problems can arise. If the blood is inadequately stored or if its sterility is violated, bacteria can grow in the stored blood and cause septicemia (infection in the bloodstream) when infused. This can lead to severe illness and death. If the blood is frozen or agitated, both of which can damage or shatter the RBCs, kidney damage can result when the blood is given.

  Some athletes shortcut this process by taking a transfusion of someone else's blood. There is no removal of their own blood and no three-week wait to rebuild their own blood count. But this raises the problem of a transfusion reaction, which can happen even if the blood is adequately cross-matched. It was alleged that during the 1984 Olympics, some members of the U.S. cycling team blood-doped a week or so before their competition. They apparently didn't have time to do it properly and used type-specific blood donated by relatives and friends. This blood of the same type (for example, O-negative), which has not been matched for compatibility against the recipient's own blood, greatly increases the chance of a reaction, not to mention the transmission of hepatitis or AIDS.

  Physicians use type-specific blood in only the direst of medical emergencies, situations where there just isn't time for a complete cross-match because the patient is bleeding to death. You do what's necessary in these circumstances and then deal with the consequences. A bicycle race hardly qualifies.

  Another substance used for this type of performance enhancement is recombinant erythropoietin. Erythropoietin occurs naturally in the human body and stimulates the production of RBCs. It is manufactured by recombinant DNA techniques and, when injected, artificially increases the RBC count. Medically it is used in patients with chronic kidney failure where anemia is common and difficult to treat.

  One problem that can arise in blood doping, regardless of the method, is a thickening of the blood. The more RBCs the blood contains, the more viscous it is. In fact, there are several medical conditions, such as polycythemia vera, where the concentration of RBCs becomes so great that the patient must be bled. We call this a phlebotomy. Yes, Renaissance medicine still lives. If the blood becomes too thick, it can literally sludge in the capillaries and cause strokes, heart attacks, kidney damage, and loss of digits. It can happen to an athlete whose exercise leads to dehydration if his blood is artificially thickened.

  An athlete can botch the process and have a transfusion reaction, damage his kidneys, or become infected, or he can successfully complete the blood doping only to suffer a fatal heart attack during the competition. Or he can get away with it and win the race.

  What Is the Basic Procedure for Blood Donation?

  Q: It has been a few years since I donated blood. What is the basic medical procedure for drawing your blood? What questions do they ask beforehand?

  A: Review the answer to the question regarding the basic medical questions a physician asks in emergent situations. These are important in the donor situation since certain current and past medical problems and the taking of some medications preclude the donation of blood. Other questions are designed to determine the presence or possible presence of any transmittable diseases such as hepatitis or AIDS.

  The procedure is basic. A large-bore needle (14 or 16 gauge) is introduced into a vein in the soft depression on the inside of the elbow (called the antecubital fossa). The blood is then drawn into a bottle or plastic bag. The needle is removed and a bandage placed. The major concern for the donor is dizziness or fainting. Some people develop what is called the Vasovagal Syndrome. This is what happens when someone sees blood and faints. It is caused by a massive outpouring of stimuli from the brain, which excites the vagus nerve. This nerve exits the stem of the brain and wanders (like a "vagrant," thus the name) through the body, enervating the heart, lungs, blood vessels, and most of the gastrointestinal tract. It is involved with the regulation of blood pressure, heart rate, and a multitude of other bodily functions. When it is stimulated, the blood vessels dilate (open up), and the heart rate and blood pressure may drop dramatically, leading to dizziness and loss of consciousness.

  Also, the removal of a pint of blood in a short period of time decreases the blood volume—the old "quart low" phenomenon. This can also lead to dizziness when the person stands. That is why orange juice or some other fluid is given and the donor is watched for a half hour or so. This gives the body time to rebalance the blood volume.

  Over the next few weeks the body revs up the bone marrow to replace the donated blood, and life goes on. Donations should not be made any more often than every six weeks or so to prevent the development of iron deficiency and anemia in the donor.

  What Medical Emergency That Required Quick Action Would Likely Occur in a Gunshot Victim in a Hospital ICU?

  Q: I'm writing a scene in which a paramedic is contemplating pulling the plug on a critically ill bad guy in the hospital ICU. Just as he decides to do so, however, the bad guy (a gunshot victim, by the way) suffers some kind of life-threatening emergency (cardiac arrest?), and the paramedic, acting strictly on impulse, performs some form of medical heroics to save the guy's life before hospital staff can reach his room.

  Can you suggest a viable set of circumstances to fit such a scenario? What type of life-threatening emergency would specifically fit the bill here, and what could our paramedic do to avert disaster in the fifteen or so seconds it is likely to take the staff to respond to the situation?

  A: A cardiac arrest would be perfect. Sudden and intense, it can be remedied with a single quick response. The paramedic could be at the bedside, contemplating his actions, when the monitor above the bed shows a sudden change in the intended victim's cardiac

  rhythm. It can be either ventricular tachycardia or ventricular fibrillation. An alarm would sound in the room and at the nurses' station. The nurse watching the monitors at the station would see the same tracing, recognize the need for emerg
ent intervention, and immediately a Code Blue would be called over the hospital speaker system: "Code Blue, ICU 3! Code Blue, ICU 3!"

  The Code Blue team typically consists of ICU and/or ER nurses, the ER physician or any M.D. on the floor, a respiratory technician, and other ancillary personnel. They race to the room with a "crash cart" that has all the medicines, IV fluids, portable defibrillator, and so forth, needed for a resuscitation.

  Meanwhile, the paramedic could act. A portable defibrillator unit would likely be at the bedside. He could grab the paddles, place them on the patient's chest, and fire away. The single shock could immediately return the person's rhythm to normal so that when the nurses and others arrived, the crisis would already be over. The doctor would then examine the patient and request an EKG, lab work, and other items in an effort to figure out why the event occurred.

  Another possibility would be to have another Code Blue going on down the hall or in another ICU cubicle. Maybe when the victim's cardiac arrest occurs and the alarm goes off, a young and inexperienced nurse or a nurse's aide can run into the room and say the code team is tied up. He then can enlist her help (this would give you an opportunity for some interaction or dialog if that works for you), or he tells her to get one of the ICU nurses from the other Code Blue. After she runs out of the room to get help, he realizes he can't wait and must act now or the man will die.

  This would be a likely real-life occurrence. I remember one wild night as an intern when we had three codes on the same floor at once. To say the resources were stretched thin would be an understatement.

  What Information Would Emergency Department Personnel Give Out Regarding a "John Doe"?

  Q: In my current novel my character's husband is missing. She calls the hospital, which informs her that there is a John Doe there matching his description. She immediately goes to the hospital to take a look.

  My questions: Would they mention over the phone that they have a man fitting her husband's description? Is there a procedure for her to see and talk with this person, or would she just be allowed to take a look?

  A: I assume that the man would be injured or unconscious or amnesiac or confused. Otherwise, he could tell them who he was and give permission to notify his wife. The police may be present in such a circumstance, especially if some sort of trauma is involved.

  The charge nurse or the emergency room (ER) doctor would likely tell the caller that there was a John Doe in the ER but wouldn't give too many details—nothing that would violate patient confidentiality. But since the ER personnel and perhaps the police don't know who the person is and would be trying to identify him, anyone who could do so would be helpful. They would likely ask that she come to the ER.

  When she arrives, the nurse or the doctor would probably let her see the victim. Remember, the doctor is responsible for the man's care, and he would want all the information he can get. Having a family member or friend identify the victim is a huge step in that direction. He could then ask about the victim's past medical history, allergies, current medical problems, current medications, and so forth—in other words, the things he needs to know to care for the patient.

  What Medical Expertise Would a Seasoned Commando Possess?

  Q: I have a character who served as a commando in the Israeli special forces and was specifically trained as a medic. He spent time in war zones where he carried out medical treatments for which he was not officially trained. His strategic skills quickly gave him an international reputation for planning and executing daring raids, rescues, and so on. While I rarely use his medical skills in the stories, I want to be accurate when I do. It seems he would be midway between someone with Boy Scout or Red Cross first aid skills and a medical doctor. Realistically, what would be the limits of this man's medical abilities?

  A: His medical skills could be almost any level you wish. His abilities would be at least those of a well-trained paramedic. He would know CPR and how to handle many types of emergency situations. Since he served as a combat medic, he should be able to perform the initial treatment for all types of war injuries—wounds caused by gunshots, shrapnel, knives, explosives, and others. He would be adept at controlling bleeding, maintaining an airway, stabilizing fractures, and suturing most superficial lacerations. His biggest asset would be his grace under fire. When faced with any serious injury or emergent situation, the first step is to avoid panic and use common sense. That goes for M.D.s, too. He should be well equipped in this regard.

  If you avoid the temptation of allowing him to perform sophisticated surgeries and treatments, you should be okay regardless of what he does.

  Can Firefighters Estimate the Survival Time of a Victim Trapped in an Airtight Enclosure?

  Q: An amateur illusionist walls himself up in a very small space in his basement, assuring his wife he can free himself without assistance. Naturally, she calls 911 so that rescue personnel can get him out. My question: How would firefighters arriving on the scene estimate how much oxygen he had left in the enclosed space? Is there a calculation they use based on the space in cubic feet, the height and weight of the trapped individual, and other information? If he was a diabetic and forgot to take his insulin with him, how would this complicate the situation?

  A: Estimate? Maybe. Calculate? No way. This situation is much too complex. Let me explain.

  First, the physiology. In the simplest of terms, the lungs take in air, transport oxygen (O2) from this air into the bloodstream, remove carbon dioxide (C02) from the blood and exhale it back into the environment. This simple process is actually very complex and requires good air, good lungs, a good circulatory system, plenty of red blood cells, and a ton of chemical reactions. The diseases that can interfere with this process are numerous. In your scenario, however, we are dealing with a healthy person who has normal lungs and other criteria.

  Unfortunately, that doesn't simplify the calculation very much. Let's take a glimpse at just how complicated such a calculation can be.

  I'm sorry, but the metric system must be used here. Remember that one meter (m) is about 39 inches (3 feet 3 inches) and equals

  100 centimeters (cm). A cubic centimeter (cc) is a measure of volume. One cc is a volume that is 1 cm X 1 cm X 1 cm.

  Air at sea level is 21 percent oxygen.

  An airtight room that is 3mx3mx3m (roughly 9 feet on all sides) would contain 27 cubic meters (or 27,000,000 cc) of air and about 5.67 cubic meters (5,670,000 cc) of oxygen.

  A normal breath is about 500 cc. However, about 30 percent of each breath never reaches the alveoli (air sacs) and thus isn't involved in gas exchange (the passage of oxygen from the lungs into the bloodstream). This is the air that fills the bronchi (breathing tubes), which is termed the "anatomic dead space." Thus, 70 percent of each breath is potentially useful. Since an individual at rest breathes approximately 16 times a minute at 500 cc per breath, these are the calculations:

  Total air intake = 500 X 16 = 8000 cc "Useful" air intake = 8000 X 70% = 5600 cc Oxygen intake = 5600 X 21% = 1176 cc

  A person at rest therefore inhales about 1176 cc of oxygen per minute. This means that the oxygen in the room would last about 4821 minutes, or 80 hours (5,760,000 divided by 1176).

  It seems like a long time to survive in an airtight box, doesn't it? It is.

  These calculations assume that the person could use every cc of oxygen in the room. Not so. Remember that with each breath the percent of the air that is oxygen drops, and the concentration of carbon dioxide rises. By the time the O2 concentration fell to 15 percent or so, the person would be in severe trouble. This means that only about 6 percent (21 minus 15) of the oxygen content can be used to calculate survival time. And, of course, the mounting CO2 level compounds the problem.

  When you add to this the fact that bigger people have higher 02 requirements and that any activity, even standing or walking, increases 02 usage, the calculations become extremely complex. And we've considered only the basic physiologic components of this situation. There are many others tha
t are simply too intricate to explain. So even though these calculations can be done, they are not easy and cannot be performed by firefighters trying to save someone.

  As you can see, this is a nice exercise in math and physiology, but it doesn't really answer your question.

  When the rescue personnel arrive, they would be faced with an emergent situation where every minute counted. Rather than employing complex mathematics to calculate the time left, they would use signs and symptoms to determine how much trouble the victim is in and make a guess as to how fast they must move.

  What we are talking about here is called "hypoxia" (low oxygen content in the blood). The symptoms and signs of hypoxia are similar to those of alcohol intoxication. The symptoms might include fatigue, lethargy, giddiness, headache, drowsiness, blurred vision, delusions, hallucinations, sleep, coma, and death. The signs would be loss of attentiveness, poor coordination, slowed reaction times, poor balance, rapid breathing, weakness, and finally collapse. These can occur in any combination and progress as your amateur magician consumes more and more oxygen and his hypoxia worsens. These should give you plenty to work with in constructing your scene.

  Your firefighters would assess the person to determine how far along in the process he is. If he is giddy and confused, they would have more time than if he is in a coma and barely breathing. The first thing they would do is try to break open the chamber, but I assume that in your scene this isn't going to be accomplished easily. Short of that, they would attempt to bore a hole through which they can pump oxygen and buy some time.

  The addition of diabetes to the situation would greatly complicate things, but only if the person is an insulin-dependent diabetic. Diabetics who are insulin dependent manufacture little insulin

  themselves and must depend on the injection of insulin for survival. Missing a dose can result in a rapidly rising blood sugar level, the onset of diabetic ketoacidosis (DKA), coma, and death.