you medical people on my journal...

[kaigou]

I know there's some of you out there, so if you have any ideas:

I've got a character who was poisoned. Think a milder, survivable form of strychnine (I think that's the one I mean), where the poison freezes the muscles up. He got a small dose, but it was still close, and as a result his heart's going to take awhile to recover from getting stomped like that. The analogue I've been using is open heart surgery, which apparently does a fair bit of heart-stomping. So I've had the character gradually work his way back to some form of moving about, following the advice given post-surgery to heart patients: walk a bit, then rest, walk a bit more, rest, work your way up to walking up a flight of stairs, lots of rest, etc.

However, the story takes place in the equivalent of the 16th century, so well before any of our fancy modern medicines. Doesn't mean there's no medicine, just that the reasoning might be off (even if the end results work), like thinking aspirin works because of humours, or whatever.

Anyway, so I've got a bit where the character has exerted himself too much, and from what I could tell of the warnings to post-surgery patients, this is why patients often take blood-thinning medicine, to make it easier on the heart. Extrapolating from that, seems like the heart would tire out, can't pump but the body's demanding it, and suddenly you have lack of enough blood, ergo, passing out.

Here's where it might get tricky: the medical person's logic is that a drunk person bleeds twice as much as a sober person from the same-sized wound, so alcohol must make blood run faster and/or be thinner. If blood is normally thick, and the heart is weak, then thinner blood would be easier for the heart. Thus, alcohol is the make-do medicine for someone coming to after dizzy spell, whose heart continues to beat too fast.

In discussions with one of my beta-folks, the point was made that alcohol also raises blood pressure. I know it's a sedative (calm down the heart?), and I thought I found something that mentioned it's also a kind of blood-thinner, so would those positives outweigh the blood-pressure increase? Or would the addition of two shots' worth of alcohol make no substantive difference, or would it actually just kill the character outright?

Anyone? even wild guesses, if there aren't any doctors in the house. tia!

Comments

Wild guess here

[kathmandu]

Alcohol is nervous system depressant. It slows down reflexes in general, could slow down the heart if the heart was being overstimulated *by the nervous system*, but I don't see drinking alcohol making anyone LESS dizzy unless it were by raising blood pressure from a shock-type low-blood-pressure condition.

I'm not sure what your goal is here. Are you determined to include alcohol as a treatment, and looking for ways to justify persons of that time believing it would work? Determined to include alcohol as a treatment, and looking for grounds to declare that it does so work in this storyverse? Or are you looking for any treatments that might actually work in real life, so you can choose one and put it in the story?

[kaigou]

I'd rather have something that would actually work (or at the very least, NOT kill the patient!) and then I'll find ways to justify it. If that's not possible, then I'll wrangle things so alcohol would be a reasonable treatment. The one holdup in all of it is that even with decent reasoning, there's still limitations on what kind of treatments would have been available -- mostly herbal-based.

(I mean, it's not even a culture where milk is common, so the original poisoning got wrangled anyway, under the pretense that vinegar would neutralize (at least the edge of the) poison, much the way milk is supposed to. On that grounds I could probably fiddle with things, but this isn't poison, this is just simple "heart got damaged" and thus a bit harder to finagle. I mean, hearts is hearts. Kind of hard to argue the laws of biology don't apply when it's just a human heart.)

In this case, alcohol made for a decent assumption, since the logic doesn't require advanced knowledge of medicine or biology -- just a set of observations, extrapolated to fit the situation. Which means that if alcohol + condition = certain results, then I could always add those in, as well. Like if it made the person ten times worse hungover in the morning, or dizzy for considerably longer, or whatever. I mean, short of actually killing the patient. That would kind of not work for the story!

[surskitty]

Is willow-bark tea or some other source of aspirin a workable possibility? :|a

[kaigou]

I thought there was something about how you don't give aspirin to someone who's bleeding, or recently passed-out? Uh. Cripes, it's been a long time since I wrote whatever it was that made someone tell me that aspirin's a definitely-not.

But if aspirin (or equivalent) would work, I'm sure I could figure out a way to logic that in there. Hrm.

[surskitty]

Well, it interferes with clotting, and that's either the main or a major idea of blood thinners in general. I know you don't take aspirin or NSAIDs in general if you're already on some sort of blood thinner unless ulcers sound like a good idea to you, but Naka isn't, so.

[kaigou]

ohhh, so that's it! that would work. I mean, generally speaking, it's anything that'll thin the blood that might work in this context (at least to take care of the worst of things) -- and probably a lot less likely to give one a hangover, too.

[cyphomandra]

Hmm. I think there are two issues here – your analogy for poisoning, which can easily be tweaked, and then your search for treatment, where it does depend what you want from the scene.

First up – strychnine (which I’m going to use as your comparison) basically binds to the nerves that control the motor system (everything you can move voluntarily) and causes them to remain activated. This results in spasms, convulsions, and vomiting, but the main thing that kills people is asphyxiation, due to the muscles that help breathing going into spasm. Toxins from damaged muscles can also poison the kidneys, and if you have a weak heart it may give out under the stress (not directly – heart muscle is not under voluntary control), but basically if you’re otherwise healthy, once you’re over the acute poisoning there should not be any long term outcomes – the blocked receptors the strychnine binds to are removed and replaced automatically, and the strychnine passes out of your system. There’s a case on the net here - http://ccforum.com/content/6/5/456 - and he seems to have been back to normal physically five days later.

Open-heart surgery, by contrast, is usually not done in otherwise healthy people, and involves directly injuring the heart, so recovery is going to take longer for all sorts of reasons. There are poisons that do damage the heart, but there’s a bit of a balance between picking something that causes heart damage and having something your character can ultimately recover from (I’m presuming you don’t want long term complications?). Inflammation of the heart (myocarditis) can make it unstable, prone to abnormal rhythms especially under stress, so a character would run the risk of potentially fatal complications or further damage if they exercised before the inflammation settled, but it needs a different mechanism from strychnine – something that inflames muscle will cause pain and weakness, not spasm.

The thick/thin blood thing and its role in patients with heart problems is one of those areas where better terminology is needed. Blood is, basically, a mixture of cells and liquid. If the proportion of cells – usually red blood cells – goes up, the blood gets thicker, the heart has to work harder, and it’s more prone to clotting. This is what happens in athletes who blood dope, which is why they occasionally have heart attacks or strokes and fall off their bikes.

But blood can also clot for other reasons. Damage to blood vessels (clotting is a defense mechanism), abnormal flow (stasis) or increases in the parts of blood that favour clotting (cells like platelets and various proteins) all cause clots. Treatment for any of these causes tends to involve identifying and treating the cause, but also giving drugs called anticoagulants, which block proteins involved in blood clotting and will help prevent clots regardless of the cause. These drugs are often called blood thinners, but they don’t actually thin the blood in terms of reducing the proportion of cells to liquid, and they won’t reduce the work the heart has to do. People who have too many blood cells usually take anticoagulants, but they also get bled regularly or take drugs to stop them making so many cells.

Patients who have had open heart surgery are prone to clotting because of damage to blood vessels, the healing process after surgery, and the fact that they’re usually lying very still. If they have had certain types of heart surgery (like putting in a replacement heart valve) they are also at more risk of clots. They are on blood thinners for this, not to decrease the work of the heart.

This is a very long answer to say that a) I don’t think your character’s heart would be that stressed unless there’s another mechanism of damage or they have an underlying problem and b) “blood thinners” are not really what you’re looking for. Having said all that, alcohol is a weak anticoagulant. Depending on your level of technology, digitalis (from fox glove) is probably the best historical treatment for a weak heart, and an anti-inflammatory (I think someone else has mentioned aspirin) for myocarditis. Um. I am happy to answer further questions if you have them!

[kaigou]

Maybe I should go back to the original assumptions for the poison in the first place (and the reason it'd even be around):

1) in view/carrying, it's loosely based on mistletoe (the poisonous kind), in that it's the berries that carry the poison
2) in use, it's like digitalis, in that it does have medicinal properties in low doses but is lethal above a certain level
3) and for good measure, I threw in that it's also used as a recreational drug by some folks, so there's a black-market use for it as well
4) since it's not a milk-drinking, beef-eating culture, I went with vinegar as a stop-gap wash (inc. mouthwash) for accidental exposure, with the in-text caveat that this is only a stop-gap; if the poison's over that threshold, or intensified via mixing with certain other substances, the vinegar won't do a thing
5) greatest danger is to younger/smaller people (less body weight) and older/elderly people (less strength or stamina)

The idea is that the poison does two things, the most important being that it constricts the upper-throat muscles. At worst, it basically strangles the person (thus the work-around treatment is a crude kind of tracheostomy). Depending on level/intensity of poison, next it hits the heart, and locks it down as well. I didn't realize strychnine works via spasms -- I was thinking lockjaw kind of symptoms, I guess? Where everything just freezes, contracts to its greatest point. Which means the damage to the heart would come from the heart being kind of crushed, in that it's trying to move but the poison won't let the muscles work.

The off-brand use would be very light doses for mild strangulation during sex -- whatever that fetish is called, when you want to limit oxygen intake. The on-brand medicinal use might be, idk, something where the heart is working overtime and needs to be slowed down a notch.

There's a bias, that I completely forgot "heart surgery patient" would already be pretty damn ill going into surgery, compared to a roomful of characters (especially the one in question) who are mostly active, well-fed, and strong. I think I only killed off two or three, who'd had enough *and* were either much older or much younger/smaller. The rest survived, except for two who then went jogging or the equivalent, and it was too much, too soon. Keeled over dead.

The long-term damage (or just very slow healing process) is a major plot point, since that's the reason the character makes the choices he does -- doctor's advice being that getting up and trekking thirty miles in a day from battle to battle just isn't in the cards for several months or longer. I took the outermost recovery time in muscular injuries like shoulder dislocation and whatnot, and upped it to be four months minimum. With as-yet-unknown damage (or any additional heart issues) an individual might be recovering longer, or never at all. Between the amount ingested, its intensity, the character's symptoms, the in-text guess was at least six months before he's fully recovered, and it's really only been like a month or so at most. Which means he's recovered much faster than estimated, but his stamina would be down anyway, since he hasn't been operating anywhere near his pre-poison level of activity.

The alcohol ended up being something that would be available with dinner, just like vinegar (in the pickled dishes). More very-medicinal things -- unless also eaten regularly as food, like, idk, mushrooms or something -- would probably not be quite so ready-to-hand. But if alcohol is a weak anti-coagulant, then it might ease things slightly, at best. At worst, it'd just make the character tipsy. But not necessarily kill him, right?

I suppose there's always the possibility that a modern knowledgeable person might read and say, "no, it doesn't quite work like that, although that's a good guess," and (hopefully) accept the medical character isn't modern/trained -- and that at least the guess wouldn't kill the patient. It's another matter altogether if pouring two shots of rice wine down the throat of a just-come-to patient would promptly send the person into death throes!

[cyphomandra]

Heart muscle doesn't really work like that - it's different from skeletal muscle (for a start, it contracts and expands an average of 60x per minute), and the only way you can crush it is by tightening the membrane bag around it. If the whole thing is clenched shut, you'll get sudden death rather than long term damage. I also think you're still thinking of muscle injury as a single thing, but there are different sorts of muscle injury and a lot of them heal very quickly. A shoulder injury might take weeks to heal because the whole belly of the muscle has been torn, but if you go running you'll give yourself microtears throughout your calf muscles that will heal within a few days at most.

From a writing plausibility point of view, tho', I would actually be tempted to split the effects you want into poison/antidote. So, your poison either locks up people's throats or paralyses them so they can't breathe, and the antidote/treatment is with a cardiac stimulant to keep things going and just boost them through the whole thing, but the stimulant itself stresses the heart so much that anyone getting it has to take it easy afterwards. (possible natural stimulants - well, digitalis and strychnine). For me this would get around the different mechanisms and time courses involved, and also I quite like the narrative kick of having the treatment complicate the disease. However, if you want a poison that locks up the muscles acutely and then kills them off slowly in the longterm, you could certainly write it, but I'd keep things vague.

Ethanol alcohol is a natural antidote for antifreeze (ethylene glycol) poisoning, actually, but the symptoms don't really fit. If you want something else that would work today (regardless of how it's justified then), I'd be thrilled to see charcoal used as an antidote - crushed up and mixed with liquid to swallow, for example - as this is pretty much the current standard antidote for most poisons. This stops any more poison from being absorbed, but it won't deal with what's already in the system.

[kaigou]

CP pointed out that if someone's recovered fully w/in 5 days of strychnine, then it's not like this has to be known per se -- iow, the assumption could be that "it'll take a really long time to recover" and everyone's just amazed at how fast the character recovers. Except then I can't think of him to have a reason to pass out (which would naturally be assumed to be due to the original poisoning, even if medically/modernwise it isn't at all).

Wait, just regular charcoal? Everything I read talked about activated charcoal, and I got the impression this is different from just pulling cold charcoal out of your fireplace and crushing it. Like it had to have something extra done to it. No? Is it not the "activated" part that makes it work? Because otherwise that would totally be fine -- there was certainly enough charcoal in braziers, at the time.

[cyphomandra]

Powdered charcoal will still work - not as well, because the activation process gives the charcoal lots more little pores to soak everything up, but well enough (I can't find a good reference, but a more dodgy one suggests about 4-fold difference in effectiveness). It's certainly been used historically, and I'd buy it as a reader. The more ground up it is the better - the aim is to increase the available surface area.

What Cyphomandra said

[kathmandu]

Activated is best, powdered still helps, charred toast also helps.

In fact, the standard broad-spectrum poison remedy is burned toast plus black tea plus milk of magnesia. Burning toast til black (and then soften in milk/water/whatever) is another way to generate free carbon bits, to approximate activated charcoal from a guaranteed-edible source.

[The black tea is to provide an acid; the magnesium is a base. Overall the idea is to neutralize and block from absorption the bad thing you ate.]

[kaigou]

Hold on, what if it's not the heart that's damaged? Is there something else that could be damaged instead that results in long-term recovery? Like the lungs, or the liver, or the kidneys, or something? After all, all I need is for the recovery to be slow and arduous, and generally require rest as the body takes care of itself. But it doesn't necessarily have to be the heart, since iirc getting over bronchitis & pneumonia it took a bit for me, and I was in great shape at the time -- it was like I just didn't bounce back overnight. Took a week or so, after I was officially better. So maybe something that hurts the lungs, instead?

Wow. I sound so... callous towards this poor character! LOOK JUST TELL ME HOW TO HURT THE GUY OKAY. Bwah.

[cyphomandra]

Whump away! The problem from a medical pov is combining a) acute poisoning in life/death situation with b) prolonged recovery without c) prolonged decline due to lack of medical treatment. For example, c) makes it difficult to knock off the kidneys, as they don't really cause symptoms until it's too late to do anything pre-dialysis/transplant era. Scarred lungs also won't heal with time - you just slowly get more short of breath, so not ideal.

Think about mechanisms of injury rather than site - infection/inflammation are the main things in this context that will take time to get over but will (usually) get better, like your bronchitis & pneumonia. Something that causes widespread inflammation as a poison is going to have different symptoms from your muscle spasmodic, tho' - more fevers, dizziness, flu-like symptoms, pain, weakness etc.

(sorry for delay! I think we are in completely incompatible timezones)

[kaigou]

I went and played on webmd (which naturally gave me lots of warnings of IF YOU ARE FEELING THIS RIGHT NOW, GO TO A HOSPITAL IMMEDIATELY and doesn't have an option for "no, just researching on how to whump a character, thanks!") and basically what I want is something that starts like a kind of severe allergic reaction -- that would be the can't-breathe part -- and ends with bad (3-4 month) bout of mono. Never had mono myself (I think I maxed out on my quota by getting strep every blooming winter until the age of 12), but as I understand, it kind of comes and goes during the virus' run, including fatigue, muscle soreness, some fever, that kind of loose set of flu-like symptoms.

Since the key point for the story is a) in the onset, difficult breathing to outright impossible to breathe and b) slow recovery -- then could it be that if you survive the first part, then your body just has to work the rest of it out of your system? The rest of the symptoms are easy enough to add in (fever, dizziness, weakness) as part of the onset. The really dramatic part of throats closing up is what I don't want to let go of, since it's also acting as a bit of character reveal for the MC, too. But instead of the throat muscles spasming, if it's inflammation, would they just swell up so much the throat closes? I was thinking something like tonsillitis, where it's the top of the throat that gets blocked off. That would be handy.

Now I shall go poke around on webmd and see how many more terrified alerts I can get. Heh. It's the little things that amuse the most, sometimes.

[kathmandu]

Acute allergic reactions to food certainly have a reputation for swelling the throat to the point where breathing stops. I just don't know how you'd keep that from being fatal, pre-epi-pens.

[erika]

Sorry to show up 3 days later, but does it have to be a poison? I can think of a disease that'll do that.

[kaigou]

Yep, has to be a poison of one kind or another, since it's an intentional attack on a large group of people. There's only one character of that group who's a central character in the story (so we only see his recovery), but he's just one among many in the original attack.

The crux seems to be that most toxins/poisons work their way out of the body pretty quickly, and a long recovery means long-term damage that may never get better (and in fact may just get worse). So I'm considering that the poison has a side-effect of, idk, like suppressing the immune system and opening the window to illness, and when the character does catch something that is what actually prompts the long bronchitis-level recovery, not the poison itself.

Although mostly I can be somewhat vague about it, since this isn't a culture with modern medicine. Mostly I just wanted to know whether alcohol would kill the poor guy, when he does pass out (for whatever reason).

[erika]

Nah, probably not. I doubt it would help him, but it won't /hurt/ him. It also depends on the 'dose'-- are you saying he's going to be given 5 shots worth of alcohol, or is the 'doctor' giving him 2?

If you go with the 'illness during recovery' bit, may I recommend whooping cough? After the initial infection stage, person feels completely fine except for major coughing spasms every 10-15 minutes. It's supposed to work its way out of your body in 3 weeks even without antibiotics, BUT I can tell you for a fact that once it gets established in someone with a crap immune system, you're looking at a 3-6 month recovery period. AND, I can also tell you for a fact that there's no long term damage -- my lungs have the same/better capacity as they did before I had it. :)

[metanewsmods]

Hi,

Can I link this from metanews?

[kaigou]

Uh, sure!