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Fri Jul 06, 2018 7:36 am
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StellaThomas says...



Hey @bluewaterlily! Thanks for following the thread, and thanks for the question :) Sorry for the delay in getting back to you, I started, then I was on many planes for many hours, and I forgot to finish.

Ah. Smoking.

First of all to answer your easiest question - yes, 10 cigarettes is about half a pack xD

Then onto the stickier stuff.

The thing about addiction comes down to this: are you addicted? Do you fulfil the criteria for addiction - or dependence, as we more politely call it? So if some of these apply to him, then he's addicted. And a month seems a reasonable amount of time to me for these to develop.

There are criteria, and these can be applied to any substance- alcohol, cigarettes, heroin, whatever. I'm going to go through them not just for the sake of it but also because they can actually inform us a lot about addiction even if we've never experienced it. I'm nursing quite a considerable caffeine addiction - I know because I tick a number of these boxes xD.

1. Craving - you want it, you need it, you crave it.
2. Withdrawal - you experience withdrawal without it. This depends on the substance - for caffeine it's dreadful headaches, for alcohol it's tremors, agitation, hallucinations, seizures. For nicotine, it's agitation and restlessness, insomnia, sometimes a tremor.
3. Loss of control - you don't feel in control of the habit. There's a drink or cigarette in your hand before you've really noticed.
4. Tolerance - you need more and more of it to achieve the same effect. When one cigarette might have done him before bed, now he needs ten a day.
5. Continued use despite harm- this can be harm to a relationship, your finances, your health. Maybe he feels short of breath going up the stairs and knows it's because of the cigarettes. Maybe he knows he's spending too much money on them.
6. Primacy - this one is hard to explain but basically: it takes precedence over everything else. It's the most important thing. If you have a tenner in your pocket and you can buy lunch or a pack of cigarettes, you buy the cigarettes.
7. Inability to stop- fairly self explanatory.

So if he ticks enough of those boxes then he's addicted. And the thing is that you can still feel those things even when you're not using the substance. You can still think, Boy, I need a cigarette. You can still exhibit some of those symptoms (even if you have, in fact, stopped). So I guess that that also answers your question about psychological withdrawal!

With regards to physical withdrawal - as I said, agitation, restlessness, headaches, tremors. We would offer short term nicotine replacement therapy, usually in the form of patches but it depends. In theory, patches are supposed to be a short term solution. It depends on local guidelines but for someone who smokes ten cigarettes a day he would probably be on a low-dose patch for maybe two to four weeks. Buuuuut many people are reluctant to give up the patches after four weeks and mightn't feel ready to, so may well still be using them to help fight the cravings. And otherwise, you would just treat his symptoms, maybe a paracetamol for the headache, and some people might give him a sleeping tablet if he's got insomnia.

Psychological withdrawal... I've never really dealt with smoking in this way, but I know that there are smoking cessation counsellors and hotlines and stuff where there are people to talk you through it and try to keep you on the straight and narrow.

Hope that was helpful, sorry if I'm a bit disjointed!
"Stella. You were in my dream the other night. And everyone called you Princess." -Lauren2010
  





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Mon Jul 09, 2018 8:38 pm
Cadi says...



Hey Stella!

I've only skimmed through the rest of the thread, so I hope this isn't along the lines of something you've already answered that I missed...

A young woman comes into Urgent Care with minor burns on her forearms. She's with a friend, who has read the relevant NHS page and followed the first aid advice, before persuading her to come in. (The cause is magical, and can be altered in intensity - I'm looking to surprise her more than cause her significant lasting damage.) I assume she'll wait a while, then be seen by a triage doctor - but then what? How high a priority would this be? What actual treatment would she be given?

Thanks in advance for any advice! <3
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Mon Jul 09, 2018 9:52 pm
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StellaThomas says...



Hey @Cadi! Good question.

First of all, we don't have urgent care in the HSE. God bless the NHS. So I'm not sure. What I would say is that generally triage is done by a nurse. More than anything, because it's a nursing skill that nurses do better than doctors. But it might be different in urgent care I'm not sure.

When it comes to burns, this doesn't sound like it would be a major priority. Things that make burns top of your list are:

- over 10% skin involved (an entire arm is around 9%)
- involvement of the face or hands
- 3rd and so-called 4th degree burns
- other injuries like smoke inhalation

These are all life threatening (maybe not hands but they're still important enough to us as humans to make them a priority). And below are two things which aren't life threatening but would make you more likely to keep someone overnight:

- involvement of a major joint
- circumferential burns, that is, a burn going the full circumference of a limb. Think hand dunked in water.

The first of these is because they may need surgery and grafts to keep the skin over the joint supple so that they can move normally. The second is because as burns heal they tighten and this can cause compartment syndrome where a limb's blood supply gets cut off by its own muscles - and the only treatment is cutting the skin open. Nice.

Anyway so maybe your character's friend runs it under cold water and just begins to get concerned. I suppose you need to decide what level of burn you want to give her. Second degree seems a good call to me but maybe there's a small enough area of third degree to cause alarm. Small enough that it's unlikely to need a skin graft but large enough to cause concern and eventually leave a scar. Second degree are nasty, red, angry, blistering and painful. Third degree are white, waxy and painless. Or maybe the friend just doesn't fancy the look of the burn.

Anyway, presuming we aren't jumping to plastic surgery at this point, urgent care will probably just dress it, give her some pain relief and some hydration. Depending on how busy they are and how concerned they are they might run a litre of fluids into her to hydrate her but if not, they might just send her home to drink lots of water. Losing fluid through the burn is the way in which it's most life threatening. But some fluids, some pain relief and some dressings- don't ask me about dressings! Like triage, it's a nursing skill xD but she'll be fine, if a bit spooked.
"Stella. You were in my dream the other night. And everyone called you Princess." -Lauren2010
  





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Tue Jul 10, 2018 7:04 am
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Cadi says...



Thanks! That's definitely enough for me to write a scene off :) (and apologies for my complete inability to tell nurses and doctors apart! :P )
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Tue Jul 10, 2018 7:40 am
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bluewaterlily says...



Thanks so much Stella! Your response was amazing and helpful!
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Tue Jul 10, 2018 11:01 am
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StellaThomas says...



Cadi wrote:Thanks! That's definitely enough for me to write a scene off :) (and apologies for my complete inability to tell nurses and doctors apart! :P )


Not a problem at all! But it's my duty to my nursing colleagues to mot claim all the credit ;)
"Stella. You were in my dream the other night. And everyone called you Princess." -Lauren2010
  





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Mon Jul 16, 2018 8:20 am
rebelpilot says...



I hope this isn't getting to annoying, but I have some more questions.

1. How likely would it be for someone to survive getting their windpipe crushed and how would that kind of injury be treated? The character in question receives medical attention quite quickly.

2. Would someone who had had their windpipe crushed continue trying to breath and would be able to get any air into their lungs?

3. What would be to correct way to give anesthetic to someone who is already unconscious?

4. How long would it take someone who is under the affects of anesthetic to wake up and what after effects would there be? The character in question is an adult human.

All of this is about my star wars fan fiction.
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Mon Jul 16, 2018 5:15 pm
StellaThomas says...



No problem @rebelpilot! The only thing, as I said, is Star Wars plays by its own rules, but hopefully my experience can help inform you a little bit.


1. How likely would it be for someone to survive getting their windpipe crushed and how would that kind of injury be treated? The character in question receives medical attention quite quickly.

So as I've said, your airway is the most most important thing for your survival. No airway, you die in less than a minute.

Crushed is a bit vague so I suppose it comes down to this: can it be uncrushed? For instance after hanging attempts we can usually intubate, but sometimes not depending on the inflammation. But if it was something really forceful then it mightn't be possible to uncrush it, per se. Also consider the force and if it's likely to break their neck too.

So we need - NEED - to establish an airway. Irl we try to intubate first- this means sticking a breathing tube down through your mouth and throat. It's rigid and can't be squashed or obstructed by inflammation etc. The tube is then usually attached to either a bag that someone squeezes (short term) or a ventilator (long term).

But, what is the voicebox is crushed, or the rings of the trachea? Then you have to go below the obstruction. We call this a tracheoatomy (hole in your trachea). Occasionally on tv you'll see people perform amateur ones with pens and stuff called crichothyroidectomies or "emergency crich". This is very specific and cut into a very particular membrane (just below the Adam's Apple in a man, more guesswork in women). A crich is crude but it works. A more permanent tracheostomy (trache) will be neater and more easily reparable, but some people will end up needing one forever. If you have a trache, you can't talk unless you have a thing called a speaking valve. Even if you don't have a trache, remember that after such injuries people's voices will be radically changed, they may be hoarse for the rest of their lives.


2. Would someone who had had their windpipe crushed continue trying to breath and would be able to get any air into their lungs?

They would struggle for a short while but, assuming complete obstruction they wouldn't get anything. If it's only a partial obstruction they will make a noise called "stridor" - a high pitched gasping whistling noise trying to get air into their lungs. Either way they will probably lose consciousness in a matter of minutes at most.

3. What would be to correct way to give anesthetic to someone who is already unconscious?

Usually we give anaesthetic intravenously - in fact we put people to sleep with gas in theatre and then give them a more long lasting anaesthetic through the vein while they're asleep.

4. How long would it take someone who is under the affects of anesthetic to wake up and what after effects would there be? The character in question is an adult human.

It all depends on the type of anaesthetic and how long they've been asleep but really for the most part they're how you feel when you first wake up! Confused, groggy, talking nonsense and often they won't remember this part later. Depending on the anaesthetic their blood pressure might be low as well.

Remember that the main issue with people being under anaesthetic for a long time is that they aren't using their bodies. This can cause pressure sores if they aren't being looked after but, assuming someone is looking after that, they will still be very weak, their muscles will be atrophied and it can be a few days before they're able to walk and function - sometimes even longer! And sometimes they can have nerve damage from this as well - areas of numbness and tingling fiery pain. This, like the muscle atrophy, usually recovers in the few weeks afterwards.
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Mon Jul 16, 2018 8:51 pm
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rebelpilot says...



Thanks again. :)
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Tue Jul 17, 2018 9:24 am
rebelpilot says...



Sorry for double posting, but I was wondering what the affects of sleep deprivation are? One of my characters has PTSD which means that they can't sleep properly. Also would they get to a point where they are so tired that they can't stay awake? And would it be possible to help them sleep somehow?

Thanks in advance, this thread has been very helpful.
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Tue Jul 17, 2018 12:13 pm
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StellaThomas says...



Hey @rebelpilot.

Sleep deprivation is super common with nearly every single mental illness, except maybe schizophrenia. Anxiety (under whose umbrella PTSD comes), depression and mania all cause it. So, as such, I spend a *lot* of time talking to people about their sleep and their sleeping habits.

Firstly, the effects of sleep deprivation depend on whether it's chronic- long term or acute - short term. Chronic... well it's all the stuff you'd imagine. Fatigue. Daytime somnolence/sleepiness and maybe nodding off. Irritability. Poor memory. Poor concentration. Eyes looking puffy and red. People with poor sleep also tend to put on weight - unclear as to why. It can make your mood more changeable/labile. Clumsiness.

Acute sleep deprivation is a funny thing. My colleagues and I will often talk about being "buzzed" or even "hypomanic" after a long shift without sleep- 24 to 36 hours. What I didn't realise is that if you go that long without sleep you actually are a little bit hypomanic. Sleep regulates your dopamine, so without sleep your dopamine levels go up. This can make you feel that way - you're a step towards manic but not actually manic. You're full of energy, maybe even a little jittery, but overall happy and upbeat, you'll notice your speech going faster, but your sentences mightn't quite make sense and you can't keep track of your thoughts, your concentration is way down. Try staying awake for 30 hours and see! (Don't. You'll eventually crash and it's *awful*). Anyway out of academic interest short term sleep deprivation has been used in some cases for refractory depression to give them a so called "kickstart" . Unorthodox. But cool.

Can it make you go to sleep eventually? Yes. Most people with bad sleep deprivation will still sleep for at least an hour or two at night. It might be broken, poor quality, they mightn't remember it, but their body and brain will be so exhausted that they'll grab whatever sleep they get. The only time I've seen someone not sleep at all for several days at a time was with mania, and eventually they became completely exhausted and slept for four hours straight. Most of the time though the other disorders will make your sleep bad but they won't make you have no sleep.

So how do we help people with sleep deprivation? (This is advice for life)! First things first we talk to people about something called "sleep hygiene" - Google it, there's more to it than what I'll say here. Basically it's all about having good habits about sleep. Going to bed and waking up at the same time every day. Only using your bedroom for sleep and sex and keeping anything else in other rooms. No phones or other sources of blue light. Chamomile tea. Lavender on your pillow. No food two hours before bed. Yoga or some other light exercise just before bed. No caffeine after 5pm. It all sounds a bit wishy washy, but all of these things help. And while we have sleeping tablets, they're addictive and not without their dangers, so if turning their phone off at night is enough for someone, happy days.

So yeah. Sleeping tablets. There's a good few different types. Most commonly we use "hypnotics" or "z drugs" - like zopiclone or zolpidem. Some people might use a benzodiazepine like temazepam but if the z drugs are slightly addictive, benzos are highly addictive and withdrawal can be dangerous. The other thing we use from time to time is low doses of anti-psychotic medication - like quetiapine at 1/32nd of its maximum dose. Anti psychotic have a lot of side effects though not usually at these tiny doses, and a lot of stigma, but they work.

At the end of the day, most doctors are happy to help someone get some sorely needed sleep but the only thing that's going to cure the sleep deprivation is helping them control their PTSD and that can take a long time.
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Sun Jul 22, 2018 2:00 am
rebelpilot says...



I was wondering if you could please go into a bit more detail about the long-lasting residual effects of getting your neck snapped are? Thanks in advance.
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Sat Sep 01, 2018 7:49 am
Rosendorn says...



Bumping for a question!

If somebody was stabbed in the lower ribs— three cuts, about an inch long— going deep enough to puncture the lung, how long would it take for that wound to become critical, and what sort of symptoms would be expressed? I figured aspirated blood would be a thing, but I have no idea how long it would take to bleed out.
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Sat Sep 01, 2018 12:15 pm
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StellaThomas says...



Hey guys!

@rebelpilot I apologise that I seem to have missed your most recent question! I suppose to answer it I need to know what you mean by "having your neck snapped". If it's at the level of C3, it usually means death. Between C4 and C8, it can range from death to quadriplegia. As it stands, this is an irreparable injury, so any effect from it is residual and long lasting. There's a lot more slightly more complicated stuff regarding the autonomic nervous system - like regulating your blood pressure and temperature, pain, bladder and bowel control, sexual function etc., that, to be perfectly candid, I'm not totally au fait with, having never worked in a spinal rehab. But at best, it means permanent paralysis, and at worst, it means death. I'm not sure on how to be any more specific about this one, and I apologise for that. I don't know if maybe you meant, were the neurological damage to be repaired, would there be other residual effects, but as I say, currently we have no reference for that.

@Rosendorn -

So, first things first, remember that your lungs don't fill up your full ribcage. At full capacity, your lungs usually reach down as far as your eighth or ninth rib - in full inspiration, in expiration they shrink up. They're literally like sponges. I know this is something that people know in the back of their minds, but just to remind you to consider the mechanics of the conflict you're writing, because you'll need your characters elbows to be up and out of the way for them to get stabbed at that height. Remember that the heart is roughly a size of your fist, roughly right in the middle (but a little more to the left), and you don't want to damage it, or any of the other vital bits in the centre, which we refer to as the mediastinum (aorta, trachea, oesophagus etc etc etc).

So. When we puncture a lung, bleeding out isn't your issue. In fact, the lung itself isn't the issue, the issue is your pleural space, a potential space between your ribcage and your lung. What 'potential space' means is what it says on the tin, ordinarily, the two layers of pleura are kissing. But interrupt that kiss, and the space can fill up pretty easily. And it's going to fill up with one of two things: air, or blood.

This leaves us with three possibilities:

1. haemothorax
2. pneumothorax
3. tension pneumothorax

The problem with all three of these isn't the wound in and of itself - in fact, the wound could be useful, we'll come to that. The problem is that once you've turned the pleural space from a potential space into an actual space, it restricts the space you have for your lung to expand. Your ribs are a bit like your skull, they're this beautiful protective shell, but they don't leave any room for extra stuff, like blood or air. Let's go through them.

1. Haemothorax

The space between your lung and your ribcage fills up with blood. This will leave the person short of breath, because one of their lungs can't expand to its full capacity, because there's a load of blood in the way. Now, the wound that the person has could be useful in protecting your character from this, because the blood is more likely to come out of the wound than stay inside. Either way, eventually either the mass of the haemothorax itself or the rest of your organs will probably stamp off the bleeding vessels, so you wouldn't bleed to death. But assuming that there is a haemothorax (which, as I say, there might not be, it's really luck of the draw as to whether the blood seeps out of the wound or stays in there), then you have to drain it. This isn't particularly complicated, you stick a tube in there and let the blood come out (you might have to flush the drain a good bit to stop clots blocking it though, which would make it more complicated).

2. Pneumothorax

The same as a haemothorax, but instead of blood, there's air in the pleural space. This is the most common one, you probably know someone who's had a spontaneous pneumothorax - the lay terminology is "collapsed lung". Sound familiar? Yeah, this happens a lot, in particular to tall, skinny young men who smoke. One day, their lung randomly collapses, they get suddenly very short of breath and have to go to hospital. This is the same thing - except this time, your pneumothorax isn't spontaneous, it was caused by a knife to the ribs.

The mechanism for draining it is much the same as a haemothorax, you stick a drain in (in the fifth intercostal space in the mid-axillary line - that is, below your fifth rib, in line with your armpit). The drains are a bit complicated and I have a poor working understanding of physics but basically it has to be an "underwater seal" drain, that is that the air that drains out gets sealed underwater so that it can't flow back up the tube and back into the chest again. Does that... make sense?

The other thing - and I'm sure it applies to haemothoraces too, I'm just less familiar with them as they're more uncommon - is that you need to reinflate the lung. This is partly because, you know, lungs are useful, but also because you need something to push the air out. Make sense? So we usually put people on high flow 100% oxygen. In fact, if your pneumothorax is pretty small, this is the only treatment you get, because chest drains are painful and put you at risk of infection. So just oxygen. Neat.

3. Tension pneumothorax

Ah. The most misunderstood condition in medical television.

I just went down a rabbit hole trying to find one of these and, in fact, the first one I came across was the opening scene of iZombie which, bizarrely, isn't the worst one I've seen, and is reasonably sanitised:

phpBB [media]


What it is, is basically the same as a pneumothorax, but there's like, a valve-flap cut into your lung as well. What this means is that every time you take a breath in, more air goes into the pneumothorax, and it begins to crush your lung. Then it begins to crush your other lung. Then it begins to crush your heart. People can rapidly, rapidly die from this - not so much from the other two - and it's clinically different from a pneumothorax because they just get worse and worse, sicker and sicker, until they arrest. They're also very rare - in my intern year, only one of the entire cohort of interns ever decompressed one - but TV would make you think they happen all the time. That's because they're cool. You don't have time to Xray to confirm, because the person will die, so you rely on your clinical judgement - usually you can recognise it because their trachea is deviating off to one side. Then you do, well. what she does in the above video but probably with less panache, and stick the biggest needle you have to hand, with an empty syringe, into the second intercostal space in the mid-clavicular line - so like in the top, front corner of their chest. And the air hisses out, and they immediately get relief. Of course, TV never shows you that you then have to put in a chest drain as definitive treatment. The needle decompression is cool, but it doesn't actually solve the problem.

So. It really depends on your story and what works for you. I also don't know what sort of setting we're looking at, and how much knowledge they have. It's probably instinctual that you might have to clean out a lot of clotted blood from a chest wound, but pneumothoraces would be a little trickier to understand in a setting that isn't quite so up to date with things. Some of them will seal themselves off, and your character will be acutely short of breath for a while and will improve - especially if you can give them oxygen. Consider that it might be a good idea to leave a chest wound open, for lack of having a sterile way of draining the blood or air, but be aware that that leaves them ripe for infection too.
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Mon Sep 03, 2018 6:49 am
rebelpilot says...



About the stuff about the broken neck, I meant when you answered my first question then you said that there would be long-lasting residual effects. I was just wondering if you could go into a bit more detail about those.

How injured would someone be if they get thrown into a wall by someone that is strong enough to easily pick them up and throw them around?

Also if someone got hit in the chest hard enough to break their ribs what other injures would they get?

And once again, thanks in advance.
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