Murder and Mayhem (16 page)

There are several significant and even lethal complications of this disease. Brain or spinal cord abscesses, pneumonia, meningococcal arthritis, endocarditis (infection of the heart valves), and meningococcemia (a severe infection of the bloodstream that can kill quickly) are not uncommon.

Treatment is with high doses of intravenous penicillin to which the bacterium is very sensitive. Most victims of this illness recover completely with proper treatment.

Is Shock Therapy Effective Treatment for Severe Depression?

Q: I need to know about shock therapy for depression. One of my characters is severely depressed and has tried all the medications. Is shock therapy still done? How is it done? Does it work? What are the complications?

A: Major clinical depression is a common and significant medical problem. It robs the sufferer of all that is good about life. The person is sad and lonely, sees no future, enjoys no one's company, avoids

social activities, cries, and often fails to care for himself. In its severest form the person's clothes are dirty: he doesn't bathe and eats poorly, if at all; and his health declines from this personal neglect. The mortality rate in severe depression approaches 15 percent, mostly due to suicide.

Electroconvulsive therapy (ECT) was discovered in the 1930s. Over the years many methods have been used to invoke the convulsions necessary for this type of treatment. Initially, drugs were used and then insulin, which drops the blood sugar to such low levels that a seizure occurs. Finally, electric shock delivered to the brain was employed.

The mechanism of its action and benefit are poorly understood. It seems as though the chaotic electrical activity that rages through the brain during the generalized (grand mal) seizure that the ECT produces somehow alters the mood center of the brain. No one knows for sure, but the results can be dramatic.

In the early years ECT was done without anesthesia so that when the seizures occurred, the recipients would sometimes severely bite their tongues, vomit and aspirate, or even break bones in their extremities from the violent nature of the provoked convulsions.

In 1975 the movie
One Flew over the Cuckoo's Nest
hit the screen and painted a negative picture of ECT. Here it was used as a punitive device, as opposed to a therapeutic endeavor. Currently, it is making a comeback, simply because it works. It is safe and effective as the first line of treatment for severe depression, with response rates of 80 to 90 percent. In people who have failed medical therapy, as in your character, it is effective in 50 to 60 percent of cases. As with any therapy, relapses after ECT may occur.

The procedure is much less barbaric than it once was. The patient is placed on a stretcher, an IV is started, cardiac monitoring electrodes are placed on the chest, and the ECT electrode patches are applied to each side of the head. Either an Ambu bag with face mask is placed over the mouth and nose or an endotracheal tube is introduced into the trachea (windpipe) in order to ventilate the patient during the procedure and until the anesthetic and muscular paralytic agents wear off.

The patient is then given a short-acting general anesthetic and a muscle relaxant, which prevent the outward manifestations of the seizure and thus prevent the tongue biting and bone breaking of the past. Short-acting anesthetic agents used in this circumstance might include 25 to 50 milligrams of Diprivan (propofol) given by IV and repeated as necessary or 2 to 5 milligrams of Versed (midazolam HCL) given by IV and repeated as necessary. Their effects are seen immediately and wear off quickly. Muscle paralytics used might include .10 milligrams per kilogram (1 kilogram equals 2.2 pounds) of Norcuron (vecuronium bromide) given by IV or 1 to 4 miligrams of Pavulon (pancuronium bromide) given by IV. Each of these takes effect immediately. Dosing can be repeated as necessary and wears off over twenty to thirty minutes.

The physician performing the ECT pays close attention to the patient's heart rhythm and airway to prevent complications from aspiration or cardiac arrhythmias. The electrical current is applied to the brain, and the seizure activity is induced. Since the patient is anesthetized and paralyzed, no tonic-clonic jerking, which happens in generalized seizures, occurs.

For severe depression six to twelve treatments are given at the rate of three times a week or longer, until the desired response occurs. Long-term side effects appear to be minimal, if any. In the short term there may be a dulling of cognitive function (thinking and problem solving) for a few days or weeks. There may also be amnesia, which can be retrograde (events that occurred prior to the ECT) or anterograde (events that occur in the period just after the ECT). In either case, these tend to resolve over a few days or weeks.

Besides this treatment being effective, it does not have the long-term problems associated with many of the psychotropic drugs used in the treatment of depression. These medications not only

have significant side effects but also may interact with other medications and certain foods.

What Are the Symptoms of a Miscarriage?

Q: I'm working on a scene in the early 1900s with a female character falling ill, probably having a miscarriage. Can you help me get an idea of what a miscarriage would feel like? Severe cramps? Bleeding? Warning signs?

A: A miscarriage occurs when a fetus is no longer viable and the uterus expels it. This may result from many causes. The fetus may be genetically defective so that its full-term survival was impossible from conception; the placenta may be poorly formed or function improperly, resulting in fetal death; the uterus may be scarred from old infections or trauma such as a previous dilatation and curettage (D and C) or abortion and may not be able to support the growing fetus; or a healthy fetus may be injured or killed by trauma or infection. The Hollywood staple is for the woman to fall or be pushed down some stairs or fall from a horse. These and many other types of blunt abdominal trauma may injure or kill the fetus and result in fetal loss.

The symptoms of impending miscarriage include vague or cramping lower abdominal pain, nausea, diaphoresis (sweating), dizziness, and vaginal bleeding. The bleeding may be minimal and spotty, which may occur in pregnancy without impending miscarriage, or it may be brisk and profound. Ultimately, it will become significant and may be associated with "water breaking" if the pregnancy has progressed far enough for a significant amount of amniotic fluid to develop. This would be followed by passage of the fetal and placental tissues. Early on, in a pregnancy that is only a few weeks along, these tissues are amorphous and ragged, looking

more like a large clot of blood. After two months or so a formed fetus may be expelled.

A miscarriage may occur fairly suddenly or may stutter along for several weeks, depending on many factors. For example, the woman may experience severe lower abdominal pain, nausea, sweating, weakness, and the passage of blood and tissue over a period of an hour or two. Needless to say, fear and anxiety would accompany this, since this is a painful and potentially lethal event. On the other hand, she might experience several days or weeks of mild cramping and perhaps some spotting. Ultimately, the cramps would become more intense, followed by more significant bleeding and tissue passage.

Afterwards she may bleed a little or a lot, even to the point of exsanguination (bleeding to death). She may develop an intrauterine infection with high fevers and shaking chills, from which she may or may not recover.

One hundred years ago there was little that could be done, and survival depended on how severe the miscarriage was, the degree of blood loss, the occurrence of infections (for which there was no treatment), and luck. She would be put to bed, fed lightly, given warm tea, and sponged with water to relieve any fever. The family would gather, the priest would visit, and the doctor, if there was one, would be summoned, though there would be little he could do.

What Complications of Pregnancy Would Lead to Hospital or Bed Confinement?

Q: I am writing a story that revolves around the pregnancy of an unwed sixteen-year-old. Her pregnancy is difficult in that she experiences nausea, weight loss, and depression. For plot purposes I want her to be confined to bed for the last several weeks of her pregnancy. I

know that several problems can lead to this recommendation by her doctor. What are some of the common ones I should consider?

A: The four most likely would be premature labor, premature rupture of the membranes (water breaking), preeclampsia, and peripartum cardiomyopathy. Let's look at each of these.

Premature labor is when the uterus begins to have contractions weeks or months before the expected delivery date. If these contractions continue, a premature birth could follow, putting the child's survival in question. Typically, the contractions begin as mild and intermittent lower abdominal discomfort, and progress in frequency and intensity over several days. The expectant mother may ignore or deny them at first, but if they progress, she will have to seek medical help. Mild bleeding or spotting may occur.

For premature labor she would be given bed rest, though she would likely be able to get up for bathroom use, bathing, and eating. The major concern here is that she avoid as much activity as possible. If the contractions do not subside with these conservative measures, she would be hospitalized and given intravenous magnesium sulfate (mag sulfate, for short) in an attempt to stop the premature uterine contractions. If this is not successful, delivery, perhaps via cesarean section (c-section), might be done.

Premature rupture of the membranes is when the water breaks weeks or months before the expected delivery date. This is more serious than premature labor. When the membranes break, amniotic fluid is lost, and the "cocoon" within which the fetus lives is breached. This often triggers full labor, followed by delivery, or allows a route for infection to enter the uterus. Occasionally, with proper treatment and good luck, the membranes heal, the amniotic fluid re-forms, and the pregnancy continues as planned.

For premature rupture of the membranes she would be hospitalized and observed for signs of infection (fever, chills, vaginal discharge) or fetal distress (increase or decrease in the infant's heart rate or abnormal fetal movements). She would be put at strict bed rest and likely placed on intravenous antibiotics. If she was twenty-eight to thirty-six weeks along, her M.D. would try to buy time with this treatment. If she was thirty-six weeks or more, he might choose to induce labor. Either way, if signs of infection or fetal distress appear, delivery would follow in short order.

Preeclampsia is a common but poorly understood entity. It is estimated that worldwide more than fifty thousand women die from this each year. It is a complex interaction between the mother and the fetus that likely involves the immune system. It is more common with first pregnancies and in women who have diabetes. It is also more common when either the mother or the father was a product of a preeclamptic pregnancy. Curiously, it is less common in women who smoke cigarettes.

Symptoms and signs of preeclampsia include elevated blood pressure; edema (swelling) of the ankles, feet, and hands, and around the eyes; irritability; headache; lethargy; confusion; and protein in the urine. Untreated, it can evolve to eclampsia, which is marked by seizures, coma, severe elevation of blood pressure, and a high mortality rate.

If your young lady developed preeclampsia, she would be hospitalized, put at strict bed rest, given intravenous mag sulfate, and placed on diuretics and other medications to control her blood pressure. Again, this treatment would be continued to buy time until the fetus was beyond thirty-six weeks, and then delivery would be performed.

Another possibility is peripartum cardiomyopathy, a mouthful to say the least. Translation: "Peri" means around. "Partum" means the time of delivery. "Cardio" means heart. "Myo" means muscle. "Pathy" means disease. So peripartum cardiomyopathy means a disease of the heart muscle that occurs around the time of delivery. This is not so difficult after all.

In cardiology there are several different types of cardiomyopathy. Most have in common a weakness of the heart muscle which leads to the heart's performing poorly as a pump—its main function. The term for this is "heart failure." The weakened heart no longer pumps the blood through the body as vigorously as it should, the blood pressure falls to low levels, pressure builds in the lungs, and the lungs fill with water and become congested—a condition known as "congestive heart failure." Major causes are hypertension (high blood pressure), coronary artery disease with heart attacks, toxins such as alcohol, and virus infections of the heart muscle.

Peripartum cardiomyopathy is a special form of congestive heart failure. Its cause is unknown, but it occurs in one of every three thousand to four thousand pregnancies. For unknown reasons, during the last month of pregnancy and up to five months after delivery, the mother can develop a weakened heart muscle and slip into heart failure. The symptoms are shortness of breath, fatigue, and edema of the legs. The treatment is rest, salt restriction, and diuretics. Sometimes digitalis, which strengthens the heart muscle, is given.

Typically, it begins in the last few weeks of pregnancy and resolves within a few days after delivery. It worsens with each subsequent pregnancy, and women who suffer this are usually advised against future pregnancies. There is no known way to either predict or prevent its occurrence.