The tickle of curiosity. The gasp of discovery. Fingers running across the keyboard.

Sunday, February 8, 2015

Looking for Zebras - What a Doctor Thinks When Your Unconscious Heroine Shows Up in Emergency: Info for Writers with Dr. Carlon

Plains Zebras (Equus quagga), more specificall...
 (Photo credit: Wikipedia)
Your plot is moving right along. You have a stud muffin of a hero, built like a dancer from Magic Mike. He's a good guy too, and every single one of your readers is swooning for him. But now he's in a panic. The love of his life (shhh, it doesn't really matter that he met her last night - just go with me on this) has passed out. He spots a doctor's office, screeches into the parking lot, lifts the unconscious woman  -- who drapes gracefully from his arms (and somehow did not pee on herself) -- and races through the doors.

What happens next?

To answer this question, Dr. Michele Carlon is visiting us.

Dr. Carlon attended college at the University of Pittsburgh at Johnstown and graduated summa cum laude with a Bachelor's of Science degree in Biology. She attended Robert Wood Johnson Medical School (formerly known as Rutger's Medical School) in the Camden Program where she graduated with honors and was elected to the Alpha Omega Alpha Honor Society. She attended a three-year residency in Internal Medicine (medicine for adults) at Michael Reese Hospital and Medical Center in Chicago.

Dr. Carlon likes to take time with her patients and finds that her favorite part of being a physician is getting to know her patients well. She likes the diversity of patients and ailments in an Internal Medicine practice. And Michele is also my friend and go to gal.

Michele, here comes hunky dude.

Michele -
Ohh laalaaa

He rushes through the doors, "Help! PLEASE! I need a doctor!"

Can you please tell us about the concept of the zebra.

Michele -
Okay, a zebra is a diagnosis that is not common. So in the normal world, when you hear the sounds of hoof beats, you think horses, not zebras.

Doctors are taught to think about common things commonly.
I have a propensity to attract zebras.

So, for example when someone comes in with a cough, they usually have a cold. I tend to see weird stuff, like histoplasmosis. 
I think broadly about all of the diagnoses possible and that includes “zebras.” I also attract zebras because my reputation is that I listen.

Fiona - 
And histoplasmosis is?

Michele - 
Okay. Histo is a fungus.
It's in the midwest, and you can get it from spelunking, or camping,
or being near a river. It causes infections in the lungs, liver, spleen and looks like little grains of sand on an -xray. 

Histoplasmosis causes coughing, weight loss fever and can be mistaken for cancer or TB.

Fiona - 
So let me pick apart what you just said. You tend to think of zebras and you also tend to attract zebras. 

Do you think that maybe the other doctors are seeing through horse colored glasses so the heroine comes in with some horrible lung fungus from spelunking and the doctor says, "You have a cold and you'll feel better in a few days..."

Michele -

That's exactly it. I tend to take a lot of time, asking probing questions, taking an excellent history. You can make a diagnosis often just with a good history. One should have a good idea of what the diagnosis is before you lay a stethoscope on the patient.

I had a patient, young woman who came to me with bloody diarrhea. She had been patted on the head and told she had irritable bowel syndrome.

She didn't.

IBS doesn't cause bloody diarrhea. Also, IBS doesn't ever wake you up at night. She had ulcerative proctitis. I sent her to GI , who diagnosed it with a colonoscopy. She had been in tears before because she was sick and no one would do anything.

Fiona -
In the case of our draped heroine, Stud Muffin is strong, but he's starting to form little beads of sweat on his lip. He needs to put her down somewhere. Can you walk us step by step through the process of seeing the unconscious woman and finding some horrible life threatening disease that will bring them closer together as they fight the good fight to keep her alive.

Pick a romantic disease please.

Michele - 
Hmmm. let me think.
Ohhh-something she got when they went somewhere together on a honeymoon. Not New Jersey?

Maybe loa loa?

Fiona - 
Loa loa! LOL Isn't that eye worm?

Michele - 

Yeah - that's not romantic. How about malaria?

Fiona -
Malaria is good.

Michele - 
Okay. Malaria .

So she is febrile, spiking temps to 104. Mr. Hunk has a thermometer. He's checking it, and she has periodic fevers.
She has shaking chills and then after a couple of days she's okay.

She goes about her daily activities until the next episode.

Fiona - 
Tell me the story from your POV - You see the hunk. You think Yowza! You gesture him into the exam room, and he lays her on the table. Take me through each step.

Michele -

Okay, I’ve managed to shake our heroine awake so she can answer questions.

The first thing we usually ask is what brings a person in today. I obviously see that it’s Mr. Hunk and smile at him.

She says, “Doc, I’m having these horrible fevers and shaking chills.”

I immediately start thinking about the causes of fevers and chills. I stay quiet though and let her keep talking until she’s done. The studies show it only takes 3 minutes for a person to “tell their story” to the end. Doctors often interrupt patients within 30 seconds.

You ask about chronology of the symptoms.
* Acute illnesses are less than 6 weeks long.
* Subacute are 6 weeks to 3 months
* Chronic are over 3 months.

I take the “Review of Systems,” which is a litany of questions starting with the head and going down to see if other symptoms are occurring—like sore throat, runny nose, cough, chest pain, nausea, vomiting, diarrhea, abdominal pain, urinary symptoms, rashes, sores, numbness, tingling, etc.

Once we’ve done that I can start narrowing down things.
* If it’s acute, it’s likely common things
* If it’s subacute or chronic, one starts to think of more unusual 

   conditions. TB, fungus, cancers, autoimmune diseases, etc.

Fiona - 
So how long has little Miss Stoicism been running hot then cold

Michele -

Malaria causes people to get quite sick and they often will show up in the ER (now called the “ED” for Emergency Department).

The key bit of history in this case is the travel history.

Once I’ve established that she is a nun in Mother Teresa’s clinic and Mr. Hunk is her brother, I start to flirt with the brother.

Oh. I also know I need to look for zebras. India is rife with tropical diseases, and I need to examine Mr. Hunk since he was her bodyguard. We step into my office, and I ask him to disrobe…
Oh, wait, that’s not right. Got side tracked there.

(I was just kidding; I know they're really not related and are deeply in love.)

Fiona - 
Okay - just to throw a monkey wrench in here.
Lets say she hadn't travelled but she is presenting with some weird issues - why/when would a doctor ask for genetic heritage?

Michele - 

Family history is important in this case.
There are diseases more common in some groups, like FMF (Familial Mediterranean Fever) or Sickle cell disease.

FMF patients are often written off as drug seekers because they have mysterious abdominal pain for which no cause can be found

Sickle cell disease occurs most often in African Americans in the US.

Fiona - 
I saw a movie once about a girl who had FMF. The mother tried everything to get her a proper diagnosis. The girl had had multiple exploratory surgeries, etc. Finally, the child was taken into social services custody and the mother charged with abuse via Munchausen by proxy. Turned out a doctor asked the mom the right questions (at the prison) - yes, the child was conceived during an affair; the biological father (NOT her husband) was from the Mediterranean. Diagnosis given, mother released, child saved, divorce pending. I always thought that was a good plot twist.

Michele - 
Breast cancer - 

I had a woman once who had an aggressive case of breast cancer and had a family history of prostate and ovarian and breast cancer. She had an Irish surname. On a hunch, I asked her whether she was of Ashkenazi Jewish heritage.She looked at me like I was nuts.

Two weeks later, after she’d asked her family, she found out that her family HAD been Jews and during WWII had changed their names and became Catholic to avoid the Nazis. That was interesting. It wasn’t that uncommon a survival strategy, but often, later generations have no idea that they’re Jewish.

She was BRCA positive.

Fiona -
Very cool. So you've asked if the patient has travelled - no. 

You got her family heritage, and she's 100% English and everyone lives to be 105 in her family. 

You're stymied by what you are seeing - now you turn to pets?

Michele - 

When taking a history, a lot of doctors forget to take a history for pets, occupations, and travel. With the Ebola virus, and now with measles, we see how important the travel history part is, but many forget about pets and jobs.

Pets can carry all kinds of fun diseases.

Let's start with birds.

Birds can cause psittacosis and avian hypersensitivity pneumonitis amongst other things.

Avian hypersensitivity pneumonitis is caused by an allergy to the bird. You can test for the specific bird’s avian antigens. It’s done in very specialized labs.

You have to know they have a bird. They get severely SOB, develop respiratory failure, and interstitial changes on their Chest x-ray. They can die from it.

I diagnosed that over the phone once. I heard a parrot over the phone whilst talking with the patient’s daughter.

Fiona - 
SOB? I know some severe SOBs but didn't know it was part of a disease profile, is it contagious?

Michele - 
Yeah, I had a patient see that I wrote SOB and got really insulted.

Okay, Dogs!
Dogs eat their own and other dog’s poop and have ticks and fleas. Ticks carry lyme disease amongst other things. Dogs also get leptospirosis and worms, along with other lovely diseases.

There is a canine vaccine for leptospirosis now!

Dogs AND cats have a bacteria called Pasteurella multocida in their mouths. When a dog or cat bites and punctures the skin, it can cause a rapidly spreading cellulitis (skin and subcutaneous tissues infection) that can cause septic shock and death. Our doc needs to do a skin check for rashes, puncture wounds and bites.

There’s cat scratch fever too, which is bacterial infection that you can get from petting an infected cat and rubbing your eyes as well as from cat scratches.

Mice and Rats:
Rats carry fleas. Fleas carry Bubonic plague!

Mice carry Hantavirus. The feces become aerosolized into dust which is inhaled by the victim and causes respiratory failure and sometimes death.

A physician takes a structured approach to physical examination:
The doc will:
* Check Vitals: Blood pressure, pulse, respiratory rate, temperature.
* Check general appearance like: skin coloring-jaundice, paleness, 
   redness, blue discoloration of nails and lips; puncture wounds or
   rashes; muscle wasting, obesity, etc.
* Look in the eyes, ears, nose and throat for signs of illness
* Feel for swollen glands in the neck, underarms and groin
* Listen to the lungs for sounds consistent with fluid or infections 
   or solid masses.
* Listen to the heart for murmurs. Heart valves can get infected and    when blood flows across heart valves that are damaged, it is 
   turbulent and makes a noise called a murmur. Maybe she is an 
   Intravenous drug user and has Subacute bacterial endocarditis.
* Examine the abdomen for distension, bowel sounds, organ 
   enlargement or masses.
* Do a genital exam: looking for chancres (syphilis), abscesses
   (boils), vaginal or penile discharge (Sexually transmitted 
   infections or STI’s), a Chandelier sign (when you move the 
   uteran cervix-the pain with pelvic inflammatory disease is so bad
    the woman screams and jumps towards the ceiling).
* Rectal exam: looking for black or bloody stool or for worms, for 
   abscesses or masses
* Looks at the joints and muscles for swelling, redness, and fluid. 
   Joint infections can cause swelling, redness, heat and pain in a 
   joint and STIs can cause joint infections as well as can regular 
   run of the mill skin bacteria.
* Neurologic signs and symptoms: Level of consciousness, 
   delirium, dementia, weakness, numbness, temperature sensation,

Whew! So that’s the approach.

Fiona -
So say she has a pet rat named Algernon and she developed the Bubonic plague. Now what? Do you put her in quarantine?

If Hunky and damselle are not married, can they stay in the same hospital room if they want to? Can they hold hands and make doe-eyes at each other? OR are you, the Dastardly Dr. Carlon going to separate these young lovers so they are pining away and in agony on opposite sides of the hall?

Michele -
If they have Pneumonic plague, they will be on “Droplet precautions” which means people have to wear masks and eye protection when they enter the room.

They won’t be well enough to MOVE their eyes much less MAKE DOE eyes! They’ll be on life support most likely.

If they have Bubonic plague, they’ll need IV antibiotics. They’ll be sick, febrile, (feverish) and won’t be in the mood, although they won’t be on isolation.

Malaria-no isolation. They can hold hands and dream of their future together between episodes of parasites swimming around in their bloodstream making them sick.

Oh—if they have Falciparum malaria, they might die. That one is nasty, so let’s call the chaplain and marry our two star-crossed lovers before they succumb.

Fiona - 
A scenario from MISSING LYNX and questions:

A man comes off the plane we don't know from where. Last leg Dallas DC he deplaned and passed out. Just before he does, Lynx asks if it's a recurrence of malaria. He says yes. An ambulance rushes him to the E.D. He gets to hospital all but dead, and they don't know where he had flown in from,  but this is not simply malaria. 

What precautions does the hospital take to safeguard themselves and other patients while waiting for a diagnosis? And how fast can pathology work stuff up if it's STAT!!!

Michele - 

If he’s alive, he’d be put in reverse isolation and with any possibility of Ebola, he would be put in level 4 isolation.

Unfortunately, there is no “stat” with cultures. They take days to months depending on what they’re looking for. They can do stains for different bacteria, like AFB for TB, gram stain for bacteria, special stains for other less common bacteria, parasites, etc. Pathology results, where the pathologist stains tissues and looks at them under the microscope usually takes at least a week to come back.

They would likely interview family, friends, and acquaintances, and get his travel history. Check his flight records.

Fiona - 
Is there a lottery system for the lucky nurse who gets to go in there?

Michele -
Short straw?

No, it's standard of care....unless it's Ebola, and they actually have a volunteer system. My husband volunteered. He does critical care.

Fiona - 
Great guy! I wouldn't kiss him for a while though

Michele -
I told him he wasn't coming home.

Sleep in the hospital until you're cleared.

Fiona - 

"I have a tent set up for your outside, honey."

Michele - 

Fiona - 
Traditional question on ThrillWriting - your favorite scar or harrowing story?

Michele - 

I was a first year medical student.

While skiing in Vermont under bad conditions, someone cut me off. I fell but my bindings didn’t release. I hurt my knee badly and was brought off the mountain by ski patrol in one of those baskets. I was strapped in and unable to move. I prayed that the guy wouldn’t lose control leaving me to careen down the mountain and unable to get my hands out to stop the basket…

In the ED at the bottom of the mountain, the Doc found out we were medical students and decided to teach us ALL ABOUT TORN LIGAMENTS. He did a Clinical Correlation –a method of teaching students at the level they are. We had just finished the anatomy of the leg. He took a piece of gauze and tore it slightly side to side to demonstrate what a torn ligament was like. I had a VERY vivid imagination and almost passed out.

I hadn’t developed the emotional wall that all physicians develop, separating the grosser aspects of what we do, from our emotions.

Anyway, I ended up having extensive knee surgery and have a 12 inch long scar along my knee, and haven’t skied since.
Fiona - 
How can people stay in touch with you, Michele?

Michele - 
My blog is:

Fiona - 
How is your writing going?

Michele - 
I was published in The Chicago Muse with a short story called, "The Round Faced Boy" and am working on two novels at the moment, and hope to find time to finish them. One on bed bugs spreading psychosis from a Level 4 CDC research lab. One on superpowers developed in postmenopausal women with their hot flashes.

Fiona - 
Oh FABULOUS! Last question - as a doctor what's your pet peeve that writers get wrong in their plotlines?

Michele - 
When they describe procedures wrong. I bought a trilogy recently, and ended up not reading past the first half of the first book because the details on the medical procedures like central lines, and iv insertions were all wrong.

Fiona - 
What would you suggest to writers so they can get details like that correct? I just wrote a medical section into my novella MINE, and I have some background from my graduate work, but I had a nurse working with me to get the details precise.

Michele - 
That is a terrific approach. Nurses see everything in the hospital. They actually help with all of the procedures, and do the majority of the work in the hospital. If you have a friend who is a nurse, or even better a Nurse Practitioner who is hospital based, they are worth their weight in gold. You want to ask someone for sure because procedures change quickly. What was standard of care last year, may be out of date this year. So you can date your book AND you have to make sure that if you are writing 2000 storyline that you aren't using 2015 interventions. 

Also medical textbooks aren't enough. If you take a description right from a textbook, it stands out. I've seen some authors do that and they use the terms incorrectly and it's ---ugh

Fiona - 
Thank you so much, Michele, for your time and expertise.

Thank you so much for stopping by. And thank you for your support. Cheers,When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.


  1. Replies
    1. Humor saves us docs from the suffering we see every day. I laugh at myself, finding humor in my OWN suffering. My Irish Father told me that no story was worth hearing without something to laugh at. He didn't want to hear about his grandkids unless it was a funny story. I got frighteningly good at finding the humor in scrapes, falls, poop explosions, and atomized barf.
      Michele (aka DoctorDiva)

  2. LOL - yup that describes Michele and me ~ sick but funny.