My Own Medical Thriller

I don't write medical thrillers because I only like to do research up to a point, and the amount of research I'd need to write in that field is well beyond that point.

We all can name a few biggies, though. Robin Cook and Michael Palmer each wrote several. I first met Michael Crichton through The Andromeda Strain, and learned years later that he won the Edgar for A Case of Need, originally published under the pen name Jeffrey Hudson. Tess Gerritsen, also a doctor, wrote several thrillers before she unleashed the Rizzoli and Isles series.

I'm now involved in my own medical thriller without planning it at all. So far, it has a happy ending.

Two Sundays ago, I finished my workout at my health club and returned to my car. I had found a space ten feet from the entrance, and now I was sandwiched between two SUVs, each slightly smaller than the state of New Jersey. Looking behind me was like looking through a soda straw.

The entrance driveway lay at about 7:00 to my space. The driveway is narrow, especially when cars park on both sides of it, so a sign proclaiming "One Way [right turn only]" guards the entrance. It was almost directly behind me. Another sign says "Do Not Enter" and stands to the left. This makes sure all traffic in that narrow driveway moves counterclockwise. Theoretically.

I eased out, looking to my left, where traffic should come from, and a driver who decided to turn around and take the short way back hit my car. Damage to both vehicles was minor--I have a broken taillight and a dented quarter panel--and I got the worst of it. We exchanged insurance information and notified the appropriate people, then went on our way.

Several hours later, my left arm felt heavy and weak. I've hosted a bad back since 1971, and this felt like the mild collision aggravated the long-standing problem. Oh well. Then my wife noticed I was having trouble using that hand to type at the PC and insisted that we go to the hospital.

The staff looked at my symptoms and medical history (both my mother and grandmother had strokes) and sent me for a CAT scan. Over the next several hours, I got lots of practice telling various doctors, nurses, interns, nurses, technicians and administrators my age (72), the month (January) and that we were in New Britain, Connecticut. I became expert at repeating "Today is a sunny day" and touching my index finger to my nose the other people's fingers in turn.

Every two hours, a nurse or tech asked me for an encore. I had to resist their pushing and pulling with my left hand, which was discernibly weaker. I had no indicators of being a stroke risk: I weigh 15 pound more than when I graduated from high school in 1965, I quit smoking about 15 years ago, my cholesterol level has pleased my primary-care physician for years, and I don't use cocaine. I average about half the "tolerable(?)" amount of alcohol allowed to men my age, and women are more prone to strokes anyway.

So what? The staff decided to treat the issue as a Transient ischemic attack (TIA), in which the blood supply to the brain is blocked for a short period of time and produces symptoms that resemble a strok. In my case, that was the weak arm.

My listening station for The Eagles

 By about 5 am the following morning--roughly 17 hours after the accident and ten hours after my arm first felt weak--I felt fine. But the night felt like I was a shooting scene with police scouring me for shell casings, blood spatter, footprints, and a partridge in a pear tree. I lost count of how many people asked me to answer those questions again and tested my arm and leg strength and coordination. They were like different detectives asking the same questions to see if my story changed.

By early afternoon, they also gave me an MRI, which is kind of cool if you're not claustrophobic. The kids running the machine both looked like former students. Truthfully, when you teach in the area for 33 years, everyone looks sort of like a former student. These two guys let me choose the music to listen to while they ran me through the tube. I picked the Eagles over Katy Perry, Adele, and someone else I'd never heard of.

Back in my room, I talked to two more doctors, three more nurses, had my sixteenth and seventeenth blood pressure checks, and told my age, location and the month again. Finally, the lead doctor told me he was pretty sure I did not have a TIA, but they wouldn't definitely say my troubles were related to the fender-bender, either.

The MRI and CAT scan ruled out a thrombotic stroke, but he wanted to be sure I didn't have an embolic stroke (a clot forming in the heart and traveling to the brain instead of originating in the brain itself) and ordered an echocardiogram, basically a heart sonogram. It was fun and the woman administering it was young, attractive, ultra-competent, and hilarious. She let em hear what my heart sounded like during the procedure, more of a gurgle than the lub-dub I expected. She also apologized for the coldness of the gel she spread on my chest and for having to rip the sensor contacts off my chest and taking all three chest hairs with them.

An echo-cardiogram (posed by model)

They finally discharged me about 24 hours after Barb drove me in. I spend the next month taking Plavix, Lipitor (They both sound like Superman villains, don't they?) and aspirin. They don't think I had a TIA, but they're taking no chances.

I still blame the minor accident. On the other hand, it was cool watching a bunch of people who really knew their stuff give me a first-hand tutorial on medical mystery research.

Rapists are Criminals: Why do they live among us?

by Mary Fernando, MD

This is my second interview with the Clinical Forensic Medical Examiner, Dr. Kari Sampsel, the only Canadian physician with a fellowship in Clinical Forensic Sciences. She is a Staff Emergency Physician and the Medical Director of the Sexual Assault and Partner Abuse Care Program at The Ottawa Hospital. 

When victims of  sexual violence come into the emergency room, she is in charge of the rape kit, assessments of sexually transmitted disease and pregnancy. She is also responsible for setting up long-term physical and mental health care for these victims.

In the last interview, she stated that one in three women will be assaulted in their lifetime, but less than 20% of victims report the rape immediately. Many suffer with increasing symptoms and then are seen. Some never speak up at all.

There is no other crime that I can think of where the victims are so reluctant to report the crime. Further, a society that believes in the rule of law is poorly served when so many criminals are allowed to commit a serious crime and yet are not held accountable. Imagine, for example, how emboldened car thieves would feel if they knew less than 20% of the thefts would be reported. 

Rape is rarely a crime committed in dark alleyways by strangers. In fact, 85% of rapes are committed by people who know the victim. This suggests that the poor reporting of rape emboldens rapists to assault women they know, largely without fear of any legal consequences. While children are most commonly raped by family members or friends of the family, adult are most often raped by current or past partners, or acquaintances and friends. 

One of the rapes with a great deal of stigma is the rapes by present partners. Many don't see how a present partner can be a rapist. To explain, Dr Sampsel says: “Think of cake. You like cake. But if someone shoves it in your mouth and forces you to keep eating until you feel sick, that would not be OK.” 

The other way to look at this is that rape is assault. If a partner, past or present, or a friend beat a person till they were bloody, breaking their nose and perhaps a few limbs, this would be considered unacceptable in civil society. Assault that is physical, but not sexual, is viewed as unacceptable. Sexual assault should be equally unacceptable. 

When a victim reports a rape, or a series of rapes, the response they encounter can make them walk away and not finish the report. Dr. Sampsel explains that there is often a stereotype of how a rape victim should behave: upset and crying.  

However, the reality is that victims display many behaviours. Some are so upset that they are closed off, unable to make eye contact or articulate what happened. Others, will be angry and in ‘protester’ mode, trying to get justice. Some can even look fairly normal, reporting as factually as they can about the incident or multiple incidents.

Add to this the fact that trauma can make victim forget details, the report itself can appear incoherent and less trustworthy. 

Dr. Sampsel points out that, “People are pretty savvy about when they are not believed. If you give someone the ‘I don't believe you vibe’ then they can be done with the process.”

Which brings us to the process itself. It is long and difficult. Completing the evidence kit takes about 2-4 hours. Every sample must be labeled, dated and gathered in a way that maintains the chain of evidence. Also, many of the samples are gathered from places that we think of as private and, if there are lacerations, this can also be painful.

After the history is taken and the samples are gathered, the victim is often faced with the reality that it isn’t safe to return home. If the rapist was a present partner or past partner with access to the victim’s home, either going to a shelter or staying with family or friends helps. Even if the rapist is a friend or acquaintance, their knowledge of where the victim lives could make it unsafe for them to return home. 

Many cities have a victim service, which provides everything from cell phones to volunteers - who will drive victims to their own home to pick up personal belongings, and help them get to a shelter.

If charges against a rapist are laid, they often get 12-18 months in jail. If a weapon was used or there was an attempt to murder the victim, the jail term could be longer. When the rapist is released from jail, the victim is vulnerable to retaliation from the rapist and may get a restraining order.

Does the punishment for rape fit the crime? Jail is certainly punishment. And the rapist must register as a sex offender and this limits the jobs they can get. Perhaps the biggest part of all this is that the rapist learns that they cannot rape with impunity. Rape is a crime. Punishing criminals is not merely about each individual criminal, it is also about deterring future criminals. If every rapist truly feared jail time, the stigma of being a registered sex offender and limited employment opportunities, perhaps one third of women wouldn't face the ordeal of being raped in the first place. 

The making of a psychopath - A vignette

by Mary Fernando

If Leigh Lundin suggests an article topic, it is always one that is both intriguing and complicated. His ideas keep me up at night. They get under my skin.

When Leigh asked me what creates a psychopath, I knew that was a question worth tackling. It is too big a question to answer fully. I would, however, like to present a small vignette, a window into this issue: please let me introduce Phineas Gage and the ventromedial prefrontal cortex, or VMPC.

In 1848, a railway foreman named Phineas Gage, had a horrific accident. An explosion shot a metal rod shot through his head. If you look at the diagram of how the rod entered his brain, the fact he survived was remarkable. At first it appeared that Phineas survived the accident with his physical and mental abilities intact. However, as time passed, it became increasingly clear that his personality changed. He went from being a well-liked, balanced man who was socially adept, to being socially inappropriate and uncaring.

Phineas and metal rod

What is interesting for the purposes of our question, is that Phineas developed an ‘acquired sociopathy’, or ‘pseudo-psychopathy’. Since then, we have noted that lesions to this part of the brain have left other people with similar impairments, with otherwise normal intellectual function. They have an absence of empathy. They lack interest in the well-being of others.

Every area of the brain is a true team player. No area functions independently, each receiving inputs from many areas and sending outputs to many areas. So, to just talk about one area is a little odd but for the purposes of this essay, I will treat the VMPFC as a sole player. It deserves a spotlight and to take centre stage.

We know that damage to this area causes a defect in empathy. However, few psychopaths have injuries to their brain like Phineas. There may be a genetic component to the development of psychopaths, but here I would like to concentrate on the development of this area.

The VMPC does not come fully developed at birth. It grows and develops, most rapidly before one year of age, and continuing during early childhood.

The VMPC changes in response to the relationships the baby has which can either enhance or diminish its growth.

Enhancing the VMPC growth comes from being loved, with hugs, holding and – most importantly – a responsive adult who says, hey, you are hungry, scared, alone, in pain, let me help. I will hold you, feed you, take care of you. That interaction is the opposite of neglect. It is love in action. And love for a baby is always love in action. From this, the baby gets the social information to form connections later on, and the happiness bathes the VMPC with growth enhancing substances released by the brain.

If an infant is neglected, the VMPC does not grow as successfully, in part, because of the lack of social information and growth enhancing substances. The rest of the story is that the stress of being unattended bathes the baby’s brain in the stress hormone - cortisol - that has a corrosive impact on brain development. This is not an all-or-nothing situation. However, true neglect, like that found in infants raised in orphanages with no interaction, results in true deficits. In some severely neglected infants, we find a functional hole in not just the VMPC, but in the area around it called the orbitofrontal cortex.

Abuse is another way that the VMPC gets damaged. The VMPC of a frightened infant will be bathed in corrosive cortisol and that does not bode well for future empathy.

Now that I have introduced a few of the players in the crafting of a psychopath, I would like to emphasize another one: nuance. Many neglected and abused people do not turn into psychopaths. There is something in the severity of the early experiences and also, likely, a genetic predisposition.

A final thought. For mystery writers, the issue is often about murder and, quite frankly, most murders are not committed by psychopaths. The vast number of murders are committed by people who forget to look into someone’s eyes and see another person. This can be momentary or it can be part of a general lack of empathy. So, nuance means that people who are neglected and/or abused may have a deficit of empathy that allows them to commit murder.

If Phineas and the VMPC have another lesson to teach us, I believe it is that we need to treat our infants well. We all make mistakes as parents but if, on balance, we love them, hold them and don't let them live in fear, we are likely to grow that part of the brain that allows them the most human gift of all: empathy.

Good Drug, Bad Drug

by Mary Fernando

I would like to introduce my colleague: an Emergency Room doctor with a passion for crime novels. He is a father and an all around good guy who saves lives regularly. He is also a passionate fan of crime novels and has some interesting ideas about murder. I will call him Emergency doctor Extraordinaire or EE for short.

My interview with EE was wide-ranging, but one of the issues he discussed at length was fentanyl - a drug that we hear about daily as a killer of addicts. In EE’s hands, fentanyl is transformed into a character, a noble one that has fallen into disrepute, and finally becomes a murderer of one person at a time, or many in one fell swoop.

Let me tell you EE’s story of fentanyl: the good guy gone horribly wrong.

Although fentanyl has been in the news as a deadly street drug, it has far nobler origins. Since the 1960s, fentanyl has been used as a pain reliever when other opioids aren't strong enough. About 50 - 100 times more potent than morphine, fentanyl is used for cancer pain and thank goodness we have it. In the hands of a doctor who prescribes the right dosage, it is a safe and decent drug. I stress the word decent, because if you haven't seen a person screaming in pain, then you have no idea how relieving this pain is the height of decency and good medicine.

However, if the dose of fentanyl is too high it can cause death. Fentanyl binds with opioid receptors in the brain that give a sense of well being. The problem is that these same opioid receptors are found in the area of the brainstem that controls breathing. So, breathing - essential to living - can be shut down by this same sense of well being - everything is fine it says - no oxygen needed. A high dose of fentanyl gives people such a sense of well being that they forget to breathe.

That last sentence should give us all pause: smothering while surrounded by air. For those of us who write about murder, the focus is always justice - righting a wrong. The murderer is that vile, unsavoury creature to be chased down and brought to justice. However, not all methods of murder are equal and, I would argue, the method of murder is a character in itself. And you will find few viler methods of murder than fentanyl and smothering a victim in air.

So, back to my EE and his thoughts: ‘In a fentanyl naive patient, it can kill at much smaller doses, so a patch that is therapeutic for cancer patients, can kill someone who has never received fentanyl.’
As with all drugs, a tolerance develops. So, patches, clear and small, can be put on the skin of a victim who is fentalyn naive. EE thinks a nicotine patch or other patch could easily hide it and be removed after. Another intriguing method of delivery is a nasal spray - so perhaps a method of substituting that for Aunt Gertrude’s sinus irrigation? Would this come up on an autopsy? EE responds by saying, “At first glance it would look like someone had a heart attack and died.”

This also brings up the issue of getting fentanyl. Healthcare workers can pretend to give it and store it up. Even a couple of patches could kill an opioid naive victim. Or there is always the street market.
EE pointed out a very frightening and immensely writeable option: weaponizing of carfentanyl. This drug is 100X more potent than fentanyl, and as much as 10,000 times stronger than morphine. There is the frightening scenario of mass murder. Carfentanyl’s deadly potential comes as no surprise to the various countries that have experimented for decades with weaponizing this synthetic opioid.
Although never officially confirmed, it was reported that the Russian military pumped aerosolized carfentanyl into a theatre to incapacitate the armed Chechens who took more than 850 people hostage in 2002. In this event, more than 120 hostages died.

This has thriller written all over it. An aerosolized form can kill many - how about a chase to find the carfentanyl and those who plan to use it?

If a character can be a focus- so can the weapon of choice. There is something poignant about a noble drug, developed to ease the extreme suffering of patients, being turned into a killer. Worse, this killer can then massacre thousands. It is a noble character gone wrong. And the making of a crime novel. Or a thriller.