I see this question asked a lot, but I’m not going to answer it. Neither should you.

Why not?

Suicidality is a very real condition. In 2021, nearly 50,000 people died of suicide; over 12 million gave it serious consideration.¹ These are real people whose lives are potentially in danger. Because suicide is often an impulsive decision, someone who is contemplating suicide may not have spent a lot of time thinking about the specifics of exactly how they’re going to do it. Having to take just a little time to research their preferred method—particularly when it comes to drugs and medications—may be just enough time or space for them to slow down and think more rationally about what they’re doing.

Now imagine that someone with suicidal ideation reads your book. They read what dose your character takes, and what happens to them. That information is now in their head; it may even become an obsession they can’t stop thinking about. And when your reader’s suicidal ideation becomes strong enough, they now have a plan that they can enact without having to stop and think.  

Copycat suicides

Sadly, I’m not making this up; people really do mimic the suicides they’ve read about or seen on TV. Suicide methods used by celebrities are five times more likely to be used by the general public in the months following their death.² Children and teenagers have been known to mimic suicides seen on TV shows.^2,3 After the publication of Final Exit, a book that promoted asphyxia as a suicide method, deaths by asphyxiation in the US rose by 313%.⁴ Even more disturbing, a copy of the book was found at the scene of 27% of those deaths.⁴

Copycat suicides aren’t a new phenomenon either. In 1774, Goethe published The Sorrows of Young Werther, in which the eponymous character shot himself in the head. Even though the character died slowly and in great pain, the publication of this book was followed by a disturbing new fad: people dressed as Werther shooting themselves in the head.⁵ The book was banned all across Europe and the phenomenon of copycat suicides became known as the “Werther Effect.”    

What to do instead

Keep the details vague. Don’t provide specific doses or specific combinations of medications, drugs, alcohol, etc. I promise, your book won’t feel less realistic if your character takes a “handful” of pills in their suicide attempt, rather than a specific dose of a specific medication.

Please note that I’m not saying you shouldn’t write about suicide; I’m just asking that you avoid turning your book into a how-to manual for someone who is potentially suicidal. Who knows? You could literally save someone’s life.

Works Cited

1. “Facts About Suicide.” Centers for Disease Control and Prevention. May 8, 2023. https://www.cdc.gov/suicide/facts/index.html
2. Çelik et al. (2016). Copycat suicides without an intention to die after watching TV programs: Two cases at five years of age. Noro Psikiyatri Arsivi 53(1), 83084. www.ncbi.nlm.nih.gov/pmc/articles/PMC5353244/.
3. Kindelan, K. & Sabina Ghebremedhin. S. (2013, June 28). 2 California families claim ’13 reasons why’ triggered teens’ suicides. ABC News. abcnews.go.com/US/california-families-claim-13-reasons-triggered-teens-suicides/story?id=48323640.
4. Stack S. Media coverage as a risk factor in suicide. Journal of Epidemiology & Community Health 2003;57:238-240. https://jech.bmj.com/content/57/4/238
5. Klonsky et al. (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), 231–237. https://doi.org/10.1037/a0030278 

Writers love giving their characters multiple personalities, and I can’t blame them. More formally known as dissociative identity disorder (DID), the concept of multiple personalities offers a rich and complex terrain for exploring themes related to identity, the human mind, and the nature of the self. When done correctly, it can add narrative tension to a story, intensify the psychological complexity of a character, and allow the author to explore themes of personal identity, psychological trauma, and maladaptive coping mechanisms. However, authors can also use the disorder poorly, treating it as merely a plot twist or mechanism to try and explain gaping plot holes.  Don’t be that author.

What is DID?   

DID is characterized by the presence of two (or more) distinct and separate identities existing within the same person, called “alters.” Each alter has an individual personality and unique memories. Alters can be of different ages and genders, and will have a unique perspective, skill set, and worldview. Different alters will have different handwriting and may even require different glasses prescriptions! A person with DID can have up to 100 alters, or as few as two. It is theorized that different alters have unique traits that help them to survive and/or cope in different circumstances.

A person with DID will not be able to choose or summon their alters at will, though there are sometimes “positive triggers” that are more likely to bring out one alter over another. Because alters do not share memories, blackouts are another common symptom of DID. Memory problems—such as not remembering a person they met while another alter was out—are another challenge faced by characters with DID. Confusion, feeling disconnected from their body and/or reality, hearing voices of other alters, and not being able to recognize themselves in the mirror are also common symptoms. A character with DID will often—but not always—feel as if they are more than one person.

Is DID the same thing as schizophrenia?

No. Characters with split personalities or DID are often described as having schizophrenia, but the two conditions are completely distinct. Schizophrenia is a psychotic disorder characterized by disruptions in perception, cognition, and overall thought processes. A character with schizophrenia may experience delusions—fixed, false beliefs—and hallucinations, such as hearing voices. These symptoms may significantly impact their ability to understand what is real and what is not. However, their single, core identity remains intact.

How common is DID?

Good question. Unfortunately, the answer is quite complicated. Some practitioners believe that DID does not exist at all. They believe that it is a confabulation by highly suggestible patients suffering from other psychiatric disorders, particularly borderline personality disorder, to explain their repressed traumatic memories. Others believe that the condition is actually underdiagnosed. So where does that leave writers?

My advice is to utilize DID in your stories with great caution. At the very least, DID is a controversial diagnosis that is deeply misunderstood. If your story doesn’t absolutely require your character to have DID, I strongly suggest you do not include it. However, if you’re going to write a character with DID, make sure you do your research.

Happy December! I haven’t posted on this blog in a while, so I’m going to try something new. Since it is now the season of capitalism – I mean, Christmas – it’s time to think about giving gifts to the people we love. And if someone you love is a writer, this post is for you.

Buying the perfect gift is always a challenge. Writers are particularly hard to buy for, because what could we possibly need besides a computer (or notebook) and a healthy dollop of inspiration. Hah! So, in this post, I thought I thought I would share some of the best writing-related gifts I’ve received (or would like to receive…).

1.      Books on Writing

Writing is a lifelong journey. Every writer, no matter how advanced, has something they can learn. Give the gift of knowledge by giving them a book on writing. Some of my favorites include Save the Cat Writes a Novel by Jessica Brody, The Emotional Craft of Fiction by Donald Maas and The Writer’s Guide to Medicine series by me (obviously). Is this whole post a shameless plug for my books? Absolutely not. Did I happen to put my own series as my #1 recommendation for gifts for writers? Absolutely. #sorrynotsorry

2. Inspirational Writing Books

Sometimes, writers are less in need of guidance and more in need of inspiration and motivation. Enter these motivational books. Personally, I love Bird by Bird: Some Instructions of Writing and Life by Anne Lamott and Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert. For those of you who are fans of Stephen King, On Writing: A Memoir of the Craft is supposed to be both instructional and inspiring.

3. Inspirational Music  

If there’s anything writers seem to have in common, it’s our need for some epic music to get us through the day. Nothing says “bang out that word count,” like a rockin’ beat. Every writer is going to have their own taste, obviously, but I find that instrumental tracks – particularly soundtracks and neoclassical music – work best for me. Right now, I’m really into the Dream Worlds album by Immediate Music and Episodes by Florian Christl. I also love anything by Hans Zimmer or Two Steps from Hell. Of course, if you aren’t sure what type of music keeps your writer on track (get it?), you can always get them a subscription to a streaming service.

4. Tea (or coffee) + Writer-themed mug

You know what else keeps writers going? Coffee. Or, in my case, highly caffeinated black tea. Buy them some fancy local teas/coffee beans and a cute, writing-themed mug. Etsy has some really cute ones. Don’t know what writer theme to go with? Try some publication swag!

5. Publication Swag

Getting something – anything – published is a huge step in a writer’s career. Most non-writers have no idea how difficult it can be to get even a short story published. If the writer in your life has had something published – particularly if they’ve achieved this milestone recently – celebrate it! There’s “Published Author” t-shirts, mugs, ornaments – you name it. My husband framed my very first check – f $10 from a small literary magazine – and it sits proudly on my bookcase in the front room. And don’t worry if your writer isn’t published yet – there’s plenty of “Future Published Author” swag as well.  

6. Writing Software

While some writers may be able to organize their entire novel in Word (or a notebook!), others of us need help. Personally, I use Scrivener, a writing program that helps me organize my novel – including research, character notes and worldbuilding. It’s not all that expensive and I use it literally every day. I also have a subscription to Grammarly, which not only helps with spelling/grammar, but can also help writers with word choice and clarity. If you’re thinking of going this route, you may want to drop some heavy hints – not every writer loves (or needs) every program. I’ve also heard of writers using programs like Atticus, Plottr, and World Anvil, but I’ve never used them myself.   

7. A nice set of pens

Back in medical school, I color coded all of my notes. I had the perfect set of pens, in 42 separate colors, and I knew exactly what each color stood for. Nowadays, I do all my writing on a computer, but when it comes time to for line edits, I go back to pen and paper. And while not every writer is going to be quite so type-A about the color scheme for their edits, most writers won’t turn their nose up at a good set of pens. Even if they do all their edits on the computer, they’ll still need some fancy pens for all those book signings, right? 

8. Book of creative writing prompts

I took a class recently that focused on warm-ups for writing, and it blew my mind. Whoever heard of warming up before a writing session? Yet, back when I played violin (who am I kidding – I still play violin!), I would never consider jumping into a practice session – or worse, rehearsal – without warming up. Creative writing prompts can be a great way to jumpstart your creative juices or get over writer’s block. 

9. Blank Journal

While lots of us take notes on our phones, there is just something satisfying about pulling out a notebook and scribbling down an errant thought. I keep one beside my bed so I can jot down any genius, middle-of-the-night ideas without leaving the warmth of my covers.  

10. Books

Writers are readers, and readers can never get enough books. Seriously, have you ever known a writer who didn’t have a TBR (To Be Read, for those not in the know) pile as long as their arm? Me neither. You can help them out by giving them a gift card to their local bookstore. Want to make the problem worse? Give them a few of your favorite books to add to that TBR pile.

For those writers (like me!) who prefer audiobooks, the options are more limited. You can purchase them a subscription from Audible, Scribd, or other audiobook subscriptions. You can also gift audiobooks directly through the Apple store or Libro.fm.  

Now that you’ve gone through this list, I hope you have some good ideas for gifts for that writer in your life.

Note: I don’t make any money off any of these recommendations, besides the books in my own series.

A. While the character is seizing, keep them safe by clearing the area.

Seizures can look really scary, but most of the time they’ll stop on your own. If you want your character to look like they know what they’re doing, have them clear a space around the seizing character, moving furniture and other objects out of the way so that they can’t hit anything hard or sharp while they’re flailing around. Your character should also check for a medical bracelet before calling 911; seizures aren’t dangerous most of the time and people with epilepsy get seizures often enough that they would go bankrupt if an ambulance were called every time they seized (welcome to the American healthcare system!). And for the love of God, do not have them put anything in their mouth; the character biting their tongue is far preferable to them choking on a tongue depressor or biting off a well-meaning character’s finger. 

What about once they’re done seizing?

After a tonic-clonic seizure – what used to be a “grand mal” seizure – your character may remain unconscious for a few minutes. They may even snore. But they should wake up within a few minutes – any more than that is worrisome. However, they won’t be totally back to themselves when they wake either. Instead, they’ll be experiencing the final phase of a seizure, called the postictal phase.  

Postical State

Postictal states are a period of time during which your character’s brain is no longer actively seizing, but it isn’t back to normal either. Basically, it’s the time during which your character’s brain recovers after a seizure.

If your character is postictal, they’ll probably be drowsy and confused. They may also:

• Feel weak or unable to move half their body (called “Todd’s paresis” or “Todd’s paralysis”)
• Be unable to speak
• Make repetitive motions, such as smacking their lips, rubbing their face, or picking at their skin.
• Have a headache
• Cough, spit, drool, or wipe their nose a lot
• Feel nauseated and/or thirsty
• Feel sad, embarrassed, or depressed
• Be sore and physically exhausted

If your character had a seizure, they probably won’t remember the seizure itself (the “ictal period”) or the postictal period.

Not all seizures are tonic-clonic, and not all types of seizures have postictal periods. If your character doesn’t lose consciousness – such as if they’ve had a Focal Onset Aware seizure – they won’t experience a postictal state. Similarly, if your character has Absence Seizures, they will return to normal consciousness as soon as the seizure is over.

Want to learn more?

Interested in learning more about different types of seizures? Need more details on what it what it feels like to have a seizure? Want to know how medical professionals would diagnose and treat your character’s first seizure? Then check out Ch. 6: Syncope & Seizures of Illness & Injury, the second volume of my “Writer’s Guide to Medicine” series. Release date July 31, 2022!  

A: An abortion is the loss of a pregnancy prior to 20 weeks gestation

Abortion has been in the news a lot this week, and rightfully so. But I’ve seen a lot of miscommunication being thrown around, particularly around the idea of what an abortion is, and what it is used for. The purpose of this post is not to be political. Instead, my goal is to present the facts: how medical professionals define an abortion, and the clinical indications for why a woman would need one. Let’s start with definitions.

The embryonic stage is from 2-9 weeks gestation. At this stage, it is called an embryo.

The fetal stage is from 10 weeks gestation to birth. At this stage, it is called a fetus.

An abortion is the loss of a pregnancy prior to 20 weeks gestation.

A stillbirth is the loss of a pregnancy afte 20 weeks gestation.

As you can see, the medical definition of “abortion” is quite broad. For this reason, doctors further narrow abortions by specifying the type of abortion. Sometimes, these types can overlap. Subtypes of abortions include:

• A spontaneous abortion occurs when the embryo/fetus dies and passes out of the uterus on its own.
• A missed abortion occurs when the embryo/fetus dies but remains inside the uterus.
• An incomplete abortion means that the embryo/fetus is dead and part of it – but not all – have passed out of the uterus.

A miscarriage – a colloquial term, not a medical one – could be any of the above types of abortions. Missed abortions and incomplete abortions are particularly dangerous. Since there are fetal parts still inside the uterus, the woman is at risk of getting an infection. If this happens, she now has a septic abortion. Septic abortions – infection of the uterus due to loss of pregnancy – are quite dangerous and can be severe enough to cause death.

An elective abortion is when a woman chooses to end a pregnancy. There are myriad reasons a woman might need an elective abortion, but most fall into one of 3 categories: the health of the mother, the health of the fetus, and socioeconomic factors. Maternal indications for an elective abortion for the health of the mother include cancer, heart disease, autoimmune disease (such as multiple sclerosis or lupus), kidney disease, lung disease, blood diseases (anemia, clotting disorders, etc.), rape/incest, and mental illness. Elective abortion might also be recommended if the fetus has drastic birth defects, including major heart defects, chromosomal abnormalities, congenital malformations, and disorders that are incompatible with life. I’m no expert in public health, so I’m not going to comment on the socioeconomic factors other than to say that there was a major, large-scale study that came out recently called the Turnaway Study. This prospective cohort study showed that women who were denied abortions were worse off in nearly every metric than women who were able to get abortions.

If your character needs an abortion, there are two main types. A medical abortion, also called the “abortion pill” is a medication that stimulates uterine contractions in order to pass the embryo/fetus. Medical abortions are more commonly prescribed early in the pregnancy, around twelve weeks or so. Surgical abortions are a surgical procedure, called a dilation and curettage, or “D&C, which physically removes the fetus from the uterus.

But elective abortions are not the only reason a woman might need an abortion. Medical and surgical abortions are also used to treat:

• Ectopic pregnancy
• Missed or incomplete abortion
• Septic abortion

And finally, there’s the whole “late-term abortion thing.” I’m not going to get too in-depth here. Just like miscarriage isn’t a medical term, neither are “late-term abortion” or “partial birth abortion.” According to the CDC’s abortion surveillance data, the vast majority (more than 91%, ) of abortions occur by week 13. After that, abortions are named by the week (i.e. 18-week abortion). Less than 1% of abortions occur after week 20, and many of these were due to lethal fetal anomalies and/or significant health risks to the pregnant person.

A: There are 3 overarching causes of an inability to speak: psychiatric changes, neurologic changes, and changes to the mouth and throat.

Mutism is an inability or refusal to speak. It can be congenital – meaning that the reason your character can’t speak is something they were born with – or it can be acquired.

1. Psychiatric Changes

There are several different psychiatric conditions that can cause mutism.

• Catatonia is a psychiatric syndrome that is often associated with mutism. Catatonia can be caused by a variety of conditions ranging from severe depression to schizophrenia.
• Developmental delays, such as in children with autism, Down syndrome, and other congenital syndromes, may also cause delayed language development and subsequent mutism. Some people with language delays may never learn to speak, but may communicate using sign language, hand signals, communication boards, or other assistive devices.
• Selective mutism is a type of anxiety disorder, in which your character cannot speak in certain situations (school, work, etc.) despite being able to speak in other situations. Selective mutism usually affects children and often symptoms appear before age 5. While people with selective mutism often “grow out” of their inability to speak, they will usually still have signs of social anxiety. Interestingly, selective mutism is generally not associated with trauma or traumatic events.

2. Neurologic Changes

There are a lot of neurologic conditions that can cause an inability to speak. There are three main neurologic conditions that cause inability to speak for three very different reasons. Most of the time, these conditions are caused by stroke or traumatic brain bleeds in particular areas of the brain.

• Aphasia is the inability to understand or express speech. The most common type of aphasia is Broca’s aphasia. Caused by damage to the brain’s language centers, Broca’s aphasia causes an inability to express language. Your character will be able to understand what is said to them, but won’t be able to find words to reply. They might be able to read but unable to write. It’s an incredibly frustrating condition. Broca’s aphasia is most often caused by stroke, but it can also be caused by traumatic brain injury, ruptured brain aneurysms (hemorrhagic stroke), and brain tumors.
• Apraxia of Speech (AOS) is the inability of the brain to communicate with the physical structures of the mouth and throat in order to make words. Your character will know what words they want to say (and thus should be able to write), but their brain has trouble getting the message through. For this reason, your character will be able to make sounds, but they may not be understandable. AOS is most often caused by stroke, but it can also be caused by traumatic brain injury, ruptured brain aneurysms (hemorrhagic stroke), and brain tumors.
• Akinetic mutism is a rare condition that is characterized by a complete lack of motivation to do – well, anything. A person with akinetic mutism will be totally conscious but will not move, despite hunger, thirst, or pain. People with Creutzfeld-Jakob disease – also called “Mad Cow Disease” – often develop akinetic mutism, though that is not the only cause.
• Dementias can also cause an inability to speak. Severe Alzheimer’s disease can cause aphasia, often first spotted by their inability to name everyday objects. Other types of dementia, such as frontotemporal dementia (FTD) or “Pick’s disease” can also cause mutism.
• Cerebellar mutism is a rare condition of mutism that occurs after brain surgery on a specific type of tumor called a medulloblastoma. This condition is most often seen in children, since they are more likely to develop this type of tumor.

3. Changes to the Mouth & Throat

Physical damage to the structures required for speech – the mouth, tongue, and larynx in particular – can difficutly speaking. These organic causes of muteness can be acquired or they can be congenital. Often, injury to these structures will result in a soft or a hoarse voice, rather than a complete inability to speak.

• Dysarthria is difficulty speaking due to trouble with the muscles used for speech. Rather than causing an inability to speak, dysarthria causes slurred, slowed, monotone, or irregular speech. Dysarthria tends to be caused by neurologic diseases that affect the muscles, such as ALS (“Lou Gehrig’s disease), cerebral palsy, multiple sclerosis, myasthenia gravis, and Parkinson’s disease. Dysarthria can also result if the nerves innervating the muscles of the neck and face are damaged.
• Laryngeal trauma – trauma to the voice box – will cause a hoarse voice, trouble speaking, neck swelling, and a specific type of noisy breathing, called stridor. Untreated, your character may need to be intubated to prevent their airway from swelling shut.
• Vocal cord paralysis occurs when the muscles of the vocal cords aren’t getting the signal from the nerve that controls them. Symptoms include a breathy or hoarse voice, trouble breathing, trouble coughing, and a flat-sounding voice. It can be caused by trauma to the neck, certain infections (Lyme disease, mononucleosis, even possibly COVID-19), and tumors of the neck and throat.
• Glossectomy (tongue removal) is a time-honored way of silencing characters. After all, what better way to shut your character up than to brutally cut out their tongue? But that’s not the only way for your character to lose a tongue – cancers of the tongue, mouth, and throat can also necessitate its removal. Depending on how much of the tongue is left (glossectomies can be partial, half, or full), your character may be unable to talk or swallow.

Speech Language Pathologists (SLP)

Speech Language Pathologists (SLPs) are healthcare professionals specializing in speech and swallowing. Whether your character is suffering from aphasia, dysarthria, or even language delay, SLPs have techniques that will help to improve their communication. If your character is going to suffer from a speech difficulty (and your story is set in contemporary USA), consider utilizing an SLP in your story who can help them recover their ability to communicate.

A final note

Note that I didn’t mention deafness on here. Most people who are deaf aren’t mute – they are able to speak quite fluently using sign language. Furthermore, many deaf people can speak verbally as well, particularly if they were hearing during language development.

Answer: It Depends

I know that isn’t very satisfying, but hear me out. Hypothermia occurs when your character’s core temperature – usually somewhere between 97-99^oF – drops to below 95^oF. There are a lot of different factors that contribute to your character’s core body temperature. These include:

• The ambient air temperature
  • While hypothermia can theoretically occur at any temperature less than human body temperature, it usually isn’t a concern until the ambient air temperature drops below 50^oF.
• The windchill
• If your character is soaking wet, completely dry, or somewhere in between.
• If your character is submerged in water.
  • Water conducts heat really well, so your character will develop hypothermia more easily.
  • Hypothermia is possible in water temperatures as high as 70-80^oF.
• Your character’s clothing
• Your character’s body habitus
  • Fat characters will lose heat more slowly than super skinny ones.
• Your character’s age
  • Older characters (<65 years old) are more likely to develop hypothermia
  • Newborns, infants, and young children (<5 years old) are also more susceptible to hypothermia.
• Whether your character has recently drunk alcohol, taken drugs, or takes certain prescription medications.
• The surroundings, including their immediate surroundings (cold cement floor vs. carpeted floor)
• Your character’s body position
• Your character’s physical state
  • An exhausted or dehydrated character will be more susceptible to hypothermia.

It’s also important to note that not all hypothermia is equally dangerous. How low your character’s core temperature drops will determine the symptoms they exhibit.

• Mild hypothermia (90-95^oF): Shivering significantly. Awake and alert but unable to care for themselves.
• Moderate hypothermia (82-90^oF): May be conscious or unconscious. May or may not be shivering.
• Profound hypothermia (<82^oF): Unconscious. No longer shivering.

If your character’s body temperature drops too low (<75^oF), they may even appear dead. But there’s a saying in medicine: “you’re not dead until you’re warm and dead.” Cold temperatures have a way of preserving brain function. So even if your character is profoundly, devastatingly hypothermic, don’t let the other characters give up on them! With proper rewarming and resuscitation, they just might live.

Finally, if you’ve read through this whole blog and are still looking for some more concrete times, there is a formula you can use to calculate survival times in cold water. Developed by Hayward et. al. in 1975, this formula was developed by testing the core body temperatures of people – men and women of medium build wearing light clothing and life jackets – during submersion. The equation is:

Survival time (minutes) = 15 + 7.2 / (0.0785-.0035 x water temperature in celsius)

Hayward et. al. Feb 1975. 10.1139/y75-002

There isn’t an equivalent for air temperature – there are just too many variables – but you can check out this National Weather Service Windchill Chart to get an idea of how quickly frostbite will set in. Depending on how warmly your character is dressed, hypothermia may not be far behind.

This is a great question. Some bleeding during childbirth is totally normal, but too much can be life-threatening. In fact, postpartum hemorrhage –excessive bleeding during/after childbirth – is the #1 cause of maternal death during childbirth. There are several underlying causes of postpartum hemorrhage. Here are a few.

1. Genital Trauma

No one ever said pushing out a baby was easy, and sometimes tears (lacerations) happen. Vaginas are both highly sensitive and highly vascularized, so these tears can bleed like crazy. Improper repair can lead to chronic problems, such as chronic pain, painful sex (dyspareunia), and incontinence.

Old wives’ tales about women not feeling perineal pain after childbirth are generally rooted in racist & sexist stereotypes; women definitely feel pain down there, even after childbirth. The exception is if your character had an epidural, in which case she should already be numb.

2. Retained Placental Tissue

Sometimes, the afterbirth (placenta) isn’t delivered or is incompletely expelled.  If your character has retained placental tissue, she’ll experience profuse and heavy vaginal bleeding, severe abdominal pain, fever, and foul-smelling discharge complete with chunks of tissue. The bleeding may last for days or even weeks after delivery if it isn’t treated. Untreated, retained placental tissue can lead to uterine scarring, infection, hemorrhagic shock, and even death. 

Treatment ranges from breastfeeding (which stimulates uterine contractions) to complete removal of the uterus (hysterectomy). The longer the condition takes to be diagnosed and treated, the more likely there are to be complications.  

Placenta acretta–a condition in which the placenta attaches too strongly to the muscular wall of the uterus–is a cause of retained placental tissue that may require emergent hysterectomy in order to stop the bleeding.

3. Uterine Atony

When the placenta tears itself away from the uterus, there’s bound to be some bleeding. Normally, the uterus deals with this by contracting strongly, clamping the blood vessels shut. It’s surprisingly effective. Providers can encourage this natural phenomenon with a uterine massage; literally grabbing the uterus through the abdomen and massaging until it turns into a hard knot.

Sometimes, however, the uterus does not contract as it should, and it continues to spew out blood at an alarming rate. This phenomenon is called uterine atony, and it is the most common cause of postpartum hemorrhage. It can also be fatal.

When this happens, the goal is to make the uterus contract as strongly and as quickly as possible. The great thing (for writers) about uterine atony is that there are effective treatments for the condition that don’t require complex medical equipment or knowledge. The first of these is a uterine massage – literally grabbing the uterus through the front of the abdomen and kneading it like a ball of dough. This encourages the uterus to contract into a little ball, cutting off the bleeding blood vessels. Breastfeeding also stimulates oxytocin production (the “love hormone”) that also encourages the uterus to contract.

If these steps don’t work, your character will need higher-level medical care. If uterine massage and breastfeeding fail, your character will be given a cocktail of drugs to try and make the uterus start contracting. If that fails, she’ll need an emergency hysterectomy.

A Note About Maternal Mortality

Pregnancy and childbirth are conditions that carry significant mortality rates. In 2020, the maternal mortality rate in the US was 23.8 per 100,000 live births (1). For comparison, the fatality rate of skydiving that same year was 0.39 per 100,000 (2). The mortality rate of influenza in 2018-2019 was 1.6 per 100,000 for people in their childbearing years and jumped to 22.1 per 100,000 for people over age 65 (3). In other words, a pregnant woman is about as likely to die from her pregnancy as an old person is to die of the flu.

Carrying and bearing a child changes a woman’s body forever and can literally cost her her life. No one should be forced into that situation against their will.

Works Cited

1. Hoyert, Donna. “Maternal Mortality Rates in the United States, 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 23 Feb. 2022, https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm#:~:text=In%202020%2C%20861%20women%20were,20.1%20in%202019%20(Table).
2. “How Safe Is Skydiving?” United States Parachute Association, 2022, https://uspa.org/Discover/FAQs/Safety.
3. Elflein, John. “Flu Mortality Rate in U.S. by Age.” Statista, 7 Oct. 2021, https://www.statista.com/statistics/1127799/influenza-us-mortality-rate-by-age-group/.

What Won’t Happen

There are a lot of rumors, misunderstandings, and misconceptions surrounding the treatment of suicide attempts. I’ll start out by addressing some of the most flagrant here.

• Your character won’t wake up in restraints. In fact, they won’t even be put in restraints unless they are extremely agitated and cannot be calmed down (and even then, they’d probably be given “chemical restraints” — aka a shot of a sedative.)
• The psychiatrist won’t ask for your character’s life story or try to perform any sort of psychoanalysis. Their focus will be on the recent suicide attempt and determining if your character remains a danger to themselves.   
• Your character won’t have their stomach pumped (gastric lavage) unless they ingested the substance very recently (within an hour)
• Your character won’t go straight to the psych ward – if 911 was called, they’ll go to the ED first, even if they aren’t critically injured.
  • If you’re writing historical fiction (or if your contemporary character is filthy rich) they may be admitted directly to a private psychiatric hospital.
• Your character won’t be sent to the psych ward while they have an acute medical condition.
• Your character won’t be involuntarily committed to the psych ward while they are unconscious.     

What Will Happen

Now that I’ve got that out of my system, let’s move on to what will happen.

If your character is brought to the hospital after attempting suicide, the very first thing doctors are going to do is treat any life-threatening conditions. If your character tried to shoot themselves in the head, they’ll be taken for neurosurgery. If they took a ton of pills, they’ll be given a reversal agent (if there is one), then have their breathing and blood pressures closely monitored. If they took a ton of pills less than an hour ago, they’ll give them activated charcoal or perform a gastric lavage . If they are very ill and need to be admitted to the hospital or the ICU, they will be.

If your character was brought to the ED alone, they’ll be assigned a “sitter” – someone employed by the hospital to sit with them and make sure they don’t try to hurt themselves again. If your character is brought in with a friend or family member, that person can sit with your character instead.

Once your character is awake and no longer in critical condition, a psychiatrist will be sent down to the ED (or the ICU/hospital floor if they’ve already been admitted) for a preliminary evaluation. The psychiatrist will ask your character a lot of questions, trying to determine your character’s diagnosis and whether or not they are a danger to themselves. They will ask about your character’s known mental illnesses, and how they’ve been feeling recently. They will also ask about the suicide attempt: what precipitated it, how they planned it, and what they did. They will also ask if your character is currently wanting to kill themselves, and if they have a plan to do so. This will help determine the level of hospitalization your character will require.

Medical vs. Psychiatric Admission

Psychiatric wards are not equipped to care for patients needing high-level medical care. If your character requires surgery, intubation/ventilation, airway monitoring, IV fluids, high-level nursing care, or even just consistent monitoring of their vital signs (blood pressure, heart rate, breathing rate, etc.), they will be admitted to the medical hospital, rather than the psych unit.

Criteria for Inpatient Psychiatric Hospitalization

Inpatient psychiatric hospitalization – the “psych ward” – is reserved for patients who are an immediate danger to themselves or others. Your character will be recommended inpatient hospitalization if:

• They are actively suicidal and have a plan to kill themselves
• They are suicidal and show signs of impulsivity
• They are suicidal and do not have good social support (no friends/family, homeless, etc.)
• They are acutely mentally ill and appear to be concealing an intent to hurt themselves
• They are acutely mentally ill and a danger to themselves or others
• They are acutely mentally ill to the point where they cannot care for themselves (particularly if they have concomitant health problems, such as diabetes, that require a higher level of care)  

Voluntary vs. Involuntary Admission

If the psychiatrist recommends inpatient hospitalization, they will try their best to get your character to sign themselves in voluntarily. Voluntary admission means less paperwork for the doctor. Names and rules for involuntary holds vary widely by state, but they always require an absurd amount of paperwork, so the doctor will try their best to get your character to sign in voluntarily. Only if your character refuses will they go down the involuntary hospitalization route. In Oregon, where I trained, an involuntary hold requires filing a detailed form called a 5150, which allows the patient to be held for up to 72 hours, at which point the psychiatrist must file at 5250 to extend the hold for up to 14 days, during which time the patient gets an automatic hearing presided over by a judge.¹⁶ It’s a headache for everyone involved.

Only once your character is medically stable and has signed the paperwork – or the psychiatrist filled out the involuntary commitment forms – can your they be transferred to the inpatient psychiatric ward. But they may not get to go right away. Psychiatric wards are notoriously overbooked; it wouldn’t be unusual if your character had to camp out in the ED for hours, even days, before they are able to secure a bed in the psych ward.   

Not All Emergent Psychiatric Care is Inpatient

If your character doesn’t fulfill the criteria for inpatient psychiatric hospitalization, they will probably qualify for a partial hospitalization or intensive outpatient program. These day programs usually run from 9 am-5 pm every day, including weekends.

The purpose of these outpatient programs is to provide a level of care similar to inpatient hospitalization, just without 24-hour monitoring. These programs provide daily group and one-on-one therapy as well as close monitoring by an attending psychiatrist. However, your character will get to sleep in their own bed, wear their own clothes, and eat food that didn’t come from a hospital cafeteria. In order to qualify for this level of care, your character will need adequate social support – someone who can stay with them during the hours the program isn’t running. That person will need to drive your character to-and-from the program, administer your character’s medications and ensure that the home is free of lethal means. These programs are also quite expensive.

Summary

If your character attempts suicide, the first priority will be to save their life. This may require admission to the hospital floors or ICU. Only once they are medically stable will they be offered psychiatric hospitalization. Most psychiatric hospitalizations are voluntary. If your character is not an immediate danger to themselves or others AND they have adequate support at home, they may be offered intensive outpatient treatment instead.