A miscarriage is often a traumatizing event in a woman’s life. They are also extremely common – nearly 1 in 4 pregnancies end in miscarriage. And yet, miscarriage is a taboo subject, rife with misunderstandings. If you are writing a story where a character miscarries, I hope you do your research, avoid the tropes, and treat the subject with the respect it deserves.

Medical Terminology

            Pregnancy loss before 20 weeks = Abortion

            Pregnancy loss after 20 weeks = Still birth

Miscarriage is the loss of a pregnancy prior to twenty weeks gestation. After twenty weeks, it’s considered a stillbirth. But miscarriage isn’t a medical term – the proper term is abortion.

There are many different types of abortions. A spontaneous abortion occurs when the fetus dies unexpectedly in the womb, then passes out through the vagina. Medical and surgical abortions are triggered by a pill or surgical procedure, respectively. A missed abortionoccurs when the fetus dies in the uterus but does not pass on its own and is usually diagnosed by a lack of heartbeat on ultrasound. An incomplete abortion occurs when part of the fetus passed, but other parts remain inside. If your character has a missed or incomplete abortion, she will need to either take a medication to induce the abortion (the much-vilified “abortion pill”) or get a surgical procedure to clean out her uterus, called a dilation and curettage (D&C).

Most miscarriages occur before the twelfth week of pregnancy. The vast majority of these losses are due to genetic anomalies in the embryo. These genetic anomalies can cause nonviable pregnancies, such as blighted ovum or molar pregnancy– where the gestational sack forms but no embryo develops. Genetic anomalies can also cause a normally developing fetus to suddenly die. This means that nothing the mother did could have changed the outcome. This is an important point, so I’m going to repeat it; in the vast majority of cases, nothing a woman could have done could have stopped her miscarriage from happening.

Causes of miscarriage

Maternal health conditions, such as sexually transmitted diseases, thyroid disease, hormone imbalance, and uncontrolled diabetes, can also cause miscarriages. Problems with the uterus – such as fibroids or endometriosis – and cervix can also lead to miscarriage.

Exercise, sexual intercourse, and mild-moderate abdominal trauma do not cause miscarriage. This is because, during the first and second trimester, the uterus – and the fetus it contains – is protected by the pelvis. It is very difficult to injure them directly; falling down a flight of stairs simply won’t do it.

 During the first two trimesters, the main way a miscarriage can by caused by abdominal trauma is if that trauma causes the placenta to rip free of the uterus, called a traumatic placental abruption. However, this requires severe mechanisms of trauma, such as motor vehicle collisions, falls from great heights, or direct hits to the abdomen, such as domestic abuse.

This all changes in the third trimester, when the fetus sits above the pelvis and the protective layer of uterine muscle stretches thin. After about 24 weeks, even minor abdominal trauma can lead to fetal loss, or stillbirth. The mother is also at higher risk of complications, including death. Think of it this way; if your character has a big ole baby bump, abdominal trauma is more likely to cause fetal loss. The bigger the bump, the bigger her risk.

If your pregnant character is exposed to major abdominal trauma, she’ll need to go to the hospital to monitor and make sure the baby is all right.

Symptoms of Miscarriage

Symptoms of a miscarriage include abdominal pain and vaginal bleeding discharge that lasts anywhere from a few hours to several weeks. Your character’s experience of a miscarriage will vary depending on how far along in the pregnancy they were. Many women miscarry without ever knowing it, and simply experience a longer or heavier period than usual. Women who miscarry later in pregnancy will experience more cramping and heavier bleeding – and I mean bathroom-looks-like-a-murder-scene kind of bleeding. They may even be able to identify fetal parts amongst the discharge.

Unlike you’ve probably seen on TV, miscarriages aren’t a one-and-done event – they take days, weeks, sometimes months for the physical symptoms to abate. Even in the best situation – an early, spontaneous loss – the miscarriage will last about as long as a heavy period (5-7 days, for those of you without a uterus). Under less ideal circumstances – a later miscarriage, an incomplete or missed miscarriage– you could make your character cramp and bleed for several weeks, serving as a daily reminder of what they’ve lost.    

No matter how far along the pregnancy was when it happened, miscarriages are painful and heartbreaking. Besides the physical toll, there is also a substantial emotional toll. One study found that 29% of women experiencing early pregnancy loss developed PTSD from the experience.¹  That number only increases as the pregnancy progresses. As you write your character dealing with miscarriage and stillbirth, please, keep this in mind. 

Citations

1. Farren, Jessica, et al. “Posttraumatic Stress, Anxiety and Depression Following Miscarriage and Ectopic Pregnancy: A Multicenter, Prospective, Cohort Study.” American Journal of Obstetrics and Gynecology, vol. 222, no. 4, 2020, https://doi.org/10.1016/j.ajog.2019.10.102.

Writers love wounding their characters – and not just emotionally. Any wound that penetrates the protective barrier of the skin can get infected. Wound infections are a great way for writers to up the stakes, making a previously minor wound suddenly becomes life-threatening. But there are some important parameters writers should know.

1) How long will infection take to set in?

          It might take a while for your character’s wound to become infected. I see a lot of writers having their character wake up the day after getting wounded with a massive, life-threatening infection, but that just isn’t how it works. Wound infections are caused by bacteria, and those bacteria need time to grow and multiply. Wound infections after surgery usually take 5-7 days for the infection to take root and grow into a problem. Dirty wounds, particularly if there is particulate matter (like dirt, gravel or wood) lodged inside the wound, can become infected much faster. Even then, it’ll still take 2-3 days before the initial infection sets in, and a few days more before the infection can get to the blood and become life-threatening.

            Certain wounds are more likely to become infected than others. If your character’s wound is large, deep, or has torn or jagged edges, infection is more likely. Contamination with foreign objects, such as dirt, wood, rocks, or glass, also increases the risk. Animal bites, human bites, and wounds from objects that were dirty or rusty are at particularly high risk of nasty infections.

2) What do infected wounds look like?

Infected wounds start out looking red, painful and swollen. Red streaks appear on the skin, and the wound may begin to smell. An infected wound may produce pus – thick white, yellow, or green fluid. As the infection spreads, your character may develop a fever, along with chills, body aches, and nausea. Severely infected wounds can lead to sepsis.

3) What is sepsis?

Sepsis occurs when the infection reaches the bloodstream. Once this happens, your character can go downhill really fast. Symptoms of sepsis include a high fever (<101 degrees Farenheit), a fast heart rate, and fast, shallow breathing. Blood tests will show bacteria in the bloodstream.

As the infection progresses, your character should become progressively weaker, sleepier, and/or confused. Once their blood pressure drops to below 90/60mmHg, your character is in septic shock; their blood pressure has dropped low enough that they are no longer getting enough blood flow to important organs, such as the brain. Septic shock is a dangerous condition with mortality ranging from 30-50%, even with aggressive treatment.

Sepsis needs to be treated in the hospital. Your character will need intravenous (IV) antibiotics, as well as IV fluids and medications to keep their blood pressure up. And they’ll need to be on those antibiotics for a long time. Depending on several factors (the source/extent of infection, bacteria involved, etc.) a course of IV antibiotics can take anywhere from 7 days to several weeks. So, if you’re giving your character sepsis, don’t expect them to go home any time soon.

4) How should my character prevent infection?

            If your character wants to prevent an infection in their wound, they should start by pulling out all the foreign objects – dirt, gravel, glass, etc – that they can see, then washing the wound liberally with lots and lots and lots of water. Ideally, they’d use sterile water, if that’s available. Then, after the wound has fully dried, they should apply an antibiotic ointment if they have it. Finally, your character should loosely bandage the wound using sterile bandaging to prevent further sources infection.    

If your character is on their own, this is probably all they’re going to be able to do. However, if they have access to medical care, they may also get a tetanus shot and antibiotics, if needed. If the wound is really messy, with lots of dead tissue surrounding it, they may need a procedure called debridement – surgical removal of dead tissue surrounding the wound.       

5) What complications can arise from an infected wound?

  If your character doesn’t get treatment, the infection can spread, causing cellulitis (inflammation of the surrounding skin and deep tissues) and osteomyelitis (infection of the bone). If the infection enters the bloodstream, it can cause sepsis – a life-threatening reaction of the body’s immune cells against the pathogen that can cause a dangerous drop in blood pressure and multi-organ failure.  

  Tetanus, or “wound botulism,” is a particularly nasty complication of wounds. It is caused by a type of bacteria that lives in spore-form that is found in dirt and rust. The spore enters the body through a wound – often penetrating wounds or trivial injuries that go untreated – the bacteria emerge and multiply. Once that happens, they produce a toxin that produces extreme contractions of the muscles. Every muscle in your character’s body will stiffen, causing their jaw to lock and their muscles to spasm. These spasms are incredibly painful and can be strong enough to break bones. Vocal cord spasms can lead to difficulty speaking and spasms of the muscles surrounding the trachea (breathing tube) can cause your character to be unable to breathe. They’ll have sweating, fevers, and a racing pulse. If the infection is severe, their spine may arch backward, a startling bodily position called opisthotonos. Some believe that tetanus infection may have been the cause of historical “demonic possessions.” 

Tetanus infection requires treatment in the hospital, often in the ICU. It’s treated with an antitoxin, along with antibiotics, antispasmodics, and wound debridement. Luckily, tetanus can be prevented with a vaccine. But if your character hasn’t had a booster shot of tetanus in the last ten years, or if your story is set before the invention of the vaccine, they can still get the disease! 

The short answer is that psychiatrists treat people with mental disorders using medications, while psychologists treat people using psychotherapy. This is a gross overgeneralization, of course, but I wanted to get it out there. For more detail, see below.

Psychiatrist  

A psychiatrist is a medical doctor. They go to medical school and complete residency like any other physician. A psychiatrist’s specialty is mental disorders, ranging from mood disorders like depression to substance abuse disorders like alcoholism. Their job is to diagnose and treat psychiatric diseases, and they usually do so by providing prescription medications and following up on their patients’.

Your character’s first appointment with a psychiatrist will probably be a long one. The psychiatrist will go over your character’s symptoms, as well as all their medications, medical history, and family history. During this evaluation, the psychiatrist will also perform a detailed physical exam – though your character might not notice. A psychiatrist’s physical exam is close observation, watching the way your character moves, dresses, thinks, and talks. Once the exam is completed, they’ll explain your character’s diagnosis and, if the condition warrants it, prescribe medications and/or therapy. Subsequent appointments will be shorter – often as short as 15 minutes – and occur less and less frequently as your character improves. During these appointments, the psychiatrist will evaluate your character’s response to treatment. They’ll ask about side effects and efficacy of the medications and will adjust dosages or change medications as necessary.

While psychiatrists can technically perform therapy, they generally don’t, simply because they can’t bill very much for it. Instead, most psychiatrists will recommend that your character see a psychologist or therapist. 

Psychologist

A psychologist is not a medical doctor, though most clinical psychologists have doctoral degrees, such as a Ph.D. in Psychology or a Doctor of Psychology (PsyD). A clinical psychologist’s job is to assess and treat mental, psychosocial, emotional, and behavioral issues. Many, though not all, provide psychotherapy. Psychotherapy comes in many forms, from Freudian psychoanalysis to cognitive behavioral therapy.

Not all therapy is provided by psychologists. Social workers, clergy, professional counselors, psychiatrists, and licensed therapists can also provide certain types of therapy.

Psychologists use interviewing and psychotherapy techniques to help your character work through their mental illness and/or emotional struggles. They cannot prescribe medications, but they can give your character homework – exercises to practice or a journal to maintain. Therapy sessions usually last 30-60 minutes and are conducted regularly; weekly or even more frequently if your character is in crisis. Psychotherapy is often used in conjunction with medications.

Visiting Hours & Restrictions

Most hospitals have moved to open visitation hours, meaning anyone can visit at any time. Studies have shown that allowing visitors increased recovery time, reduces anxiety, and improves overall wellbeing. For this reason, many hospitals have incorporated comfortable chairs and even sofa-beds into their rooms, allowing a family member to stay at their loved ones’ side even through the night. However, certain wards have more stringent requirements.

ICU:

• Visitation hours limited
• Limited number of visitors at a time
• May allow immediate family only
• May restrict visitor age (children > 12 years)
• May need to be buzzed in (locked ward)
• No cell phones
• Not allowed if cold/cough/flu symptoms

Neonatal ICU (NICU):

• Always a locked ward
• Parents allowed 24/7
• Other visitors limited
  • Limited number
  • Age restriction (children >12)
• No cell phones
• Not allowed if cold/cough/flu symptoms
• Must wash hands before entering

What can Visitors Bring?

Another important question is what can your characters bring with them when they visit the hospital. Flowers, fresh fruits, and other plants are wellsprings of potential infection, so many hospitals don’t allow visitors to bring in their own. Instead, they have to put in an order through the hospital florist, who will then bring floral arrangements to pre-approved rooms. Food is also closely regulated in the hospital; it’s one thing if your character occasionally snacks on a peppermint from the bottom of her purse, but if her family is sneaking in cheeseburgers while she’s on a diabetic diet, that’s a big no-no.

COVID Changes

During the COVID-19 pandemic, of course, all this has changed. While every hospital has its own unique set of rules, the general theme of social distancing remains. To that end, many hospitals do not allow any visitors on the floors or units. Hospitalized patients communicate with their families through their phones or video chat. Even delivery rooms often don’t allow visitors, or if they do, it is a single support person, usually the spouse or partner. Clinics also have established limitations, meaning that your character’s family may not be able to go with them to see their oncologist or cardiologist. In real life, these changes are incredibly stressful, but in writing, they make for some excellent opportunities to push your characters outside their comfort zone. How would your character feel if he heard his baby’s heartbeat for the first time through a Zoom call while sitting in the clinic parking lot? Would your character with mild dementia feel as if she were losing her mind while stuck alone in a hotel room without any of her family or personal effects to keep her grounded? There’s a lot of story potential here.

Answer: Pretty much anything.

I know that isn’t a very satisfying answer but hear me out. The extent of your character’s injuries depends on so many factors that I, without intimate knowledge of your story, can’t reasonably tell you the exact extent of the injuries your character might acquire.

Let’s say your character gets stabbed in the abdomen. Depending on the length/sharpness of the weapon, the exact location of the wound, the angle of entry/exit, the force exerted, even how much fat your character carries around their middle, the injury could range from a mere flesh wound to nearly instantly fatal. Yes, some injuries are more likely than others, but you, the author, have a lot of leeway here. It’s your story. As long as you stay within the realm of reasonable, you can do what you want.

A few caveats.

• If your character is hit on the head hard enough for them to be unconscious for more than a few seconds, they’re going to have some brain damage. Even if they’re unconscious for just a few seconds, they’re going to have a concussion. If they’re out for more than 20 minutes, they probably have serious, permanent brain damage – they might even be stuck in a permanent vegetative state.
• If your character passes out from blood loss, they’re going to die of blood loss if they aren’t treated soon.
• You can’t put weight on a broken leg. I don’t care how manly your character is, he’s not going anywhere if he broke his tibia or femur (you might be able to get away with walking on a broken fibula).   
• Yes, gut wounds cause infection, but not for a few days. The more immediate concern is still blood loss.
• Your character will only cough up blood if their lungs, trachea, mouth, nose, or esophagus are bleeding. Stop having your character cough up blood after being punched in the gut.
• Stop wrenching broken noses back into place; your character is liable to do more damage than good. Nasal bones are bones and, like any other bone, they should be set by someone who knows what they’re doing. Bad breaks may even require surgery. Unless the break is making it difficult for your character to breathe, have them ice it and take Tylenol until they’re able to get to a medical professional (or a boxing coach) to sort it out.
• Canes are used on the opposite side of the body. If your character’s left leg is injured, they’ll use a cane on the right. 

With record-breaking, 100+ degree temperatures here in the PNW, I figured I’d share an excerpt from my WIP, a ‘Writer’s Guide Modern Medicine.’ This is part of a chapter titled “Environmental Emergencies.’ As always, the information contained on this website is meant for WRITERS. It is not medical advice and should not be used as a substitute for medical attention. Feel free to leave any suggestions for improvement in the comments. Stay cool!

*Backstory: Dan and Delilah are siblings hiking the Pacific Crest Trail.* One day, as they’re crossing the Mojave desert, Delilah notices her leg muscles keep cramping. Daytime temperatures have soared into the upper 90’s, and the distances between water sources are long, so she’s been conserving water, drinking rarely. But as the sun climbs higher and higher, she starts to feel tired deep in her bones. Every step is an effort, and her head is pounding. She’s sweated through her shirt and is starting to feel nauseated. When they stop for lunch in the shade of a rock formation, she collapses to the ground and vomits. Dan hurries over and feels her forehead; she is cool and clammy to the touch.

Heat Exhaustion

            Heat exhaustion is characterized by extreme fatigue, headache, nausea and vomiting, dizziness, and profuse sweating. Your character’s skin will be cool and clammy, their heart will be racing and they’ll be breathing fast. The lightheadedness and dizziness is caused by low blood pressure. Heat exhaustion is uncomfortable and unpleasant but is generally not life-threatening.

Seeing Delilah’s state, Dan fills the rest of his canteen with Gatorade powder and makes Delilah drink it – slowly, so she doesn’t vomit. They find a spot in the shade that has a breeze, and Delilah sits and sips until she’s feeling better. They decide to wait there for a few hours until the heat of the day passes.

 Heat Exhaustion can be treated with electrolyte-rich fluids and finding whatever external method of cooling down is readily available, whether that is a shady spot or a cool bath. If your character doesn’t improve within an hour, they should be taken to the hospital. There, Heat Exhaustion will be treated with IV fluids and external cooling, such as air conditioning and fans.

The next day, Delilah is feeling more like herself. She and Dan decide to start out before sunrise to avoid hiking during the heat of the day.

Heat Stroke

            Heat Stroke, by comparison, is a life-threatening emergency. Common in the very old and the very young, Heat Stroke is differentiated from heat exhaustion by hyperthermia – a body temperature greater than 104^oF. If your character is suffering from Heat Stroke, they will have hot, dry skin and may, paradoxically, be shivering. They may seem confused tired, or delirious, and may have jerky or stilted movements. If untreated, Heat Stroke can lead to seizures and collapse the of cardiovascular system.

While heat stroke victims generally don’t sweat, it is possible for your character to sweat profusely and still have heat stroke, assuming they fit the other criteria. The uncertainty of the diagnosis–especially if your characters don’t have a rectal thermometer handy–can add some serious tension. Remember; misdiagnosis can be fatal.

            The first step in treatment for heat stroke is to bring down the victim’s body temperature, fast. This includes cooling with water sprays, fans, ice packs in the groin and armpits, even cool IV fluids. Cold-water baths (and especially ice baths) are not recommended unless someone who knows what they’re doing is monitoring the victim’s rectal body temperature very closely. Cooling too fast can be just as dangerous as the heat stroke itself.

Victims of heat stroke need to be taken to a hospital, where they will be safely cooled, rehydrated, and stabilized. They’ll also be given muscle relaxants and anti-seizure medications, and monitored closely for signs of organ dysfunction.        

Disclaimer: This article is NOT meant as medical advice. It is solely for the purpose of helping writers write about medicine, and is not a substitute for medical care or advice. Please don’t sue me.

Great question! Luckily for you, the answer is pretty much that you get to decide. People with a mild allergy might get nothing more than redness and swelling around the site of the sting. A moderate reaction – called a large local reaction (LLR) – would result in swelling, itchiness, and redness that extends beyond the site of the sting. For example, if your character was stung on the finger, their whole hand might swell up, and they might not be able to remove their rings. And while this reaction might look intimidating, it is not life-threatening. The third and most severe reaction is anaphylaxis.   

Anaphylaxis is the most serious form of allergy – a whole-body reaction that occurs seconds to minutes after exposure. It usually starts with skin symptoms – a rash or hives – but can quickly progress to breathing problems, dangerously low blood pressure, and sometimes abdominal symptoms, such as nausea and vomiting. Severe anaphylaxis can lead to asphyxiation and death.

Signs of Anaphylaxis

• Swollen face, especially noticeable around the lips and eyes
• Tongue and throat swelling
• Trouble breathing
• Fast heart rate
• Hives (red, raised, itchy rash)
• Nausea/vomiting à especially in food allergies
• Weak, thready pulse (anaphylactic shock)

It’s important to note that there are levels of severity of anaphylactic reactions as well. If there are hives all over your character’s body, it is still an anaphylactic reaction, even if their airway isn’t affected. Your character might only notice a slight swelling in their lips or eyes, or they might feel their airway closing off, but would still have plenty of time to call an ambulance or have someone drive them to the hospital for treatment. However, in a severe anaphylactic reaction, the airway can swell shut in minutes. If untreated, your character could die of asphyxiation in as little as 15 minutes

Don’t let your character drive themselves to the hospital unless you want to add a car crash to their list of injuries.

If your character’s last reaction to a bee sting was hives only, it would still be realistic for this reaction to include airway swelling. Allergies can worsen with subsequent exposures. On the other hand, if your character is elderly, they may have less of a reaction than they did when they were a child. Allergies evolve over time, and your character’s allergies can improve or worsen depending on the needs of your story.    

Let’s finish up by talking about treatment of anaphylaxis.       

Treatment of Anaphylaxis

The immediate treatment of anaphylaxis is with epinephrine. People who know they are at risk of an anaphylactic reaction are supposed to carry an EpiPen – an autoinjector filled with epinephrine that looks a bit like a chubby yellow glue stick – with them at all times. But realistically, that doesn’t always happen. EpiPens are expensive, they can expire, and–though small and portable–are too big to fit in most wallets. It is all too easy for your character to leave their EpiPen sitting forgotten in an unused purse or drawer, especially if their last anaphylactic reaction was just hives. But for someone with a serious anaphylactic reaction, not having an EpiPen available could be the difference between life and death.    

The cost of epi-pens rose over 400% between 2007 and 2016, and now can cost over $500. Why? Because the manufacturer had a monopoly and they could.  

Epinephrine has lots of side effects – it constricts the blood vessels and makes the heart beat faster and stronger. It can cause a heart attack, so if your character uses their epi-pen, they’re still going to need a trip to the hospital, even if they’re feeling better.

The Takeaway

It’s up to you! Since people with bee allergies (all allergies, really) can exhibit a wide range of reactions, you can choose the severity that works for you.

More Resources

• Mayo Clinic
• Healthline

Q: What does chemo/radiation feel like? My character has colorectal cancer.

Last week, we tackled the chemotherapy end of this question. This week, let’s take a deeper look at radiation therapy.

Part 2: Radiation Therapy

The short answer is that radiation doesn’t feel like anything. We experience radiation every day from the sun, space, the earth, even the air. The amount of radiation you’d get from an X-ray is about the same as flying across the country in an airplane. Even a CT scan, or ‘CAT-scan’, which blasts your body with as much as 500 times that of a normal chest X-ray, doesn’t feel like anything¹.

But targeted radiation, used alone or in conjunction with chemotherapy to treat cancer, is given in much higher doses. At these higher doses, your character will start to get side effects. But first, let’s give some background.

Radiation

Radiation kills cells by damaging their DNA, making it impossible to continue dividing. Like with chemotherapy, rapidly dividing cells–such as cancer cells–are the most heavily affected. But since all cells need their DNA, all cells can be affected.

Radiation dosage is given in units called Grays (Gy). One Gray is the amount of energy absorbed by a set amount of tissue (1gray = 1joule/kg)². A chest X-ray administers about 0.1milligrays (0.1mGy or 0.001 Gy). A chest CT delivers around 6 mGy. Someone getting radiation therapy for breast cancer could get as much as 60Gy over several serial sessions³: that is the equivalent of 600,000 chest X-rays! It’s important to note that this absurdly high dose is targeted to a very small part of the body, and is given over multiple sessions. The lethal dose–aka the dose at which 50% of the population would die–of whole-body irradiation is only about 5Gy⁴.

Radiation Therapy

Not every cancer is treated with radiation therapy. Colon cancer is an example of a type of cancer that is rarely treated with radiation, because it usually responds well to chemotherapy and surgery alone. In contrast, larynx and prostate cancer, are often treated with radiation alone–no chemotherapy, no surgery. However, many other cancers, like breast, lung, and rectal cancer, use a combination of chemotherapy, surgery and radiation therapy.  If radiation is used in conjunction, it is called “adjuvant radiation.”

Radiation can also be used as a palliative tool to shrink a tumor that can’t be excised surgically. This helps your character feel more comfortable, even though there’s no longer hope of a cure. If your character has colon cancer, this is the type of radiation therapy they would likely receive.

Types of Radiation Therapy

There are two main types of radiation: external beam and internal⁵.

External beam radiation comes from a loud, noisy machine that whirs and clacks–but will never touch your character. It’s targeted to the specific area of the body where the tumor is, such as the breast, prostate, lungs, or thyroid. If your character gets external beam radiation they do not become radioactive, and so have no limits on visitation. In fact, your character might even get to go home between treatments.  

Internal radiation is when something radioactive is placed in your character’s body. It can be localized–a little capsule or ribbon surgically placed near the tumor – or systemic, if your character swallows or is given an IV with radioactive materials. If your character received systemic radiation, their bodily fluids – sweat, urine, saliva, even semen–will be radioactive. Anyone visiting someone with internal radiation will need to stay at least 6 feet away and limit visiting time to less than 30 minutes per day. Kids under 18 and pregnant women can’t visit at all.    

All right, now I can actually start to answer your question. Let’s start with what it feels like to get the radiation.

The Process 

Getting radiated is time-consuming. In order to get up to that 60Gy dose by external beam radiation, your character will need to receive radiation treatment every day (sometimes twice a day), five days a week, for five to eight weeks³. The doctor in charge of your character’s radiation therapy is called a radiation oncologist. They’ll work with your character’s primary oncologist, as well as radiation oncology nurses, dosimetrists – who help calculate the appropriate dose of radiation – and technicians to develop and carry out your character’s treatment plan.

On the day of, your character will be very carefully positioned so that the radiation hits the exact right place–which will be marked with pen on their skin. Then, lead blocks or shields will be placed to protect the rest of their body from the radiation. Once in place, the actual irradiation only takes about 10-30 min. Even with the high dose, your character won’t be able to feel the radiation at all, just some discomfort from the positioning, and possibly some skin redness and tenderness⁶. This may become more prominent as the radiation treatments continue.

Side Effects

Because radiation therapy is a targeted treatment, there are very few whole-body or long-term side effects. Your character may feel some fatigue, especially if they’re also getting chemotherapy. They also might develop skin redness, tenderness, and even blistering around the site. Other than that, all of the side effects of radiation depend on the location being radiated. Here’s a list⁷.  

• Head and neck
  • Fatigue
  • Headache
  • Blurry vision
  • Hair loss
  • Dry mouth
  • Trouble swallowing
  • Cavities or loose teeth.
  • Mouth sores
• Chest/Breast
  • Swelling/tenderness
  • Trouble swallowing
  • Shoulder stiffness
  • Nipple soreness
• Abdomen
  • Appetite loss
  • Nausea/vomiting
  • Diarrhea
• Pelvis
  • Diarrhea or bleeding from the rectum
  • Menopause-like symptoms
  • Infertility or decreased fertility
  • Sexual dysfunction
    • Erectile dysfunction
    • Vaginal dryness
    • Decreased libido
  • Inability to control urination (urinary incontinence), or bladder irritation

Most of these symptoms are not dangerous and will go away once the radiation treatment is complete. One exception is called radiation pneumonitis, a cough and fever that occurs up to six months after radiation treatment to the chest, and can leave scar tissue in the lungs.

It’s important to note that if your character is also receiving chemotherapy, or if they recently had surgery, they will simultaneously be struggling with those side effects. Don’t forget to look at last week’s post to see what chemotherapy might feel like!

Drop a comment if you have any questions or suggestions!

Sources  

1. https://www.npr.org/templates/story/story.php?storyId=121436092#:~:text=It’s%20often%20said%20that%20the,comparable%20to%20500%20transcontinental%20flights.&text=That%20means%20many%20unsuspecting%20patients,for%20an%20adequate%20CT%20image.
2. https://www.translatorscafe.com/unit-converter/en-US/radiation-absorbed-dose/7-24/gray-sievert/
3. https://www.news-medical.net/health/Radiation-Therapy-Dosage.aspx
4. https://www.nrc.gov/reading-rm/basic-ref/glossary/lethal-dose-ld.html
5. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/radiation-therapy/understanding-radiation-therapy
6. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/radiation-therapy/side-effects-radiation-therapy
7. https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/side-effects
8. https://news.cancerconnect.com/colon-cancer/radiation-therapy-for-colon-cancer-5GTWcdWchkay9ZKQbg9V6g

What does chemo/radiation feel like?

What a great – and difficult – question, thanks for asking! I bet there are a lot of writers out there who are wondering the exact same thing.

I’ll start out with a disclaimer: I’ve never had chemotherapy or radiation myself, so I can’t speak personally to how it feels. For that, I will direct you to some of the discussion boards, such as the American Cancer Society’s Cancer survivor’s network or the Cancer Council Online Community.

The second important aspect is that not all chemotherapy or radiation treatments are equivalent. The side effects of radiation for thyroid cancer will be very different than radiation of prostate cancer, which will turn be very different from a chemotherapy medication given for Leukemia. Since chemo/radiation is such a big field, I am going to start with chemotherapy. Next week, I’ll dig into radiation. For now, let’s dive in!

Part 1: Chemotherapy

Chemotherapy is a drug treatment that targets – and kills – fast-growing cells, such as cancer cells. Unfortunately, hair, skin, blood cells, and the cells lining your airways and gastrointestinal tract (mouth, esophagus, stomach, intestines) – called mucosal cells – are also fast-growing, and can be inadvertently targeted. This can lead to a host of side effects, including hair loss, mouth sores, nausea/vomiting, bleeding/easy bruising, light sensitivity, and constipation or diarrhea. Whole body symptoms, such as fatigue, weight loss, and pain, are also common.   

Folfox

Since your character has colorectal cancer, let’s dig into the specifics of a chemotherapy treatment often used to treat colon cancer: Folfox (Folinic Acid + 5-Fluorouracil + Oxaliplatin). This isn’t the only treatment for colon cancer, but it is used very commonly. It can be used alone, or in combination with radiation therapy.    

To receive treatment with Folfox, your character will first need to be hospitalized and given IV access – this can mean an IV in the arm (though this is rare), a central line (intravenous line connected to a vein in their chest), or a PICC line (a tube inserted in a vein in the arm, then threaded into a bigger vein in the chest). Your character will be pre-medicated – given meds to prevent nausea and other side effects – then be hooked up to the infusion. The infusion is a clear plastic bag filled with clear liquid, hooked up to a pump that looks like a miniature computer from the ‘90s. It will then drip into your characters’ IV site over the course of about 2 days. Your character might get a metallic tang in their mouth from the infusion, but if they get pain at the IV site, the nurses will need to slow down the rate of infusion. If your character already has a central line and has done well with Folfox in the past, they might even be able to take the infusion home with them, carrying around their IV bag and pump attached to their belt.

The infusion pump sometimes makes a grinding noise, like a CD-changer or a car shifting gears. Cancer patients have reported having Pavlovian responses – salivation or nausea – after hearing those noises even well after they’re finished their course of treatment¹.  

Side Effects

The most common immediate side effects are nausea/vomiting, diarrhea, skin sensitivity to light (easy sunburning), watery eyes, mouth sores, and a metallic taste in the mouth. Sometimes, they may have pain at the infusion site. These side effects can start with the first infusion, so steps are taken to prevent them, including premedication with anti-nausea drugs. Mouth sores can be prevented if your character chews on ice; however, cold food or drinks can exacerbate another side effect, throat spasm. A less common side effect is skin reddening and peeling, especially on the palms of the hands and the soles of the feet, called hand-foot syndrome.

Another common side effect is myelosuppression – the bone marrow can’t produce blood cells fast enough. Blood cells die at a constant rate, so your character’s bone marrow is always making more. If the bone marrow can’t make new cells fast enough, your character will develop low counts of white blood cells, red blood cells, and platelets. Your character might feel breathless and/or fatigued (which can be significant), but the biggest concern is that they will also be at higher risk for infection, bleeding, and bruising.

Severe reactions are less common, but they do happen. An allergic reaction – causing rash, itching, and even trouble breathing – is a good reason for your character to stop chemotherapy. Rarely, chemotherapy regimens – including Folfox – can cause lung and heart symptoms, such as cough/wheezing, chest pain/tightness, or changes to the heart’s rhythm. These are serious side effects, and you should only give them to your character if you’re looking for a reason for them to get really sick or need to be taken off the chemotherapy.  

One side effect that isn’t on that list is hair loss. Though Folfox can cause hair thinning, it doesn’t cause hair to fall out the way other chemotherapy drugs do. And if your character is on a drug that does cause their hair to fall out, remember – it’s not just the hair on their head that goes. Most docs can tell a cancer patient not because of their bald head, but because of their lack of eyebrows and eyelashes.  

Folfox is administered every two weeks for a minimum of six months – more if your character had metastases or other high-risk features. At the end of the course of treatment, some infusion facilities have your character ring a bell, so that everyone knows they’ve finished their course. How would your character react to being made to ring a bell announcing to the world that they’ve finished their chemotherapy?

Long-Term Effects

Of course, there are long-term effects of chemotherapy. In the first year after treatment with chemotherapy, fatigue is the #1 complaint². Fatigue can be severe, impacting your character’s ability to live their life as they wish, and it doesn’t improve with sleep. For some, fatigue improves quickly, but others – especially those who have received bone marrow transplants – may suffer for years.

Pain is long-term side effect, as some chemotherapies can target the nerves. This causes a ‘peripheral neuropathy’ – aka nerve pain and loss of sensitivity – that can be difficult to treat. Nerve pain feels different than other types of pain; it is often described as tingling or burning and is especially frustrating because there is nothing visibly wrong. It most likely to be felt in the fingers and toes at first, though it can work its way upwards.

Weight changes can also be a long-term side effect of chemotherapy. Certain kinds of chemotherapy can lead to dry mouth, mouth sores, or loss/change of taste that can make your character reticent to eat. While these changes tend to be worst during the course of treatment, they can linger, leading to long-term weight loss.  Surprisingly, weight gain can also be a problem, especially if your character had certain kinds of chemotherapies for breast cancer.

Summary

• Chemotherapy drugs interfere with cell replication, killing off fast-growing cancer cells. Other fast-growing cells, such as hair, blood cells, and mucosa become collateral damage. The breakdown of these non-cancerous cells is what causes all the side effects.
• Generally, chemotherapy results in a host of nasty side effects, including nausea/vomiting, diarrhea, hair loss, immune suppression (due to low white blood cells) and anemia (low red blood cells), mouth sores, dry mouth, fatigue, weight loss, and nerve pain.
• Not all chemotherapy drugs have the same mechanism, and so each drug will have slightly different side effects
• Folfox is a chemotherapy used to treat colon cancer. It can be used as monotherapy, or in combination with radiation.
• Allergic reactions, chest pain, and difficulty breathing are severe reactions that might be enough for your character to need to stop their chemotherapy.

Whew. All right, so that is chemotherapy. Next week, I’ll tackle radiation. Feel free to drop a comment if you have any questions/suggestions!  

Sources

1. https://voice.ons.org/news-and-views/outpatient-oncology-drug-series-confidently-administer-5-fluorouracil#:~:text=Finally%2C%20you%20will%20hook%20up,as%20directed%20per%20the%20orders.
2. https://www.dana-farber.org/for-patients-and-families/for-survivors/caring-for-yourself-after-cancer/your-body-after-treatment/
3. https://www.macmillan.org.uk/cancer-information-and-support/treatments-and-drugs/folfox

The Question

What condition could lead to a baby being born without a full limb? Is it a question of genetics in the parents (one or both) or a condition in the womb? My character has a son whose arm ends a few inches past the elbow. He is seven at the start of the novel and can manipulate many objects deftly although obviously cannot do activities that require two hands. I want to explain to the reader since this condition affects much in his mother’s life.

The Answer

Great question, thanks for sending it!

Amelia and phocomelia are congenital conditions, meaning they are present at birth. In Latin, “a” means ‘without’, and “melos” means ‘limb’, so the name literally means “without limb.”  Phocomelia is the term used for limbs that are shortened. The Latin meaning of the prefix “phoco” is ‘seal,’ so phocomelia technically means ‘seal limbs’ but I don’t think anyone would appreciate it being called that.

 Amelia or phocomelia can affect any number of limbs and can range in severity from the loss of a single finger to the total absence of a limb. Tetra-amelia syndrome, the total loss of all four limbs, is quite rare. Amelia and phocomelia can be caused by several different factors.

The first is exposure to thalidomide. Back in the 1950s and 1960s, thalidomide was a drug used to treat nausea in pregnancy. Turns out, it was a teratogen that resulted in a host of birth defects, including severe phocomelia. It’s since been blacklisted as a drug to use during pregnancy, though it is still used to treat leprosy and some cancers.  

Another cause is a genetic syndrome. There is a cluster of rare genetic disorders associated with amelia and phocomelia. One, called Roberts Syndrome, is an autosomal recessive disorder, meaning that both parents must pass down an altered copy of the gene for the child to show symptoms. This means that at least one grandparent on each side had the gene as well. Tetra-amelia syndrome is another rare autosomal recessive condition that causes the total loss of all four limbs due to a defect in the WNT3 gene. Another genetic syndrome, called Cornelia de Lange Syndrome (CDLS for short), can be caused by a constellation of different genetic anomalies. Some of the genes for CDLS are inherited, like Roberts Syndrome, but some are sporadic, meaning that the gene mutation occurred during embryonic development.  

This leads me to the last, and murkiest, cause of phocomelia: random factors affecting early pregnancy. This can include drug and alcohol use (especially during early pregnancy), gestational diabetes, radiation (usually requiring a higher level than your regular chest X-ray), viral infections, decreased blood flow to the placenta, or even tight amniotic bands wrapped around the fetus’s limb, preventing its growth. Most of the time, doctors aren’t able to pinpoint a single reason.

Since your character has unilateral phocomelia (a single arm ending just below the elbow) and no other genetic anomalies (and wasn’t born in the ’50s or ’60s), he most likely falls somewhere in that third category. Not a very satisfying answer, but – like so many things in medicine (and especially pregnancy!) – that’s all we know for sure.

If you want to read more, here are a couple of great articles from Healthline, the National Organization for Rare Disorders, and the Dana Ferber Cancer Institute.