Write On: A Doctor’s Notes from the ER

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Today, we are lucky to have Dr. Brian Cohn, M.D., here with us at Write On. Dr. Cohn is an emergency physician and also an accomplished author whose first novel, The Last Detective, is coming out later this year. Today he is answering our questions about the intersection between medical expertise and fiction.

All of our mystery/horror/noir readers out there, read on. Dr. Cohn has much to share!


 1. Can you tell us a little bit about your professional background and areas of specialty?

I’ve been an emergency physician for the last 9 years (following 4 years of emergency medicine residency).  I trained and currently work in a large, level one trauma center in St. Louis, Missouri, which means I take care of lots of gunshot wounds, car crashes, and otherwise sick people.  It’s not as exciting as TV makes it out to be, but I never know what’s coming next, so it definitely keeps me on my toes.

2. As the author of the soon-to-be-released sci-fi mystery The Last Detective, how do you feel your training as a medical doctor benefits you in your writing?

The benefits definitely aren’t huge, but I’ve certainly used my experiences to guide my writing somewhat.  My debut novel starts with a dead body, and while the body is an alien (and hence well outside my area of expertise), I was still able to use my experience with gunshot wounds to add a little realism to the scene.  My second novel, which should be under contract soon, actually used my medical knowledge to a greater extent.  The protagonist and narrator is a young man with schizophrenia.  I’ve taken care of literally dozens people with schizophrenia with varying degrees of psychosis, and while it is an awful, destructive disease that robs people of their lives, it’s also quite interesting to see what the human brain is capable of when it goes haywire.  There are several scenes in the ER, and even a subplot involving heroin and fentanyl overdoses, which we see lots of at our institution.

3. If you had to condense your professional training and experience as a healer of the sick and wounded into 1 piece of wisdom, what would it be?

It doesn’t matter how good your doctors are or how strong the medicine is, if you don’t take care of yourself, you’re pretty much screwed.

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Now onto a few more specific tips for writers. . .

4. For all of the mystery/noir/horror writers out there, what are some tips for describing the body’s physical response to intense pain?

Pain is such a highly variable thing.  I’ve seen people with parts of their bodies practically ripped off who can sit and calmly answer questions.  On the other hand, I’ve seen people with stubbed toes who cry and scream because the pain’s so severe.  So the response depends on a lot of things.  For most people, there will be what’s called a sympathetic response (the whole fight or flight thing): this leads to a rise in heart rate and blood pressure, pupillary dilatation, dry mouth.  Many will become nauseated and in some cases will have associated vomiting.  Beyond that, a lot depends on the cause of the pain and the person.

5. What about how to describe the experience of becoming unconscious?

I don’t have much in the way of personal experience (unless you consider my weekends in college, but I don’t remember those incidents very well).  Again, it depends a lot on the cause.  For what’s called vasovagal syncope (which is what happens when people pass out due to emotional stress), people describe feeling very hot and flushed all of a sudden (due to dilation of blood vessels in the skin), then feel lightheaded and notice their vision going dim (due to loss of blood flow to the brain).  Then they pass out and wake up on the floor.  Blacking out due to head trauma is usually sudden, and most people don’t remember anything at all (i.e., they just wake up in the ambulance or in the ER).

6. Many writers need to describe specific injuries or wounds–can you make some basic recommendations for how to accurately describe the following:

Gunshot wounds

This depends on the type of gun involved.  Wounds involving the military are from high velocity bullets, and very different from the typical wound we see in our ER.  I’m not as familiar with these, so I won’t comment.  Wounds from low velocity bullets (i.e., 9 mm, 22’s, etc.) are surprisingly innocuous appearing.  Entrance and exit wounds are typically just small holes, like somebody poked the skin with a small spike.  It’s also often very hard to tell entrance and exit wounds apart in most cases (despite what you may read) unless high caliber bullets are involved (like a 0.45 or 0.357), which mostly isn’t the case.  Point-blank wounds are different (i.e., when the gun is pressed up against the skin).  These usually leave what’s called stippling around the wound, which is basically the skin getting tattooed with debris from the muzzle.

Stabbing wounds

These are highly variable, depending on the weapon used.  Most of what we see are kitchen knives and pocket knives, and basically leave a linear wound in the skin that is often gaping underneath.  Slash wounds are of course going to be longer, and can be surprisingly deep.

Signs of blunt force trauma

These can be surprisingly benign appearing.  I’ve seen people with major organ injury from car crashes who had no bruising on the skin whatsoever.  At the same time, I’ve seen people with lots of bruising who turn out to have not been injured more deeply.  Surface area probably has a lot to do with this.

Signs of strangulation

In cases of strangulation, there’s often a lot of bruising around the neck (linear in the case of ligature strangulation, splotchy in the case of manual strangulation).  You can also see the effects of increased pressure in blood vessels of the face due to lack of venous drainage during the strangulation process (vascular congestion).  This can lead to splotchy red spots called petechiae in the skin and subconjunctival hemorrhages in the eyes (i.e., little red spots overlying the whites).

7. What are some common medical mistakes you’ve come across as a reader that writers should strive to avoid?

I have two major pet peeves in fiction when it comes to medical issues.  The first is that nosebleeds are a sign of brain tumors.  I bitch about this a lot when I see it on TV or read it in books.  Brain tumors (with very rare exceptions) do NOT cause nose bleeds.  The second is that people shot or stabbed in the abdomen will immediately have blood come out of their mouths.  This makes absolutely no sense.  In rare cases where the wound involves the stomach and there is bleeding into the stomach itself, people can vomit blood (but this takes time). Again, this is very rare.  Almost no one with penetrating abdominal wounds will have any blood come out of their mouths at any point.

8. Are there any approachable references you’d recommend for writers who will need to research medical information/procedures for their writing?

There are several good online references, many of which require paid subscriptions.  I would avoid WebMD, but there are other free references that are pretty good (such as emedicine.com).  For procedures, you can google just about anything and find videos put out by actual physicians.  These are often meant to teach medical students and residents, but will provide a very realistic demonstration for anyone writing about such a procedure.

9. In your own reading, who stands out as an author who handles the medical aspects of writing expertly?

For me, the best writers don’t worry too much about the medical details, focusing instead on general concepts and the impact of a situation on the story.  Stephen King does this very well.  Most mystery writers have to provide at least some medical detail, but again the best ones keep it to a minimum and focus on the story instead.

10. One out of just pure curiosity: What’s the coolest case you’ve worked on as a medical doctor?  

This is one of the most common questions I get as an emergency physician.  It’s also one of the hardest to answer.  My idea of cool or interesting or neat is skewed by what I see every day.  The trauma can still be shocking (when limbs are missing for example), but that isn’t what I consider “cool.”  I once saw a guy with schizophrenia who had pulled his own eyeballs out with his fingers, which was more sad than anything.  He was still very much awake, with a bandage wrapped around his empty sockets, and every time he screamed the blood stains on the bandage would get bigger.

One of the cooler cases I had was a kid who wanted to spiritually cleanse his body, so he bought something online called Iboga root.  It’s a psychedelic substance from Central America, very much illegal on the US.  He knew it could be dangerous, so he got his mother to drive him to the hospital, then ate the piece of root in the parking lot before checking in so he could “be monitored through the experience.”  He became quite ill and had a heart arrhythmia called ventricular tachycardia that is potentially life-threatening.  Again, my idea of cool, but maybe not everybody else’s.

Write On: Adoption Facts in Fiction

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Today, we are lucky to feature my colleague and friend, Dr. Jennifer Crissman-Ishler, who is a Senior Instructor in Human Development and Family Studies at Penn State and a resident expert on the adoption process and adoptive families. Dr. Crissman-Ishler is a trained counselor and also an adoptive parent herself. She teaches HDFS 453, which examines the complex process and dynamics of adoption across the adoptive triad of birth parents – child – adoptive parents,  and is one of the most sought-after courses in our department.

We asked Dr. Crissman-Ishler for her advice for authors writing about adoption, adoptive families, and characters experiencing adoption, and are so thankful for her willingness to share her knowledge with our readership. . .

  1. What do you feel are some of the common misconceptions about adoption that you encounter in fiction and/or the media?
  • The birth mother is a single mom who is a young teenager – but the reality is that birth moms are all ages and of different marital status (single, married, etc). And in the past several years, the economy has created situations where many woman cannot afford to parent their child.
  • The birth mom (or birth parents) will come back and try to remove the child from his/her adoptive family after the adoption has been completed.
  • Adoptees are “messed up”, weren’t wanted, and/or will not be able to form meaningful relationships when they become adults.
  • If couples can’t have a biological child, they should “just adopt” (totally ignores the grieving process that adoptive parents need to experience)
  1. How can writers make sure to avoid these cliches or misconceptions in their work?
  • Become educated on the facts and realities of adoption; don’t just base your stories on what you see on TV; talk to members of the triad (adoptive parents, birth parents, adoptees) for their perspective; become aware of the 5 core issues surrounding adoption (loss, grief, identity, rejection, guilt/shame) that impact all triad members
  1. Adoption is multifaceted, and includes domestic, international, and foster care adoption. Can you provide a bit of a primer about each of these processes for our readers?
  • Domestic – any adoption between adoptive parents and adoptive child that takes place within the same country; so adoptive parents and adoptee both live in the United States, for example. For a domestic adoption that is taking place in two states (adoptive parents live in one state and the child is born or living in a different state), all parties must follow the ICPC (Interstate Compact on the Placement of Children), which means before an adoption can be completed, the rules/regulations/laws of BOTH states must be followed.
  • International – child is born and living in one country and adoptive parents are living in a different country; must follow the laws of 3 bureaucratic systems (the state in which the parents live, the country in which the parents live, and the country in which the child is residing). The central location and authority in the US that oversees International Adoption is the Department of State.  Must also work with INS (Immigration and Naturalization Services) to have child obtain Visa (I-600 and I-600A Visa Petitions)
  • Foster Care – children who have been placed in the State’s or County’s legal custody because their birth parents were deemed abusive, neglectful, or otherwise unable to care for them; goal is to place them with parents who are fostering to adopt; foster parents must go through intensive training and background checks before they can become foster parents; birth parents must have their parental rights terminated (TPR) before children can be legally adopted by others
  1. As a professional with expertise in adoption and as an adoptive parent yourself, what important lessons have you taken away about adopted children and adoptive families?
  • No two adoptive families are the same – each family will have different experiences with their adoption experience – celebrate your own unique experience
  • Find support – participate in adoption support groups; join on-line communities; befriend other adoptive families; there will be issues that adoptive families must deal with that biologically created families will not have to, so it helps to have support ready to go and in place
  • As an adoptive family, be sure to communicate – talk openly, freely, ask and answer questions; make adoption something to be proud of or “normalized”; don’t hide it
  • Being an adoptive parent is like a biological parent – there is no handbook, there is no manual. You just do the best job you can do!

  1. Are there any examples of adoption in literature that you feel represent the experience well and that authors could use as a benchmark for their own writing?
  • Todd Parr is a wonderful children’s author who does a great job writing about different families and how it is okay to be different and there are many different ways to make a family
  • For adults, Mamalita by Jessica O’Dwyer is a great book for adoptive parents
  • http://www.umass.edu/ruddchair/ (Their adoption research program is a great place for the most current and up-to-date research)
  1. Many writers examine the inner workings of their characters when writing a novel or story. If they are writing about a character who is adopted, can you identify any commonalities adopted individuals encounter during their journey through life that would be important to contemplate as an author?
  • The core issue of identity is part of anyone’s lifespan development, but it takes on a more significant role for the adoptee (Who am I? Where did I come from?  Who do I look like?  What personality traits do I share with my biological family?  Do I have siblings?)
  • Core issue of loss – losing one’s biological family (and perhaps culture, language and country); a lack of knowledge of one’s medical history, etc.
  • Grief – realizing as they age, what they have lost (for children adoptive when they are older, it could be more severe as they have memories of their families, language, culture, home, friends, school, etc.)
  1. What can you tell our readers about the differences and/or similarities experienced by children who are adopted as infants vs. those who are adopted later on in childhood or adolescence?
  • All adopted children will still experience 5 core issues in their life, just at different times or in different degrees
  • Some pros and cons to consider, though, depend on the needs of the adoptive parents…
    • Pros of adopting an older child
      • Shorter wait to adopt
      • Older children will know their birth parents/family/history (which can help with identity and grief issues)
    • Cons of adopting older child
      • Attachment bonds may take longer to form
      • Educational needs – child may need to “catch up” in school because they are behind
  1. Open adoption, where birth parents remain in a child’s life after adoption, seems to be increasing in our country–what are your thoughts about this approach?
  • Again, my thoughts are simply my own. This is a highly personalized decision and no two families will have the same reasons for how they create their families.  From a historical perspective, adoption began in our country as a closed process and it was only in the 1970s that adoption became more open.  And now, states like PA require some degree of “openness” to be part of a domestic adoption or it cannot be finalized.
  • Some advantages of an open adoption are: 1) children have a sense of where they came from; 2) they have access to important medical information and medical history; 3) they can ask questions as to why they were placed.
  • For birth parents, an open adoption gives them some control – they are making the adoption plan for their child; they can answer questions that an adoptee may have; and they are not left wondering through the years if their child is doing okay or not.  I think the only “right” answer in terms of open adoption is what every member of the triad feels comfortable with.
  1. Can you recommend any references for authors who want to include adoption as part of their novel’s or story’s narrative?
  1. If any of our readers are considering adoption for their own family, what recommendations would you have for them? What do you wish you knew before you became a parent through adoption?
  • Do your homework (interview adoption agencies and lawyers to make sure the fit is right and they know what they are doing; and that they are reputable!)
  • If doing an international adoption, check the State Dept.’s website to make sure that “your” country is not in jeopardy of closing and that your agency is Hague Compliant
  • Talk to other families who have gone through the process to see what worked and didn’t work for them (and to also start building connections and support)
  1. Ok, one more: What’s your favorite memory from your own experience with adoption (if you don’t mind sharing!)?
  • Don’t mind sharing – you know me – I love to talk about adoption and how we created our family!!! It’s hard to pick just one favorite memory.  However, one “favorite” memory would have to be Oct. 9, 2005, our “Gotcha Day” in Guatemala. Our foster mom and lawyer had just left our hotel room and it was just Matt, Emily and me.  Matt and I were looking at each other and looking at her and looking back to each other.  We kept passing the baby back and forth to hold her and saying, “Oh my gosh, we are really parents!  We are a family!  We have a baby!  Oh my gosh, NOW what do we do???”  Just that feeling of holding her, feeling her little finger wrap around my finger, her eyes gazing soulfully into my eyes and then smiling was priceless.  It was in that moment, holding her for the first time, looking into her eyes, feeling pure love that I knew it didn’t matter how I became a mom, all that mattered was that I finally was a mom and it felt so right.

Thank you so much for sharing, Jen–it has been an Education and an Inspiration!