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: The Importance of Being Ernest

Today I will be picking the brain of my friend and colleague, Francis Sparks, author of the forthcoming hard-boiled and page-turning detective novel, Made Safe (I was a lucky beta-reader for Francis–I know, I’m lucky), and resident Hemingway expert. Given my love for Papa, I was thrilled that Francis agreed to let me into his world of concision, deep-water fishing, and real-ness.

Portrait of the artist as a young man. . .

1. First off, what draws you into Hemingway’s writing and life?


There are many things that draw me to Hemingway. The first time I really read Hemingway I was working in the library at college. I stumbled across his section of books and started reading The Sun Also Rises. Clean declarative prose. Interesting and complex relationships. Action. I think effective writers have the ability to bust open their guts and show everyone what is making them hurt and he was able to do that over and over.

2. What’s your knock-down, drag-out, most favorite line Hemingway ever wrote.


That is a tough one. I think I’m in awe with the way he ends his books. The Sun Also Rises has a great line toward the end.

“Yes,” I said. “Isn’t it pretty to think so?”

SPOILERS ON A 100 YEAR OLD BOOK: It is one line that I remember and think about every once in awhile. The set up to this line and the line itself I think are Ernest Hemingway explaining his view of the damaged psyche of his generation. The men and women having endured WWI and its atrocities are damaged either physically or emotionally or both. The speaker in this line is Jake Barnes a WWI veteran who was injured during that terrible war leaving him eviscerated. The entire narrative of the book follows the ‘Lost Generation’ exploits of Brett as she tries on and discards one male suitor after another all with Jake at her side and sometimes facilitating her engagements with the other men. Jake and Brett both think they are perfect for each other but have this physical limit between them due to Jake’s war injury. Would they be together if not for the war? I don’t think so. There are Lost Generation type of things we could talk about and the expat culture but in the end, I think Brett likes Jake because he’s safe. He’ll never ask of her too much. I think possibly Jake really does love her but maybe not. Maybe he is using her just as much to fulfill his masculine shortcomings. Either way at the end I think Jake has come to terms to some degree with his life and we have caught him at a sad reflective moment where he is ready to move on. Damn Hemingway and all of his great one-liners! I love him to death.

3. Which book of his did you like least, and why?


The book I liked least of all of Hemingway’s works would probably be A Farewell To Arms now that you mention it. It is one that I have not re-read. I am sure I should go back and give it another chance.

4. Which book of his did you like most, and why?


This is a tough one but I think I always say The Sun Also Rises. It is just a fantastic work. A close second would be For Whom The Bell Tolls and who could forget The Old Man and the Sea? The Sun Also Rises is the one for me because of the way Hemingway was able to brilliantly weave the symbolism of the pamplona bull fights and running of the bulls and all the many other metaphors into his story telling about damaged people left over from WWI. Here is a great article I just read about the origins of the book.

5. For all of our readers who perhaps despised having to read A Farewell to Arms in high school, convince them why they should go back and try Hemingway again.


The Old Man and the Sea was 27,000 words and won a Pulitzer. If you find yourself struggling to elicit interest in your 200,000-word manuscript, I suggest reading Hemingway. He was a master of economical word use. If you find yourself struggling to write dialogue that sounds authentic, read Hemingway. He is roundly regarded as the master of dialogue. Those are purely suggestions for writers looking to improve their craft — for the reader looking to try Hemingway again I would suggest The Old Man and the Sea which I mentioned is shorter and less of a commitment or any of his short stories which he was also a master of (one of those guys). One last recommendation — those of you who have an interest in absinthe should read For Whom The Bell Tolls. It has one of the most complete descriptions of the complex and ritualized preparation of that drink.

Kind of makes you hate your iPad, huh?

6. Hemingway struggled with many personal demons. What do you think he found in Cuba and the Keys that he didn’t find anywhere else in the world? Or perhaps, he didn’t even find what he was searching for there?


I think Hemingway was always searching out untouched nature. He has been quoted as saying he was proud he had never lived in New York which I think is an illuminating statement. I think maybe Cuba and the Keys reminded him sometimes of his earlier days in Spain. He always had a fondness for Spain. I can’t know if he found what he was looking for but I like to think that he was wise enough to know that ‘it’ isn’t something that you find. I think he used nature and the outdoors as a tool to beat back the demons he had. Some days were better than others.

7. Do you see any connection between his struggle to represent truth in his writing with his own struggles with mental illness and substance use?


I’ve read stories that Hemingway would be out drinking all night but would rise early the next morning and immediately start writing. That might be a myth but I think that writing was the one constant in his life. If not for writing I think he might have tried to be a fisherman but I don’t think he would have lasted long. Why did he kill himself? I think he had a morbid fascination with it after his own father’s suicide. I think the artist and particularly the writer is more susceptible to darkness and despair. I think the women, the drinking, the absinthe and the writing were all forms of self-medication. Fortunately, the end product of his writing is something we can enjoy.

8. If you had one afternoon to spend with Papa, what would you do and what would you ask him?    


If I had one afternoon with Hemingway I think I’d want to go fishing for marlin with him and I would ask him if Anselmo was his grandfather and if he ever forgave his father. He would probably push me overboard.

9. Okay, I’ll give you one freebie: Second favorite line?


The old man was dreaming about the lions. – The Old Man and the Sea


Thank you, Sparks–as ever, it is a pleasure to roam around in your deep thoughts.

Sparks also recommends any Hemingway lovers (or lovers-to-be) check out this interview at the Paris Review.