An Awkward Sheep 🐑

EVERYBODY knows (or should) that you DO. NOT. STOP. in Vidor, Texas. 

It’s best to just run out of gas elsewhere. Whatever you do, black folks, DO NOT STOP IN VIDOR, TEXAS. 

There’s a good chance you’ll get lynched or just come up missing - and I’m not joking.

also do NOT stop in Harrison, Arkansas!!!! (relatively close to OK and MI) a nazi town with a BIG KKK organization.

https://sundown.tougaloo.edu/sundowntowns.php

This website has a clickable map where you can see suspected and confirmed sundown towns by state, as well as information about whether these attitudes are historical or current.

reblog for the link

Readers can’t resist turning pages when characters are facing tough choices. Use these 5 keys to weave moral dilemmas into your stories–and watch your fiction climb to new heights.

#1: Give Your Character Dueling Desires

Before our characters can face difficult moral decisions, we need to give them beliefs that matter: The assassin has his own moral code not to harm women or children, the missionary would rather die than renounce his faith, the father would sacrifice everything to pay the ransom to save his daughter.

A character without an attitude, without a spine, without convictions, is one who will be hard for readers to cheer for and easy for them to forget.

So, to create an intriguing character facing meaningful and difficult choices, give her two equally strong convictions that can be placed in opposition to each other.

For example: A woman wants (1) peace in her home and (2) openness between her and her husband. So, when she begins to suspect that he’s cheating on her, she’ll struggle with trying to decide whether or not to confront him about it. If she only wanted peace she could ignore the problem; if she only wanted openness she would bring it up regardless of the results. But her dueling desires won’t allow her such a simple solution.

That creates tension.

And tension drives a story forward.

So, find two things that your character is dedicated to and then make him choose between them. Look for ways to use his two desires to force him into doing something he doesn’t want to do.

For instance, a Mennonite pastor’s daughter is killed by a drunk driver. When the man is released on a technicality, does the minister forgive him (and what would that even look like?) or does he take justice into his own hands? In this case, his (1) pacifist beliefs are in conflict with his (2) desire for justice. What does he do?

Good question.

Good tension.

Good drama.

Another example: Your protagonist believes (1) that cultures should be allowed to define their own subjective moralities, but also (2) that women should be treated with the same dignity and respect as men. She can’t stand the thought of women being oppressed by the cultures of certain countries, but she also feels it’s wrong to impose her values on someone else. When she is transplanted to one of those countries, then, what does she do?

Construct situations in which your character’s equally strong convictions are in opposition to each other, and you will create occasions for thorny moral choices.

#2: Put Your Character’s Convictions to the Test

We don’t usually think of it this way, but in a very real sense, to bribe someone is to pay him to go against his beliefs; to extort someone is to threaten him unless he goes against them.

For example:

How much would you have to pay the vegan animal rights activist to eat a steak (bribery)? Or, how would you need to threaten her in order to coerce her into doing it (extortion)?

What would it cost to get the loving, dedicated couple to agree never to see each other again (bribery)? Or, how would you need to threaten them to get them to do so (extortion)?

What would you need to pay the pregnant teenage Catholic girl to convince her to have an abortion (bribery)? What threat could you use to get her to do it (extortion)?

Look for ways to bribe and extort your characters. Don’t be easy on them. As writers we sometimes care about our characters so much that we don’t want them to suffer. As a result we might shy away from putting them into difficult situations.

Guess what?

That’s the exact opposite of what needs to happen in order for our fiction to be compelling.

What’s the worst thing you can think of happening to your character, contextually, within this story? Now, challenge yourself—try to think of something else just as bad, and force your character to decide between the two.

Plumb the depths of your character’s convictions by asking, “How far will s/he go to … ?” and “What would it take for … ?”

(1) How far will Frank go to protect the one he loves?

(2) What would it take for him to stand by and watch the one he loves die when he has the power to save her?

(1) How far will Angie go to find freedom?

(2) What would it take for her to choose to be buried alive?

(1) How far will Detective Rodriguez go to pursue justice?

(2) What would it take for him to commit perjury and send an innocent person to death row?

Ask yourself: What does my character believe in? What priorities does she have? What prejudices does she need to overcome? Then, put her convictions to the ultimate test to make her truest desires and priorities come to the surface.

#3: Force Your Character into a Corner

Don’t give him an easy out. Don’t give him any wiggle room. Force him to make a choice, to act. He cannot abstain. Take him through the process of dilemma, choice, action and consequence:

(1) Something that matters must be at stake.

(2) There’s no easy solution, no easy way out.

(3) Your character must make a choice. He must act.

(4) That choice deepens the tension and propels the story forward.

(5) The character must live with the consequences of his decisions and actions.

If there’s an easy solution there’s no true moral dilemma. Don’t make one of the choices “the lesser of two evils”; after all, if one is lesser, it makes the decision easier.

For example, say you’ve taken the suggestion in the first key above and forced your character to choose between honoring equal obligations. He could be caught between loyalty to two parties, or perhaps be torn between his family obligations and his job responsibilities. Now, raise the stakes—his marriage is at risk and so is his job, but he can’t save them both. What does he do?

The more imminent you make the choice and the higher the stakes that decision carries, the sharper the dramatic tension and the greater your readers’ emotional engagement. To achieve this, ask “What if?” and the questions that naturally follow:

What if she knows that being with the man she loves will cause him to lose his career? How much of her lover’s happiness would she be willing to sacrifice to be with him?

What if an attorney finds herself defending someone she knows is guilty? What does she do? What if that person is her best friend?

What if your character has to choose between killing himself or being forced to watch a friend die?

Again, make your character reevaluate his beliefs, question his assumptions and justify his choices. Ask yourself: How is he going to get out of this? What will he have to give up (something precious) or take upon himself (something painful) in the process?

Explore those slippery slopes. Delve into those gray areas. Avoid questions that elicit a yes or no answer, such as: “Is killing the innocent ever justified?” Instead, frame the question in a way that forces you to take things deeper: “When is killing the innocent justified?” Rather than, “Does the end justify the means?” ask, “When does the end justify the means?”

#4: Let the Dilemmas Grow From the Genre

Examine your genre and allow it to influence the choices your character must face. For instance, crime stories naturally lend themselves to exploring issues of justice and injustice: At what point do revenge and justice converge? What does that require of this character? When is preemptive justice really injustice?

Love, romance and relationship stories often deal with themes of faithfulness and betrayal: When is it better to hide the truth than to share it? How far can you shade the truth before it becomes a lie? When do you tell someone a secret that would hurt him? For example, your protagonist, a young bride-to-be, has a one-night stand. She feels terrible because she loves her fiancé, but should she tell him what happened and shatter him—and perhaps lose him—or keep the truth hidden?

Fantasy, myth and science fiction are good venues for exploring issues of consciousness, humanity and morality: How self-aware does something need to be (an animal, a computer, an unborn baby) before it should be afforded the same rights as fully developed humans? At what point does destroying an AI computer become murder? Do we really have free will or are our choices determined by our genetic makeup and environmental cues?

#5: Look the Third Way

You want your readers to be thinking, I have no idea how this is going to play out. And then, when they see where things go, you want them to be satisfied.

There’s a story in the Bible about a time religious leaders caught a woman committing adultery and brought her to Jesus. In those days, in that culture, adultery was an offense that was punishable by death. The men asked Jesus what they should do with this woman. Now, if Jesus had told them to simply let her go free he would have been contravening the law; if, however, he told them to put her to death, he would have undermined his message of “forgiveness and mercy.”

It seemed like a pretty good trap, until he said, “Whoever is without sin among you, let him cast the first stone.”

Nicely done.

I call this finding the Third Way. It’s a solution that’s consistent with the character’s attitude, beliefs and priorities, while also being logical and surprising.

We want the solutions that our heroes come up with to be unexpected and inevitable.

Present yours with a seemingly impossible conundrum.

And then help him find the Third Way out.

I hope this helped! I’ve been really busy today, seeing how my mom had surgery and I’ve been trying to continue writing my novel today as well. I thought I’d squeeze in some more stuff for you guys!

This post is sponsored by Kathleen on Patreon! Click here to find out more about donations and sponsoring posts! Thanks so much, Kathleen!

This was quite a hot topic on the blog a little while back, and I’ve been feeling a little remiss in that I didn’t make a masterpost about this a while ago. So let’s continue the awesome Write Better Bleeding series! 

Part 1 focused on the actual effects of blood loss, and what the dying process looks like due to hemorrhagic shock. Part 2 looked at various ways of stopping blood loss, from simple bandages to tourniquets and vascular surgery.

But today on Part 3 we’re going to look at when someone might need a blood transfusion, how doctors replace blood loss, how quickly the body does it, and what some of the risks are. But first we need to understand a couple of basic lab values. In particular there are 3 we’ll talk about: RBC count, Hemoglobin, and Hematorcit. All of these are part of a package blood value order called a CBC, or Complete Blood Count. While there are other components to the CBC, including platelets and white blood cells, we’re going to look at these values in particular.

The numbers are easy to remember in that they’re triples of each other: 5, 15, and 45. It’s worth noting that males and females have slightly different values, with women tending towards slightly lower numbers than men, but humans typically fall within specific ranges.

Blood Values: Red Blood Cells 

This is an actual count of the number of red blood cells in an mL of blood; measured  as “ # x 10^6″, but commonly just expressed as a number. A typical RBC value would be 4.5 - 5.5 in males, and 4.0 - 4.9 in females. (Mnemonic: 5)

There is no critical value for RBC count, but it’s definitely something to keep an eye on when interpreting blood results.

Blood Values: Hemoglobin (Hgb)

Hemoglobin is a measurement of the actual oxygen-carrying component of blood, and is measured as grams/deciliter. While the typical value is 13-16, the number to remember is 15. But when the Hgb drops to 7, that’s a critically low value, to the point that something has to be done about it. This seems to be the safe threshold for initiating transfusion. (Mnemonic: 15)

Blood Values: Hematocrit (Hct)

Hematocrit is a percentage. Specifically it’s the percentage of formed elements (think cells) in the blood. (Whatever isn’t formed elements is plasma, which is mostly water but also contains proteins and other substances.)

Typically hematocrit is 35-45, and it should actually be about 3x the hemoglobin value. In massive blood loss that ratio should hold, at least in the beginning, because RBCs and plasma are lost at an equal level. But that can be affected by well-meaning providers who try to raise blood pressure by administering fluids, which adds water–which doesn’t carry oxygen, the most critical task blood has–and thus drops the ratio of RBCs to plasma. (Mnemonic: 45)

Also, hematocrit will fall in the few hours after a massive hemorrhage, because water and other elements of plasma will shift into the bloodstream from the interstitial fluid. So a person with a Hgb of 8–just above the transfusion threshold–should have a Hct of 24, but may have one under 20 because of fluid administration or fluid shifting.

Typical Healthy People Values: RBCs 4.8, Hgb 14.9, Hct 44

Typical values of someone who needs a transfusion: RBCs 2.4, Hgb 6.5, Hct 16.8

Okay, The Blood Values Are Crazy Low. They’ll Just Make More Blood, Right?

Yes and no! The body certainly ramps up production of red blood cells after blood loss, but making mature red blood cells takes more time than your character might have.  For reference, donating a unit of blood–about 500mL–it takes about 56 days before a donor has made enough blood to donate again. So it takes quite a while to get new blood cells up and running.

One thing that has to be evaluated is whether the person is continuing to bleed, especially internally (where it’s very hard to control). In a trauma patient, this can be evaluated in a number of ways. One that’s worth mentioning is a FAST exam, which is a Focused Assessment with Sonography in Trauma. Basically, an ultrasound probe is used to look at various places in the abdomen and the chest (including the heart), looking for “free fluid” which is assumed to be blood.

Okay, So Billy Badbones is Dying. What Now?

Well, there is going to be a flurry of activity around Billy’s bed. Nurses will be starting lines (if the medics didn’t do it already), drawing labs, administering oxygen; doctors will be doing assessments, ordering things. But in the context of this article, what we really want to talk about is: Massive Transfusion Protocol.

Just read those words. Massive Transfusion Protocol. That’s some sexy words, right? That sounds doctory. That will go well in stories! And it will, and it does, but let’s talk about what that means.

A Massive Transfusion Protocol is a specific protocol for administering blood in severe hemorrhage patients. A doctor, like grizzled attending Rusty Krust, calls down to the transfusion lab and activates the MTP. That immediately gets a cooler of blood products on its way up to the ER. Specific protocols vary, but one that’s easy to remember is a 1:1:1 combination of red blood cells (RBCs), fresh-frozen plasma (FFP), and platelets; a typical pack contains 4 to 6 units of each type. They’ll be infused together, rapidly, into Billy.

But What About Cross-Matching? Isn’t Blood Typing a Thing™?

It sure is! However, in someone who is actively dying of exsanguination, the risk of transfusion reaction is less than the risk of them bleeding to death. So the first pack will actually be an unmatched transfusion. That is, the lab will send a pack of blood products–usually O+, for reasons we’ll delve into–and basically hope that Billy won’t have a transfusion reaction.

Now, yes, blood typing is definitely a thing. For the basics, there are 4 blood types: A, B, AB, and O; and these can all be matched with a Rhesus factor, which is either + or -. So a full blood type might be A+ (the most common type in the US, and Aunt Scripty’s type, if she ever shows up bleeding in your ER). Since Rh+ is autosomally dominant over Rh-, most people (about 70%) are Rh+.

I could explain compatibility, but honestly, this chart will do more than I can with just words:

(Note: The “Blood Type” in this chart actually looks at the genetics, which has 2 chromosomes; someone who is BO is, functionally, the same as someone who is BB, because O is autosomally recessive; O is a very rare blood. Those with AB have 1 A allele and one B allele. Too confusing? Don’t worry. It’s trivia.)

So let’s take me as an example. I’m A+. (I don’t know if I’m AA or AO, and it’s functionally irrelevant.) That means I can accept blood from another type A donor, or from a Type O donor. Meanwhile, I can donate blood to a sister type A, or a type AB person.

But that chart doesn’t deal with Rh factor. People who are Rh+ can accept Rh- or Rh+ blood, but someone who is Rh- can only accept blood from another Rh- donor. So I can accept blood from someone who is either Rh+ or Rh-, which opens my options up to O+, O-, A+, or A-. But I can only give blood to Rh+ patients: A+ or AB+. Bummer.

Now, there is an exception to this. It takes exposure to a blood type to develop antibodies to attack that blood type. So the first time I–or Billy–get a transfusion of, say, type B blood, I won’t have antibodies to it by default. So a single transfusion of one to a few units of Type B blood, given quickly enough, will be the dose that sensitizes the immune system, but won’t cause severe transfusion reactions.

The same effect is true of Rh factor. The majority of the population is Rh positive, which means the majority of available blood is Rh+. And remember Billy? Dying up there, while we dither about blood types? Yeah. He’s still dying.

So Billy can get a single transfusion (even of multiple units) of unmatched  blood. Typically hospitals will reach for O+ blood for males and women over 50, and O- for women under 50. (This has to do with preventing mother-fetal Rh incompatibility should that female choose to bear children). {There could be a WHOLE OTHER SERIES of posts about sexism and gender binary biases in medicine, but that’s waaaayyyy outside the scope of this post.}

Okay, So What’s a Cross-Match?

Excellent question! A cross-match is a test that the transfusion lab will do where samples of Billy’s blood and a potential RBC unit are mixed and watched to see if a bad reaction occurs. A “Type and Cross”, or blood typing and cross-matching, screens Billy’s blood for antibodies to various blood types and actually puts units of blood on hold specifically for Billy. This basically tells the lab “Hey, this patient is going to need X amount of blood”. By contrast, a “Type and Screen” is just analyzing Billy’s blood for type and antibodies without comparing it to a potential donor unit.

Okay. So How’s Billy Doing?

Last we left Billy, he was getting a batch of O+ rushed into the resus bay. Now the blood is warmed, and hung on an IV pole, and infused rapidly through big IVs (or even a central line). He’s getting a 1:1:1 ratio of RBCs to FFP to platelets. But Billy is still bleeding. They’re scheduling him an OR, but in the meantime, he needs more blood!

But now the type-and-cross comes back… oh no! Billy is Type O-…. and he’s obviously gotten some kind of transfusion in the past, because of course he has, he’s Billy Goddamn Badbones. And all of a sudden he’s starting to not look well…

What’s Going On?

Next Time, on Write Better Bleeding…

We’re going to talk about transfusion reactions, or what happens when Billy Badbones gets blood and his body attacks it.

Thanks so much for reading!

xoxo, Aunt Scripty

disclaimer    

Whooo! The first installment of the Writer’s Guide to Bleeding dealt with the actual blood loss itself: what’s survivable, what’s not, and what really happens when a character loses enough blood to enter that conundrum of a state known as shock. So if you missed it, now’s a great time to brush up!

Now. We talked a lot about blood loss. And the number one thing, the most important thing in a patient who’s actively bleeding, is stopping the blood loss. If the blood vessels are a big tank, and the heart is a pump, as long as that pump is going and there’s a hole in the tank, water will be coming out, right?

So today we’re gonna talk about stopping the leak, including everything from simple field bandaging to surgical arterial repair, and some of the neat technologies that are out there or coming down the pipeline in the near future.

Full steam ahead! (Note that I deliberately choose bloodless pictures for this article, so that those who are squeamish can still get a good idea of what’s what.)

(This is Part 1 of the Writer’s Guide to Bleeding series! Part 2 is coming soon!)

Okay, guys, it’s time to get to the heart of most of the questions I’ve gotten in the (holyshit amazing) first 48 hours of this here little blog. People seem to wanna know about bleeding. How much do we have? How much can we lose? When do we pass out?

Gather round, kiddies. Let Auntie Scriptmedic teach you about hemorrhage and shock.