08/3/15
BrainVeins

Clinton’s Venous Sinus Thrombosis

Clinton’s Venous Sinus Thrombosis
What is a transverse sinus venous thrombosis?

In 2012, then Secretary of State Hilary Clinton became dehydrated and fell down, suffering a concussion. Weeks later she was hospitalized for what was described at the time as a “blood clot.” We weren’t told where the clot was at the time. After several days in the hospital, she was discharged home.

She was later seen to be wearing glasses with a Fresnel prism in them, a common treatment for double vision. Double vision is a not uncommon transient development in concussions. It may also develop from a blood clot on or in the brain.

Yesterday, it was revealed that Secretary Clinton had, in fact, suffered from a transverse sinus venous thrombosis and was treated with blood thinners, which she is apparently still receiving.

As a leading candidate for the Presidency, Secretary Clinton’s health is a public concern. So what, exactly, is a transverse sinus venous thrombosis?

BrainVeins

This is easiest if we think of a sinus as a large vein. Specifically, the transverse sinus is one of the major draining veins of the brain. It is located at the back of the head, extending from the midline to a point behind each ear (there is one on each side of the head). Just behind each ear, the transverse sinus makes an ‘S’ turn down into the neck, where it becomes the internal jugular vein. The internal jugular vein is THE major vein draining the brain of blood. Again, it is a paired structure with one on each side.

If we think of the internal jugular vein as a river draining blood from the brain back to the heart, then the transverse sinus is one of the major tributaries of that river. Each transverse sinus carries some percentage of the blood exiting the brain and returning to the heart. What percentage? Hard to say, since the exact size and anatomy of the transverse sinuses vary in different individuals. In many folks, probably most, the transverse sinus is larger on one side or the other. Such a dominant sinus may drain more than 50% of the blood returning from the head. Likewise, a small, nondominant sinus might drain considerably less than 50% (most of the remainder being drained by the opposite transverse sinus).

A venous thrombosis is a clot. A clot in a nondominant transverse sinus might be relatively benign. Of course, a clot in the dominant sinus is more likely to cause serious trouble. It should be noted that venous sinus thrombosis is a relatively common syndrome and that a nondominant sinus is more likely to clot than a dominant sinus.

There are several causes of venous thrombosis, one major cause being dehydration. Secretary Clinton was dehydrated, which likely lead to her clot. Nothing earth shattering there.

How significant is such a clot? It could be very significant, but probably not in this case. In a worst case scenario, such a clot leads to sludging of the blood and engorgement of the brain as the blood backs up. Think of water backing up behind a cofferdam, the difference being that the brain exists in a closed space. Engorgement of the brain (with blood, CSF, or edema fluid) will eventually raise the pressure inside the head (see my article Brain Squeeze here). Increased pressure inside the head can make a person very sick, or worse.

So how is venous thrombosis treated? For starters, with avoidance of dehydration. Second, if the clot is nonocclusive (that is, only partially occludes the sinus) and thus the sinus is still functional (blood is able to get through), then the goal is to prevent further clotting in the short run (this is probably why she was hospitalized for several days, to monitor her and prevent further clotting) and to passively dissolve the clot in the long run (with good hydration and blood thinners over months). Such patients may have a headache, and sometimes double vision, at the onset. Full recovery without a stroke is the rule.

If the clot is occlusive and no blood is getting through, the blood backs up faster, causing severe congestion of the brain and, if unchecked, a stroke. This situation warrants very aggressive treatment, requiring an ICU stay and multiple angiograms with administration of medications directly into the clot to actively dissolve it.

It does not appear that Secretary Clinton has had a stroke.

Overall, her transverse sinus venous thrombosis appears to have been a relatively minor affair, one that was treated quickly and appropriately and without significant sequelae. In this physician writer’s opinion, it should not be a consideration in her run for the Presidency, nor will it impact her decision making skills.

 

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07/31/15
Kids Best

The Worst Club in the World

The Worst Club in the World
Everyday coping after the death of a child

It’s 2:00 in the morning and I can’t sleep. I’m sitting in a hotel room in a city not my own. In fact, it’s seven hundred miles from my house. I came here to take care of some business and take in a few ballgames. I do this once in a while when I feel the need to get away. When the silence has become unbearable. 

Seven hundred miles is a long drive but a short distance compared to the journey I’ve been on for the last thirteen years. That was when I joined THE CLUB. February 25th, 2003. Hardest day of my life, no question. I can’t imagine there will ever be a more difficult one, and if there is I’m not sure I want to live it.

Endyll Sketched

Endyll McDaniels in his tuxedo.

THE CLUB. This isn’t one you’ll ever want to join, though I’m guessing if the “opportunity” comes your way you won’t have much choice in the matter. And the price will be steep, up to and including a bankrupt soul and the irreparable loss of your future. The deal, such as it is, includes an unavoidable—and rapid—descent into hell. For some unfortunate few, hell is surpassed in favor of a slow descent into madness. Not surprisingly, this is the worst club in the world to be a member of. 

There is no more lonely an experience in life than losing a child, and the only folks who can truly appreciate the level of grief one feels are those who have themselves lost a child—other members of THE CLUB, so to speak. Losing a child, even as an adult, is not only devastating beyond belief, it’s socially isolating. There’s a sense you are in it alone, as if in the vast panoply of the human experiment, some six billion and counting, this has never happened before. Losing a child is quite simply the wrong order of things. Our brains aren’t meant to bend that way. Children are our future. We aren’t suppose to bury them—they are suppose to bury us.

So what’s it like? What’s it like to have your soul filleted by the reaper’s blade, opened wide for all to see? 

Imagine living with a deep down bellyache, one you can’t get at no matter how hard you try. The pain is intense. Physical, emotional, spiritual. It’s everywhere you look and in everything you touch. The very air you breathe is tainted. If you could somehow hold your breath and just cease being, that would be ok. You want only the impossible, to breathe life back into your loved one.

If the first days are hard, and few things are harder I assure you, what evolves is nearly surreal. About four months after my son died, we ventured out as a family for the first time since his sudden death. We choose a restaurant we had never been to before. One without memories. Unfortunately, the five of us were seated—completely innocently I am sure—at a table for six. There was, of course, one empty chair.

And of course, it’s been such ever since. One empty chair. At Thanksgiving. At Christmas. At every dinner and every meal. At high school graduations and college commencements. On road trips and family vacations. One empty chair. There’s always someone missing.

The weight of that empty chair can become oppressive, but it needn’t be. Some years ago my wife started putting a lit candle at my son’s place—his name was Endyll, our first born—during family dinners like Thanksgiving and Christmas. My wife and I haven’t always been together in our grief (one reason so many couples become singles after the death of a child), but on this point she was a beacon in the darkness. And my daughter, who was only eight when her older brother died, surprised the family this past year with a montage of memories written by Endyll’s friends all these years later. Turns out she tracked them down on Facebook and they were delighted to give of themselves. She turned twenty-one herself this year (the same age as Endyll when he died) and felt she’d been too young to really know her brother. What sort of person had he been? And so she asked a few of his friends for vignettes that might reveal something of her brother. 

I could well understand her desire. I myself had spent years searching for clues as to who he was or might have become. I poured over notebooks I found in his bedroom, in which I discovered a trove of unfinished stories. He had been a writer. Sci Fi and fantasy. Wonderful. But reading those vignettes from his friends was like finding an ancient scroll thought lost forever. It was relavatory, like bathing in the waters of the River Jordan.

Kids Best

The last picture of our four kids together. Endyll is the tallest.

The acuity of the pain fades with time. Folks will tell you this and it’s hard to fathom, but it’s true. I doubt, however, it ever dissipates entirely. At least it hasn’t for me, for us. What really happens is that eventually the good days outnumber the bad days. The memories become more deliberate, more welcome. The bombs, once seemingly implanted everywhere, defuse over time. Or at least lose some of their explosive power.

They are still there though. In the curious glance of a stranger, whose eyes have the same light as your lost one. Or inside an old box from the attic, where you find his stash of men’s magazines—and thus a glimpse of his very human needs. Or perhaps the box contains the clown costume he wore to school for Halloween when he was five, when he was still your precious boy and you couldn’t imagine a time when he’d pull away from your touch. He was—is—a part of you. His life permeates your own. He will always be your precious boy.

And then comes that singular question, ever uttered with innocence, despite which can always be counted upon to bring up a ghost. How many kids do you have? This may be the hardest question in the English language—hell, in any language.

How many kids do you have?

Like the weather, asking about children seems benign. But it’s not when you’ve lost a child. More often than not, the question scratches an old wound. And deciding to tell or not is another kind of pain altogether.

If I answer one way and leave him out of the equation, it feels as if I am denying my son’s existence. I can hardly bear that, even after all these years. Especially after all these years. He died just before the internet came of age and so was never immortalized on facebook. He never had a digital life. He doesn’t go on ad infinitum in electronic limbo. I can’t pull up an infinite stream of pictures of him. To deny his existence, which remains very real to me, means he will be forgotten once I am gone. That is, for whatever reason, one of the harder things for me to deal with. I don’t know why.

Yet, if I answer the other way, there’s an awkward silence in the making. Invariably, the next questions are how old are they? Where do they live? What school do they attend? What do they do? Etc., etc,. etc. Having seemingly numbered him among the living, at least in the ears of the questioner, I now have to step back and explain. Sometimes that’s exactly what I want because it gives me a chance to talk about him, to keep him alive I suppose. But often there isn’t time, or the person asking is taken aback, feeling they’ve intruded. Or worse, they’ve overstepped. Or worse yet they were just being kind, as in making small talk. Then I’ve overstepped and it’s just plain awkward.

Other times I can’t say anything and the silence can be unbearable. It’s as if the pain has stolen my words.

I still haven’t found a good way to answer that damn question.

For awhile, I attended survivor meetings. Parents who’ve lost a child. Survivors of suicide. Grief counseling. It helped. It still helps. Talking about him (or writing about him) soothes me. I feel less alone. He feels less gone to me. 

This journey is a solitary one. My wife—she joined THE CLUB too that day—and I take solace in each other of course, but  even couples must grieve in their own time and space. Each parent must walk the journey on their own. She finds survivor meetings loathsome. She attended one and never again. When I’m having what I call a bad Endyll day, usually she’s more composed, and vice versa. We persevere. Whatever, it seems to have worked. We are still together and that’s saying something. Few things stress a marriage more than the death of a child. The pain of the reaper’s blade is deep; the swath it cuts is wide. 

Eventually though, a scar forms. And as with any scar, you can look at it and see pain and suffering. Or you can look at it and see healing.

You decide.

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07/29/15
Click the image to buy BLADE MAN for the Kindle, Just 99¢.

Blade Man reviewed by DNFB

Click the image to buy BLADE MAN for the Kindle, Just 99¢.

BLADE MAN for the Kindle is just 99¢ at Amazon. Click Now.

The Folks at Definitely Not For The Birds Review
BLADE MAN, a novella

Original posting is here.

Firstly, I want to thank Edison McDaniels for sending us a free copy of Blade Man in order to hear our opinion.  We are honored and very grateful.

Note:  This review is a bit shorter than most, as Blade Man is a novella and a very quick read.  It is also rather suspenseful so in effort not to give anything away, my comments will be brief, although my praise is high for this novella.

Most of the time, I avoid anything classified as or even remotely related to Horror.  The genre… well it impacts me.  It sort of gets my imagination going a bit too much; all sounds suddenly morph into sounds a murderer is making while he is slowly creeping towards me to deliver me my doom.  Yes, it gets quite ridiculous and stressful hence my hesitation.  However, I didn’t look too closely at the genre of this novella.  I normally don’t, and I am very glad that I didn’t.  If I had, I probably would have shied away from it and thus missed an excellent piece of fiction.

The Good:
The setting.  The setting could not have been more mundane or more perfect for this story.  I believe it was the mundane-ness that perhaps made it all the more spooky.  It is set in the middle of a blinding blizzard  – or a howler, as the protagonist so often reminds us.  A blizzard, believe it or not, is the perfect setting for this story.  Vision is blurred, as are the lines of reality.  The ambiguous nature created by this setting really sets the mood for the whole story – a mood that is crafted with great care…. and with a truly wonderful result.

The voice of the protagonist was also very unique.  I enjoyed his crassness and it added a whole other dimension to the story.

The build up of suspense was also wonderfully done.  Words and phrases were often repeated and I found that this really helped to expertly build up the tension.  There was also one crucial moment, one that I am not going to specify for sake of not spoiling the book, that was absolutely amazing.  It continued with the theme of ambiguity and also scared me.

The end.  It blew me away!  I really don’t want to give too much away, but it was very well crafted.  I was once told that a good ending should be surprising, but at the same time entirely logical, given the world of the story.  I believe that McDaniel’s had heard that somewhere once before as well …. in any case, he accomplished just that.

I just really found myself amazed at the plot unfolding and the true depth to it.  It was also easy to read, yet the writing didn’t come off as trivial due to the true, real sounding voice of the protagonist.  It’s also a memorable story – one that I will not be forgetting any time soon, if ever.

The Bad:
The only negative I found is that at very rare points, the main character’s voice can become a bit unsteady.  That is to say, he is portrayed as a gruffer man, speaking in vernacular.  The picture I had in my mind was of someone not overly educated and a bit “old school”.  For example, McDaniels writes “innernet” instead of “internet” when this character is speaking.  I believe this is the persona that we are meant to imagine.  Occasionally, the character will use a phrase or word that somewhat goes against this; words that I would assume to be beyond his vocabulary.  However, this is rare and it does not distract from the other wonderful qualities of this story.

The Verdict:
Don’t Read if:  McDaniels himself warns not to read at night if you are home alone.  I, however, did not heed this warning.  I was alright, but I definitely think it should be said that it might make the reading experience less spooky… something I probably would have been okay with.  So you may want to keep that in mind.  If you aren’t a fan of suspense or stressful reading, this is definitely not the novella for you.  Also, if you are looking for something longer, this will not be a good choice.  It is a very fast read, even for a novella.

Read:  Even if horror usually isn’t your thing, I encourage you to take a look in to this.  The murky sense of ambiguity and suspense are what really makes this novella great – something that most people can really appreciate.  If you are looking for a quick read, this would be perfect.  The writing is light but still smart, and the content/suspense drives you to devour the novella.  I read it easily in one sitting, mostly because I just couldn’t put it down.

Thanks for reading!  And just in case you do happen to read this novella and you happen to enjoy it, I thought I would mention that we have more work from Edison McDaniels in addition to this piece.  I am in the process of reading it now, so stay tuned for a review on that.  The title is Not One Among Them Whole: A Novel of Gettysburg, and I am really enjoying it so far.

Thanks again!   And I hope you all have a marvelous weekend!

Written by Rachel B.

Rachel is a co-creator and writer at Definitely Not for the Birds (DNFB). She recently graduated with a degree in English. Presently, she writes, reads, and then reads and writes some more, with a giant and ever-present mug of green tea in her hand. Follow Rachel @rrbindl and DNFB @not4birds

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07/29/15
Not One Among Them Whole, A Novel of Gettysburg, by Edison McDaniels

DNFB review of Not One Among Them Whole

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A Review of Not One Among Them Whole by the folks at Definitely Not For The Birds (a book review blog)
See the original posting here.

Mr. Edison McDaniels himself brought this novel to my attention; he sent us two pieces of his work for free to be reviewed, something that I am very grateful for.  So thanks must again be expressed to Mr. McDaniels for this.

 

I was lucky enough to read both pieces of fiction, and I am incredibly impressed with McDaniels.  The first work I reviewed, the novella titled Blade Man, (the review of which can be found here) was truly enjoyable.  It wasn’t necessarily as polished as it could have been  (you can refer to my comment in the review) but the writing was still mostly solid and the suspense was expertly crafted.  I wasn’t quite sure what to expect, though. when I turned to begin Not One Among Them Whole. The reasoning for this was that the description of this novel made it sound as though it was nothing like the novella, and I was worried that the novel would simply pale in comparison to the novella. It is, after all, hard to excel in two different genres and styles.  I feel confident in saying that my worries were unfounded.  This novel, although very different from McDaniels’ novella, is still very well done.

The Good:
The tagline for this novel is as follows: A Novel of Gettysburg

Immediately, I imagined a rather painful historic account with bland characters drenched in stereotypes.  It really added to my hesitation to read the novel after I had already read the wonderful novella.  However, the impression that the tagline had instilled in me was entirely wrong.  The character are very well developed and although there may be a stereotype here or there (not many), the characters (nor the author) don’t seen to rely on them for identity. Most of these characters take you on an emotionally roller coaster given the heightened historical content that war immediately interjects into a story – especially a war like the civil war.  I also was not expecting such a variety of characters.  I really thought it was going to entirely focus on this Civil War surgeon.  While I do think the surgeons are the readers best window into the onslaught, there are others.  I loved the diversity of view points, as I felt it provided me with a fuller overall picture – a less biased picture.

It is also the first historical fiction novel on the Civil War that I have encountered (although I must admit that I don’t read very many novel that fall into that category) in which the view points of the surgeons were taken into account.  This alone makes it unique and worthy of looking in to as I feel I gained new perspective and that other readers will as well.

The writing, especially the descriptions of the surgeries and procedures, come off as incredibly realistic and authentic.  Of course, as Mr. McDaniels is also a neurosurgeon (yes, a writer AND a neurosurgeon, not sure if there is anything McDaniels can’t do) it is safe to assume that these descriptions are indeed incredibly accurate.  For me, sometimes these descriptions were a little too real, but more on that later.

The historical facts, so important to historical fiction, were there and helped to support the story as opposed them having to be manipulated in order to accommodate the story.   With the facts supporting the fictional narrative, the lines of fiction and history were blended in the way that only truly good historical fiction can accomplish.

The Bad:
As stated earlier, sometimes the descriptions of the medical procedures were a bit too vivid for my tastes, and I had to skim over them.  I am a bit of a wimp, but I think others may have this problem as well.  It can be gross and gory, for lack of better terminology, given the combination of a reader’s vivid imagination and McDaniels detailed and vivid imagery.

 
Not One Among Them Whole, A Novel of Gettysburg, by Edison McDaniels

Not One Among Them Whole, A Novel of Gettysburg, by Edison McDaniels

The Verdict:
Don’t read: If you aren’t a huge fan of accurate and gory accounts of war, this will not be the novel for you – although I must mention that skimming through these portions helped immensely and ensured that I didn’t miss out on a great piece of fiction.

 
Read: If you have been looking for an accurate yet artful piece of historical fiction, I cannot imagine anything more perfect to satisfy that need than Not One Among Them Whole.  The writing is well done, polished, and approachable while the characters and story are convincing, captivating, and deep.

Written by Rachel B.

Rachel is a co-creator and writer at Definitely Not for the Birds (DNFB). She recently graduated with a degree in English. Presently, she writes, reads, and then reads and writes some more, with a giant and ever-present mug of green tea in her hand. Follow Rachel @rrbindl and DNFB @not4birds

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