Attention/hemoglobin deficit disorder

you will certainly not grow old in Salem's Lot with that attitude

Status Post / Stuff I’ve Been Reading

In a thus-far unsuccessful attempt to rehabilitate my attention span (I have a genuine concern that I have developed functional impairment in attention, especially in a highly distracting environment, during residency, which most likely does not constitute some sort of “brain chemistry” thing so much as a “attempted adaptation to pathologic environment” thing and thus should be reversible; anyone who has attempted to have a long dinner conversation with me recently is probably aware of this) (constant fast-paced disruptions in a high-stakes work environment are one factor, as is phone addiction and the usual dopamine-hit constant-distraction 21st-century tech environment we all live in) (these incessant parentheticals are where I’m at, all the time, always), I have been trying to read novels. 

My records indicate that I have read 6 novels and 1 novel-y nonfiction narrative this year. I’ve been selecting books likely to hold my attention, so many have been suspenseful and/or spooky. Most were pretty good. One kept me reading, but it was so very bad that I was offended that the New York Times book review section had recommended it to me. For now, though, the best recommendation has been from a friend who had started re-reading the complete works of his long-time favorite author, who happens to also be my own long-time favorite, and now due to me inviting myself along on this two-person forced-book-club journey (thanks, P), I have been re-reading the early novels of Stephen King. 

From the ages of 12-16 or so, I read every Stephen King book available in the public library or the used bookstore. On Writing was the most influential; I read it multiple times, reverently, as a young writer, and much of its advice sticks with me today. Can you believe that Stephen King tends to write maximalist-ly and trim later and still leave way too much on the page? Imagine being that sort of writer! (The Stand was perhaps the second-most influential, as I internalized that the most useful person to be in an apocalypse was a generalist physician, and had this in the back of my mind throughout all my careering career path. Happy to say that I now fully expect to be kept alive by the stronger and better-armed strangers in our roaming band on the way to meet Mother Abagail, for my practical skills if not my ability to stick with one thought until I’ve finished it.) 

So many of my memories from adolescence involve carting these books around and reading them obsessively. On Writing on a road trip in Arizona, staying up late in a hotel room to take notes on the Hampton Inn stationery. The Stand on a trip to Australia, when I should have been developing my social skills with other youths on the long bus trips, but instead was journeying across the wastelands on the way to a confrontation with Evil itself. The Shining on I-70. The Gunslinger in Pensacola. It on the school bus, where a thousand-page doorstopper with two creepy pictures (a clown’s face and a wild-eyed author photo) will make everyone leave you alone. Bag of Bones late at night in our family friends Dean and Cathy’s Ozarks lakehouse, scared shitless. 

Dean and Cathy had the most wonderful library I’d ever seen: every room of their glass-walled home was filled with bookshelves, every shelf was filled with gorgeous hardcover books, and in pride of place in the living room towered Dean’s extensive collection of Stephen King books. A lot of first editions and original covers, since he bought them as they came out over the decades. It was the closest place I knew to another early-established but lifelong-imprinted dream: Belle’s library in Beauty & the Beast. Dean died a few years ago, and Cathy very generously willed me some of his Stephen King books, which are among my most prized possessions. They’re in the prime shelf in the bookcase in my bedroom now, including Bag of Bones, and the first book that made me want to read Stephen King: Desperation. 

My mom J was reading a library copy when I was about 7, it had a terrifying creepy doll on the cover, and I was entranced. She told me I couldn’t read King until I was older; an obedient child, I complied but kept asking, and finally around 12, she told me I was “ready,” but that I could under no circumstances read Dolores Claiborne or Rose Madder. So she offered me a gentler alternative, a nice easy introduction to the world of grown-up horror: Misery. 

My other mom V is more of the reader now, but J loved King, especially the Dark Tower series, and it still connects us, like when she introduced me to a shared favorite movie, Silence of the Lambs, and I introduced her a lifetime later to our favorite podcast, My Favorite Murder. The sensibility in common to all these works is best described by the opening line of The Girl Who Loved Tom Gordon (I first read Dean’s copy, and it’s here with me now), about a reality the titular nine-year-old girl has come to understand: 

“The world had teeth and it could bite you with them anytime it wanted.”

This is something that many people either suspect instinctively or learn by hard experience. (I’m happy for anyone who doesn’t know or believe this, but I’m going to find it kind of hard to relate to them.) Some people like to read and watch and listen to things to distract them from this essential truth. Some people like to read and watch and listen to things that understand, acknowledge, make explicit this truth. My mom and I are in the latter category.

Last month I re-read Carrie, P’s favorite and King’s first. More on Carrie another time. I was younger than Carrie herself last time I read this, and probably pre-menarchal, although I remember finding King’s details on menses a little suspect. Still, his instinctive treatment of women as people was an appealing relief at an age when I knew full well there were boy-stories and girl-stories, that boy-stories are universal and important whereas girl-stories are domestic and unserious, that boy-stories are for everyone but girl-stories are just for girls and it isn’t fair to make boys have to stomach them. I read mostly male authors until adulthood. So I was glad to have a male author who could at least write genuine female characters from the beginning, even though his surprisingly common details about the sensory experience of menstrual flow seemed a bit off from my own. (God help me when I got to The Tommyknockers, which I remember mostly as a book about gushing cervices.) 

I loved Carrie again on re-read. I loved thinking more deliberately about the structure and authorial choices, identifying early King tendencies that would recur for decades, and remembering high school with horror from the other side rather than anticipating it grimly. 

Carrie is structured as a collage from multiple sources--news articles and Congressional hearings and academic articles about telekinesis--pasted around the narrative itself. One passage was an article describing the pathophysiology and genetics of hemophilia, and linking this to the hereditary nature of telekinesis. It was so effortful and yet so incorrect. I already envisioned the re-write I would have suggested to King in a workshop. (If you want a reverse-of-hemophilia syndrome mostly carried by males and displayed by females, that’s going to be tough with the pedigree we’ve got here--how about just incomplete penetrance and variable hormone-driven expressivity? Also, hemophilia has nothing to do with platelets.) But in the name of the whole point of this endeavor, which was to read guaranteed-good always-engaging novels to rehab my attention span, which required me to just keep reading and not go on a Wikipedia side tangent about Rett syndrome, I tried to move on.

But now I’m reading Salem’s Lot, King’s second, and I just can’t help myself. 

Welcome to the first of what I can only imagine will be a recurring series, Medical Perspectives on the Novels of Stephen King with an Element of Medical History and Wikipedia Deep Dives (or, why you as a novelist should hire me as a consultant to fix your attempts at medical verisimilitude, I am still a resident and can be had for cheap, lock in with these prices now). 

Spoiler alert for this much-adapted 1975 Eminem-referenced 47-year-old novel, which I think most people know involves vampires. 

9/23/75

[...]

AGE: 12

SEX: Male

RACE: Caucasian

SYMPTOMS: Shock, loss of memory (partial), nausea, disinterest in food, constipation, general loginess

TESTS (see attached sheet):

1. Tuberculosis skin patch: Neg.

2. Tuberculosis sputum and urine: Neg.

3. Diabetes: Neg.

4. White cell count: Neg.

5. Red cell count: 45% hemo.

6. Marrow sample: Neg.

7. Chest X ray: Neg.

POSSIBLE DIAGNOSIS: Pernicious anemia primary or secondary; previous exam shows 86% hemoglobin. Secondary anemia is unlikely; no history of ulcers, hemorrhoids, bleeding piles, et al. Differential cell count neg. Primary anemia combined with mental shock likely. Recommend barium enema and X rays for internal bleeding on the off-chance, yet no recent accidents, father says. Also recommend daily dosage of vitamin B12 (see attached sheet).

Pending further tests, let’s release him.

G.M. Gorby

Attending Physician (p. 168-9)

“Dead at twelve. Cause of death pernicious anemia… The boy was anemic, all right. He said that a red cell count on a boy Danny’s age should run anywhere from eighty-five to ninety-eight percent. Danny’s was down to forty-five percent.”

“Wow,” Ben said. 

“They were giving him B12 injections and calf liver and it seemed to be working fine. They were going to release him the next day. And boom, he dropped dead.” (p. 249)

I’m going to go out on a limb here and say that this 12-year-old boy who died of “anemia” after the mysterious disappearance of his younger brother, which coincided with the sudden arrival in town of a mysterious pair of men who are either gay European antiques dealers OR a couple of vampires OR probably both, got exsanguinated by a vampire/antiques dealer. 

In the narrative, the boy presents in “shock,” meaning emotional shock: semi-catatonic, traumatized by his brother’s disappearance in his presence, which he can’t remember. His “red cell count” is initially normal, then plummets. He looks terrible. They initiate treatment for pernicious anemia with B12 and calf liver, and he perks up within a few days. Then he drops dead. 

I just don’t think this is how a victim of vampirism would clinically present.

First off, the numbers here are nonsensical. CBC with diff (complete blood count with differential) was standard long before 1975, becoming more automated over the years, but with essentially the same reference ranges. So I can assure you, there is no such thing as “98% hemoglobin.” Blood that thick would clog up your vessels and you would stroke and die immediately. Also, “hemoglobin” and “red cell count” are two completely different measures. (I suppose we can excuse the latter error: a local English teacher is recounting his PCP’s gossipy pre-HIPAA secondhand account of a different patient’s death; he may not have remembered the terminology.) 

But those are just silly numbers that I would have fixed for King if he’d asked me. Stick to one measure. Make it hematocrit because the reference range involves bigger and more intuitive numbers, then the drop will sound more impressive. Say that Danny’s initial hematocrit (the percentage of his blood composed of red cells) was 45% and suddenly dropped to 20%. Whoa! Transfuse that boy!

The diagnosis of pernicious anemia is odd. I assume this was written because “pernicious anemia” sounds like it means “very bad anemia,” and that’s why it was so named! It was described in the 1800s: older people suddenly got anemic and died within a few years, unlike other more common anemias where they might just struggle pallidly along for life. Pernicious anemia’s cure was discovered before its cause: dogs with anemia due to chronic blood loss (poor dogs :() were fed liver and got better. Interesting… so they started feeding people with anemia, including that pernicious anemia, tons of liver. However, eating tons of liver is gross, so then they ground it up and started injecting people with it. And suddenly, the people with pernicious anemia got better! No idea why, but great news! Iron, maybe, they assumed? Either way, some scientists won a Nobel Prize for discovering this cure.

A few years later, they figured out that what was causing pernicious anemia was totally different from the dogs’ blood loss anemia. Chronic blood loss, commonly from menstruation or a bleeding ulcer or an occult (different connotation than in Stephen King) bleeding tumor (or, I suppose, bleeding piles, which is just another word for hemorrhoids), causes iron deficiency anemia. This is easy to recognize on a basic CBC, even if you don’t do iron studies: hemoglobin and hematocrit, two different measures of the same thing (concentration of red cells in the blood), decrease. The body continues to try to make more red cells; as the iron stores run lower and lower, the cells they produce get smaller, paler. It’s a chronic process. No vampire victims are dying of iron deficiency. (But it’s a serious problem! The majority of menstruating adolescents I test have some degree of iron deficiency, if not outright anemia. If you menstruate, or chronically lose blood in any way I guess, I would take a multivitamin with iron at the least. This is an even stronger recommendation for vegetarians and vegans, as iron from plants is harder for the body to absorb. I take mine at night because coffee and dairy inhibit iron absorption; take with fruit or juice for best absorption with some vitamin C.)

Pernicious anemia is caused by a deficiency of vitamin B12. Totally different. Rare in American children that eat a standard American diet, especially in 1975 Maine, which involves a lot of meat, by far the main source of B12. (The liver in particular is where excess iron and B12 are stored, so eating lots of liver would cure either dietary deficiency.) The most common cause of vitamin B12 deficiency is actually autoimmune, typically seen in people over 60: the immune system attacks the cells that allow B12 to be absorbed in the stomach, so no amount of vitamins by mouth will help. But monthly B12 injections (whether purified or ground-up liver) solve the problem! The hemoglobin and hematocrit drop in pernicious anemia, too, but the way that red cell production is impaired is different: the ineffective red cells they produce are larger instead of smaller. Without macrocytosis on the CBC, I don’t see any reason to call Danny Glick’s anemia “pernicious.”

You certainly can die from acute anemia (seen it, not good), but that’s typically something like hemolytic anemia, where the red cells burst and thus can no longer work to deliver oxygen to your tissues (and release various things you don’t want loose in your bloodstream). When you acutely, suddenly lose blood, e.g. to a vampire, the lack of blood volume is going to be an issue long before the lack of red cells. This is what we actually call “shock”: not emotional shock, but medical-grade shock. “Shock” is a supply-and-demand problem: the tissues that need oxygen are not getting it. Either there’s not enough volume to deliver it, or it’s not getting delivered whether due to overly dilated vessels or a weakened heart, or it’s leaking out of the blood vessels due to high demand or other pathology. I would expect vampirism victims to present in the easiest to understand of these: hemorrhagic shock. Bleeding to death.

In early hemorrhagic shock, you don’t even see a decrease in hemoglobin (much less macrocytosis as you see in pernicious anemia), because the blood you measure is still normal blood with a normal concentration of hemoglobin; you need time for fluid to shift into the vessels but before the bone marrow has revved up to make new red cells in order to see a drop in hemoglobin. So checking Danny Glick’s CBC ten minutes after a feeding might not show anemia at all. Even if checked later, a drop of 50% is way too high. 

You can lose up to 15% of your blood volume without doing too badly: you don’t feel great, but your vital signs remain normal. (Donating blood, for example, takes about 8-10% of your blood volume.) A loss of 15-30% is grade 2 shock. 30-40% is grade 3. More than 40% is grade 4, and you’re in big trouble now. (I am delighted to learn that these have been called “tennis stages” of shock, as this will enable me to remember tennis scores from now on: 0, 15, 30, 40.) 

Based on how shitty the vampirism victims look for a few days straight in Salem’s Lot, I’d guess we’re losing at least 15% of their blood volume in the first feeding. The first clinical sign is a rising heart rate, as the heart flutters faster to get more blood to thirsty tissues. Children in particular can sit at this stage for a long time, compensating with their strong young hearts. There is no way Danny Glick came in not hella tachycardic, probably with worsening capillary refill (press on the fingernail beds and they take a few seconds to go from white back to normal color). The treatment is volume, not calf’s liver: lots of isotonic IV fluids. Start this kid with a stat normal saline bolus, 20 ml/kg, run wide open if he looks this bad. He still has healthy bone marrow (and whoa, can we talk about how we apparently did a bone marrow biopsy before a barium enema?! Kind of random that Maine schoolteacher SK knows about barium enemas? Before easy scopes, did they just do a ton of barium enemas?) and months of reserve vitamin B12 in his liver; he’ll produce plenty of red cells to make up for the loss in time. 

Unfortunately, the vampires keep coming back. I’m estimating another 15% blood loss in the second feeding. Now we’re cruising into grade 3 shock. Danny’s heart rate is still high, but now his blood pressure bottoms out: faster heartbeats are not enough to compensate for a volume this low. His urine output starts to decrease as the kidneys hang on to every drop of fluid. He worsens from general “loginess” to distress, confusion; he looks pale and sweaty; he’s breathing fast now. Two more boluses, stat. What’s going to kill him is a lack of blood volume to get oxygen to his brain, GI tract, liver, kidneys, etc. He may need pressors, medications that increase blood pressure--probably the kind that tighten up the blood vessels to maintain pressure despite the lower volume. Most of all, he needs the windows locked and some kind of spell to prevent the vampires from getting back into his hospital room. Unclear how the need to be invited in applies in a semi-public building with a visitor policy. Can Security revoke their access?

Doing some basic math for an average 40-kg 12-year-old, Danny’s total blood volume is about 3-3.5 liters. At 15% per night, this vampire is sucking down a solid 16-oz pint glass of blood per feeding. Seems realistic! On the other hand, the victim himself becomes the next vampire, and now this 40-kg vampire starts drinking the blood of a full-sized 70-kg adult with 5 liters of blood, who decompensates just as quickly. Now that’s 25 ounces per feeding into a smaller stomach. Still plausible enough. But with losing this much blood this quickly, their vital signs are going to collapse too fast for them to just wander around the hospital or Dell’s local dive bar looking peaky for a few days. The smarter vampire, who wants to fly under the radar, is better off siphoning half as much, or less, day by day, enough that the victims can compensate for the volume loss with just increasing PO intake during the day. More like donating blood, but every day for a week.

If the victims can avoid going into sudden shock, this is much better. The doctors will be baffled, giving fluids and calf liver as they waste away. Then once the victim is precariously red-cell-deficient enough, a final binge feeding should take out enough volume to kill them that night, like a full 1-2 liters out of an adult. Is it absolutely necessary to consume every drop of the blood on the spot, or could we maybe siphon some into a mason jar to keep in the fridge for when we’re between victims? Then the vampire can perform whatever process transforms the victim into a vampire (not covered in Pathoma) and repeat the cycle. 

Of course, you could just totally exsanguinate them on the first feeding, but then that would leave little subtle detective work for the new Maine horror novelist in town, the beautiful heroine, the local English teacher, and the alcoholic Irish priest. Pretty straightforward when two European weirdos show up and suddenly people are dropping bloodlessly dead. If you want to stay in business for centuries, you’ve gotta suck smart.

I just wish more people would ask me for advice before infiltrating sleepy little New England towns. I feel like I could be helpful!

POSTSCRIPT: VITAMINS

The known ~13 vitamins are vitamins A-E and also K, and although numbered B1-B12, there are only 8 B vitamins. The definition of a “vitamin” is “something you need a little bit of that is not an amino acid, fatty acid, or mineral; and possibly also choline.” Vitamins F-J turned out not to be real vitamins or were re-named as B vitamins because they turned out to be related. The missing B vitamins were also scrapped as possible vitamins after further research, but the remainder weren’t renumbered. We usually use the B vitamins’ full names, like thiamine and riboflavin, except B12. You are almost definitely deficient in vitamin D; otherwise, the odds are that you are getting plenty of everything else unless you don’t eat much/any animal protein or fortified stuff. (I can’t say the same for all your minerals. The evidence isn’t ironclad, but I personally take a multivitamin, which at worst gives me iron and vitamin D I indeed need.) You can have harmful effects from many vitamins, so don’t overdo the supplements, especially A, D, and E. In Vitamin K, the “K” stands for “Koagulation,” the Danish word for something vitamin K is related to, and happily that was the first un-used letter at the time some Danes discovered it. Vitamin B12 was the last to be discovered, in 1948. Riboflavin (B2) was early and niacin (B3) was late, but the rest were more or less discovered in alphabetical order. Didn’t you always wonder but never get around to looking it up? Aren’t you glad you read until the end?

From the Toxoplasmosis Files

Since we last spoke, many and several exciting things happened in my life, but I will confine the photo evidence to these elements: I finally got COVID and thus had to buy tissues in bulk but I’m 99% fine now; we got a new rug to match both cats.

xoxo