#Head and Neck Surgery Journal

[anxiousbabybird]

Love and Deepspace men x fem!reader slightly unhinged HCs

I started Love and Deepspace yesterday so please have my slightly unhinged HCs for the men so far. And minors don’t you dare interact

Part 2

Rafayel

He’s a biter. Leaves you covered in marks from your neck all the way down your thighs.

Plans a date where he’s laid out a huge canvas on the floor of his studio, puts your fave color paint on your hands and his favorite color on his hands, plus several globs of the two colors across the canvas, and then proceeds to have the wildest three rounds of sex on that canvas as it gets progressively more covered in paint. Sells the painting for 6 figures a few weeks later and uses it as an excuse that you need to make more of them.

Tells you his best masterpiece is painting your body with his cum—got really into it once and dipped the paint brush into your cunt to collect his cum and then painted it across your breasts

Has a secret sketch book that’s nothing but pictures of you. Lots of them are of you sleeping when he can study your features but there’s still quite a few he drew from memory.

Made you lay down naked with your legs spread and be still so he could draw the most detailed image of your pussy you could possibly imagine. It’s his personal fave that no one besides him will ever see.

Sees shibari as a beautiful art form and likes to practice with you—has a whole album in his phone just of pics of you tied up all pretty for him

Rarely gets soft in a serious way, he much prefers the teasing back and forth you two usually have.

Xavier

He’s definitely broken into your room Edward Cullen style and watched you sleep

His favorite dates are taking you into the forest at night to watch the stars and moon together. Bonus points if you come across a wanderer and get to fight together.

Clingy after you become his, always wants to be touching you and doesn’t let you out of his sight (and yes that means sometimes he’s following you but it’s just because you’re brave and reckless and he worries)

When he eats you out, he holds both your hands in his for you to hold on to and does it with no hands—makes you cum more times on his tongue than you could fathom (and yes, he’s eating you for his pleasure)

Downloaded a tracker into your watch so he can know where you are at all times

Gets horny when he watches you fight and has def pulled you aside during a mission for a quickie in which you end up having your cunt stuffed with cum for the remainder of the mission

Such a cuddler but like a cat where he only wants to cuddle if he wants to—falls asleep nearly instantly in your arms like the cute sleepyhead he is

Zayne

Finds it so cute the first time he comes to your apartment and sees all the little snow creatures he’d made you sitting in a windowsill together. Makes you so many more after that. Sends you a bouquet of flowers made from his ice too (#Elsa)

Has food delivered to you at lunch on days he knows you’re super busy so you don’t forget to eat since you often forget to take care of yourself (he doesn’t mind too much since he likes that you let him take care of you)

Prefers kisses over hugs, except when he’s sad because of a patient (then he likes the warm comfort of your hugs)

Moves his glasses to the top of his head and rubs the bridge of his nose when he gets really stressed

Brings you a mild painkiller after blowing your back out, a smug but tiny smile on his lips, and tells you, “I was a bit rough so humor me and take this medicine. I don’t want you in excess pain because of me.”

Loves when you want to lay on his chest when he’s reading through cases and medical journals at night. He’ll read them out loud until you fall asleep and then finish them quietly as you snore softly into his chest

Calls you before a difficult surgery because your voice instantly calms him down

Into bondage—specifically he likes to tie you up so you can’t escape when he starts to overstimulate you. He really can’t help it, you just make such pretty noises for him when he gets you to that point that he has to keep going

Tags: @adaurielle @luffysprincess @seraphofthesimps

#love and deepspace #love and Deepspace HCs #zayne love and deepspace #Zayne HCs #zayne x reader #rafayel #rafayel love and deepspace #rafayel HCs #rafayel x reader #Xavier x reader #xavier love and deepspace

[ourhaileydavies]

Skin Closure with Barbed Sutures: An Early Evaluation of Cosmesis and Complications

Author By:  Vinay Kumar Tiwari

Abstract

Introduction: Barbed sutures have the potential advantage of decreased operative time and better wound cosmesis due to bidirectional fixation of wound. Present study evaluates the complications and scar cosmesis after skin closure with barbed sutures.

Material and Methods: This was a prospective, observational study. Patients underwent subcuticular skin suturing in surgically created clean wounds. Half of the wound closure was done with barbed absorbable suture and other half with non-barbed absorbable sutures. Comparison of scar cosmesis and wound complications was done.

Results: Mean time taken for suturing per cm of wound was lower in barbed suture group. Suture extrusion rate was higher in barbed suture group. No statistically significant difference was found between cosmesis of scar and rates of infection between the two groups.

Conclusion: The current study did not find any added advantage of using barbed sutures over and above conventional sutures in terms of cosmesis of scar. The only advantage was that of decreased operative time.

Keywords: Barbed sutures; Wound cosmesis; Operative time; Scar; Suture extrusion

Introduction

Barbed sutures have been in use since many decades. They provide effective wound closure due to bidirectional fixation within the wound. The presence of barbs leads to distribution of tension across the wound and also eliminates the need for knots. A barbed suture prevents backward slippage of the sutures, and as a result it does not gape in areas of tension allowing for an aesthetic subcuticular closure. Some clinical studies have shown a better resultant scar.

These sutures allow for a running closure of the wound, with fewer preliminary buried sutures leading to saving of one third to half of the time taken in suturing which can be their greatest benefit [1,2]. This study was done in Indian population where previously no such study has been reported. This study was done by using barbed and non-barbed suture in the same wound by dividing it into two halves thus removing all the confounding factors.

Material and Methods

This prospective, observational study includes 50 patients and was conducted from February 2018 to August 2019. Patients of all age groups were included in the study. The study population consisted of all the patients coming to plastic surgery department at our institute. All patients undergoing primary wound closure in a wound length of greater or equal to 5cm were included in the study. The study included patients with surgically created wounds and included simple surgical incisions and excisional wounds.

Patients with uncontrolled diabetes mellitus, collagen vascular disease, irradiated skin, immunodeficient states, past history of keloid formation, active cutaneous or systemic infection at the time of surgery, chronic renal or hepatic failure were excluded from the study. Preoperatively, patient’s wounds were marked, and dimensions were noted by using Vernier Callipers. Wound was divided into two equal halves and marked. Subcuticular continuous skin closure of one half of the wound was done by conventional polydioxanone sutures while the other half was sutured by barbed polydioxanone sutures. The wound closure was done by the same surgeon. Time taken for surgical closure was noted.

Post operatively various parameters were monitored to evaluate outcome and complications of patients. All patients were followed up for 2 weeks, 1 month, and 3 months after surgery and scar assessment was done by an independent and blinded observer. Scar cosmesis was compared by using POSAS and Vancouver scar scale. Width of the scar, time taken for surgical closure, median scar width and wound infection rates were compared. Wound infection was defined as wound erythema, tenderness or pus discharge from the wound.

Data was entered in Microsoft Excel spreadsheet. Statistical analysis was performed using SPSS (version 18.0). Categorical variables were summarized as frequencies and percentage. Continuous variables were presented as mean and standard deviation or median and inter quartile range based on the normality of data. Normality was assessed using Kolmogorov mirnov test. In case of non-normal or asymmetric distribution, non-parametric test was performed to assess statistical significance.

The following statistical tests were applied

(1) Quantitative variables were compared using Unpaired t-test/Mann-Whitney Test (when the data sets were not normally distributed) between the two groups.

(2) Qualitative variables were compared using Chi-Square test /Fisher’s exact test. A p value of <0.05 was considered to be statistically significant.

Results

A total of 50 patients were studied for a period of 18 months. There were 16 (32 %) women and 34 (68%) men. Maximum (54%) of patients were in the age group of 20-39 years (Table 1). The wounds involved head and neck in 7 patients, trunk in 23 patients, upper extremity in 5 patients, and lower extremity in 25 patients. The width of the scar was evaluated at 2 weeks, one month and 3 months post-operative period. Median scar width (in mm) was compared. Mann-whitney test was performed (Figure 1, 2 and 3).

There was no statistically significant difference in the width of the resultant scars between barbed and non-barbed sutures (Table 2). Time taken in suturing per cm of wound between barbed and nonbarbed suture groups was compared. In our study the time taken for barbed suture was less (23.38 seconds per cm of wound) than conventional absorbable sutures (25.16 seconds per cm of wound) and the difference was statistically significant with a p value of 0.001.

Comparison of Vancouver scar scorewas done at 2 weeks, one month and 2 months’ time period. The median scar score was higher for barbed sutures at one-month postoperative period. Mann-whitney test was performed and the difference was not statistically significant (Table 3). POSAS score (patient) was compared at 2 weeks, one month and 2 months’ time period (Figure 4, 5 and 6). Mann-whitney test was performed and the difference was not statistically significant. The median score was same for both the groups at 2 weeks follow up period. The score was higher for barbed suture group as compared with non-barbed suture group at 1 month and 3 months follow up period. But this difference was not statistically significant (Table 4).

POSAS score (observer) was compared at 2 weeks, one month and 2 months’ time period. The score was higher for barbed suture group as compared with non-barbed suture group at 2 weeks and 1 month follow up period. Mann-Whitney test was performed. The difference was not statistically significant (Table 5). Overall, no significant difference was found in wound cosmesis between barbed and nonbarbed suture group as evaluated by Vancouver scar scale and POSAS observer and patient scar scale. The wounds were evaluated for surgical site complications. Comparison of suture extrusion between groups was done.

In barbed suture group suture extrusion was seen in 9 cases over a period of 3 months. 7 cases were with wounds involving lower extremity and 2 patients with wounds in upper extremity. Only one case of suture extrusion was present in nonbarbed suture group which occurred in upper extremity. Chi square test was performed, p value was <0.01 and the difference was considered as statistically significant. Comparison of surgical site infection at two weeks, one month and 3 months’ time period was done. Chi square test was performed. Higher rate of infection was seen with barbed sutures but the difference was not statistically significant (Table 6).

Discussion

Scarring is an inevitable result of any surgery. Since time immemorial surgeons have been searching for techniques to reduce postoperative starring. Barbed sutures were introduced as tool to reduce scarring. The presence of barbs leads to better tissue fixation and lesser scarring. Theoretically barbed sutures lead to bidirectional fixation of wound which leads to lesser wound gaping and decreased width of resultant scar [1,2]. This was not seen in our study and there was no statistically significant difference in width of the resultant scars between the barbed and non- barbed suture groups.

Decreased width of scar leads to a better aesthetic outcome. A study by Koide et al displayed a significantly better aesthetic outcome in the barbed suture group than nonbarbed suture group [3]. But in our study, there was no statistically significant difference in scar cosmesis as compared by Vancouver scar scale and POSAS (observer and patient scar scale) between the barbed and the non-barbed suture groups. Our findings were similar to studies by Kristen Aliano et al, Amy P Murtha et al, Rubin et al and Grigoryants et al [4-7]. As our study evaluated the scar for only three months, a prolonged follow up is further required to evaluate the scar after remodelling. The time taken per cm of wound was evaluated for both barbed and non-barbed side.

In our study the time taken for barbed suture was less than conventional absorbable sutures and the difference was statistically significant. Similar results were seen in studies done by Koide et al, Kristen Aliano et al,Grigoryants et al, Jeremy P. Warner et al and Blacam et al [3,4,7-9]. Jandali et al, found that using barbed sutures reduced the operative time of unilateral breast reconstruction significantly, but no significant difference was seen in the operative time of bilateral breast reconstruction [10]. The only study showing increased operative time was that by Murtha et al, but the results were not statistically significant [5]. The decreased time taken in barbed suture group in our study is likely because there is no need to put a knot in barbed suture at the ends of the suture line. Also, the handling of suture is improved as the tissue gets fixed with each stitch with a barbed suture.

Our study evaluated the wound for surgical site infection. It was seen that barbed sutures were associated with a higher rate of surgical site infection, but the difference was not statistically significant. Overall, it was seen that the patients having lower extremity wounds had more surgical site infection. This may be due to a greater number of patients having wounds in lower extremity. Also, lower extremity skin is less lax hence wounds are usually closed under more tension leading to wound ischemia and more wound infection. Similar results were seen in studies done by Murtha et al, Jandali et al, where more infections were seen in barbed suture group, but it was not statistically significant [5,10].

Roberto Cortez et al, studied the complications associated with barbed sutures. Their retrospective study found that barbed sutures were associated with significantly higher rates of minor wound complications [11]. The increased incidence of infections in the barbed suture group may be due to the fact that the presence of barbs in the suture leads to colonization of bacteria and resultant higher rates of infection. In our study suture extrusion was seen in 9 out of 50 patients in the barbed suture site as compared to only one patient in the conventional sutures group. The difference was statistically significant. Suture extrusions or stitch abscesses were noted in a total of 10 patients, a probable consequence of the superficial placement of the sutures during subcuticular closure of dermal and subdermal layers.

Similar results were seen in a study done by Rubin et al, which showed increased suture extrusion on the barbed suture side than on the smooth suture side [6]. These findings were consistent with the findings of our study. In a study by Murtha et al, suture extrusion was seen in 10.2 percent of barbed suture subjects as compared with 19.7 percent control suture subjects [5]. The placement of sutures in our study was superficial dermal which might have led to the higher extrusion rate. Further study is warranted to evaluate the extrusion rate of sutures placed in deeper dermis. We used delayed absorbable sutures in our study which could also have contributed the higher rate of extrusion of sutures.

As Grigoryants et al, compared extrusion rate of slow absorbing and rapidly absorbing barbed sutures and found that rapidly absorbing barbed suture had lesser extrusion rate than delayed absorbing barbed sutures [7]. Overall, the complication rate was higher for the barbed suture group. These findings were in contradiction to a study done by Blacam et al, comparing abdominal closure with barbed and non-barbed sutures which found that the complications associated with barbed sutures were lesser. But the follow up period in this study was one month as compared to three months in our study which could have led to the difference in the findings [9].

Conclusion

Barbed sutures lead to decreased operative time but there was no advantage in terms of better scar cosmesis. Though there was an increased rate of surgical site infection barbed sutures, the difference was not statistically significant. The suture extrusion rate with barbed sutures was higher and the difference was statistically significant. Probably study over a larger sample size will give us a better picture. Barbed sutures are costlier than conventional sutures, but their use is less time consuming. So further studies in terms of cost analysis in relation to decreased operative time are warranted to fully evaluate the cost of using these sutures.

#spine surgery #Head and neck surgery #spine #Juniper Publishers #open access journals

[reneeluv154]

Apple

Hope you enjoy <3 <3

⚠️This is a smut, I’m sorry if it’s absolutely horrible, this is my first one. Also I felt mad awkward writing this. Hahah

If you like this imagine I have a couple more on my profile. 🫶🏼

Today had been a long day and it wasn’t even 12:00. Jack sat reading up on a surgery he was required to do in a few day’s. “Jack, you haven’t lifted your head from that book in the last three hour’s.” I set down my journal. “It’s important I get this right y/n.” He huffed, taking a bite out of his apple. I smirked devilishly, “Is your apple good?” I asked, walking over and straddling him. Grabbing his hand, taking a small bite out of his apple.

He looked at me, barely biting his lip, his eyebrows furrowed. “Not now Y/n.”

“Pleeease we haven’t had any fun in month’s.” I pouted, closing his book and grabbing his face to look at me.

“I know love and I apologize but I’ve been really busy.” He moved my hair behind my ear. “Don’t you miss having fun?” I asked, He nodded “I do, I promise I do.”

I smiled playfully reaching the hem of his shirt pulling it up, He didn’t fight, letting me completely pull it off and throw it to the floor. It wasn’t long before our lips were working passionately and our hands ventured.

“This is hardly fair love.” He glanced down at my shirt smirking. I smiled, both of us breathing heavily as I pulled my shirt off letting my breast’s pop out since I wasn't wearing a bra. “Fuck Y/n” He moaned grabbing my breast’s groping them roughly. “Jack please, I need you.” I moaned hard as he played with my nipples rubbing and pinching them. “Patience baby.” He whispered into my ear blowing hot breath against my ear.

After another 20 minutes of hickies,pinching, kissing, and groping I couldn’t take it anymore. I needed him in me. I broke our kiss, grabbing his pant’s, pulling them down and taking my panties off as well. I felt as though I couldn’t get undressed fast enough,Jack sat there smirking at me in my frustrated and impatient state. I finally pulled down his boxers letting his hard cock jump free. I couldn’t wait sitting down letting his cock fill my pussy before I started to bounce, still in my frustrated state. It took me a minute to notice him groaning and kissing down my neck. “Ummm baby, you're bloody tight, maybe I should starve you like this all the time.”

“Don’t you fucking dare.” I breathed going as fast as I could but it still wasn’t enough. I whimpered, “Jack It’s not enough.”

“You want some help?” He asked breathlessly. I nodded fast, “Word’s baby.” I tried to catch my breath “Ugh yes! I need fucking help Jack, Please!” He took his index finger down to my clit, rubbing it violently while moving his hips in sync with my own. “ Mmm damn baby.” He moaned. I felt his seed fill me and that was enough to throw me over the edge. I screamed cumming down his dick while he continued to move my hips helping me ride it out. “That was good, holy shit that was good.”

He gasped. I couldn’t force any word’s out of my mouth.He finally pulled out making me sigh from the empty feeling. “You okay?” He asked with a small chuckle. I slowly nodded, keeping my head on his shoulder not having the strength to move. My legs around his waist and my arms around his neck, he picked me up gently, setting me down on the bed covering me up with his thin sheets. “Are you sure you're okay?” He asked, stroking my arm. “Yeah I’m okay.” I mumbled. “Okay, scoot over gorgeous.” He softly spoke, laying down letting me lay on his chest while he opened up his second book and started reading

#jack dawkins imagine #Jack Dawkins smut #thomas brodie sangster #tbs fanfic #tbs smut #tbs #tbs imagine #the artful dodger #artful dodger #jack dawkins #artful dodger smut #thomas brodie sangster imagine #thomas sangster #queens gambit #benny watts #benny watts fanfic #jack dawkins fanfic #jack dawkins smut #jack dawkins the artful dodger #a5 newt #benny watts imagine #benny watts sex #benny watts smut #newt imagines #newt imagine #artful dodger fanfic #artful dodger imagine #queens gambit fanfic

[like-if-a-bad-idea-was-a-girl]

So I wrote, I guess fanfiction(?) about @puppygirllaika 's story Transition Diary of a Sex Doll, she had no hand in writing this it's just my interpretation and I'm posting it here with her consent.

It takes the form of a journal update from the pov of Andie several years later explaining in detail how she goes about looking after her doll.

Obviously everything you read here is fantasy and for entertainment only. The only TW I'd add to the list on the original story is I talk about calories at one point very briefly.

Hi all, this is Andie. I've had a ton of requests to let or make Jane update this. First if all 'Jane' is a dead name now, my doll doesn't have a name anymore. Second I have given it the opportunity to do so and it has declined. So here I am several years later to give you an idea of what its existence is like now and how I go about looking after it. I'm doing this, finally, because I feel like if I can help others either look after their new doll or figure out their feelings then I should. So here goes I guess

Bedsores: I can't have my doll getting infected, it'd be less useful for me. But this is a two birds one stone situation because I always need something to do with my hands and touching flesh is especially rewarding, so whenever I'm watching TV I have it on my lap and kneed the flesh where it tends to lay

Voice: originally it wanted full vocal chord removal so it'd be silent but I changed the surgery to suit me better, it now has only partial use of its voice, just enough so my doll moans when I fuck it and screams when I cut or hit it

Mind: if my doll lost touch with reality it'd start reacting to things that aren't real and I need it to be quiet when not in use so I have to keep it sane. So every day I prop it on the couch surrounded by stuffed toys and put the TV on for it. Sometimes I put on horror movies so it can practice screaming and looking scared, sometimes porn so it can practice moaning and crying out, or sometimes just nature documentaries. And I make sure I take it out of the house at least once a month, sometimes to a hookup so we can both use it, or camping or on a road trip.

Muscles: I need my doll to be able to clench around me and move its neck enough to give me head so I can't let its muscles atrophy. So i bought a tens unit and i put it on once or twice a week for a few hours to keep the muscles moving properly Skin: I like its skin to be smooth and well looked after because it's a better tactile experience for me and also because bruises look better on nice skin. So I sponge bath it often, scrubbing its skin thoroughly and cleaning all the tricky bits to keep them fresh. Whenever I cut it for the pure pleasure of parting living flesh with a sharp blade, or whenever I bite it so hard I come away with a chunk of flesh, or even when I dig my nails in so deep I carve deep gouges, then I need the first aid kit. I've got rather good at suturing wounds closed and carefully bandaging them, and then once they have healed enough I rub oils and moisturizers into the healing skin to minimize scars. And of course I keep up with its estrogen gell so its skin stays smooth.

Hair: mostly not a big job, the hair on its face it had lasered back when it was pretending to be human, the skin around its pussy was removed by electrolysis prior to the bottom surgery, and the hair on its head I keep just long enough to be useful for gripping so it has a convenient handle

Food/ water: it needs much less of both now, about half a cup of water a day and one meal every second day, it took me a long time to figure out the optimal calorie intake so its boobs would stay nice and full and its belly chub was enough that I can use it as a hold to fuck it. I make it a special all-in-one food so its bones and skin and everything else stays strong and healthy, and I make it in all the flavors it used to love because nutrients are absorbed better when the senses are properly stimulated. And then of course I brush its teeth.

I also bought one of those fancy neural link headsets, mostly for emergency use, because only it can tell me if something feels wrong in its body. But once a year I put the headset on her and force her to be a person for a couple of hours, I know she hates it and it exhausts her but I've told her it's like routine system maintenance and that seems to help. I make her reaffirm her consent for everything that I do to her. I ask her if she has any requests or anything I can do to help her be a better toy. We talk again about the possibility of a lobotomy or something more serious. I ask her if she has anything else she'd like to say. And then I take off the headset and I watch it sigh and relax as the mask falls off, as it stops pretending to be a person.

Between all that, yeah it's a big job looking after my doll properly. But it's mine and I'm careful with what belongs to me, and if I didn't feel like it was worth the effort I would have given it away or sold it by now. There's the obvious sexual uses, but there are lots more. Human bodies have sympathetic nervous systems so it really helps with my anxiety and panic attacks to cuddle it really tight to my chest. Its slow steady heartbeat and measured breathing soothe me, sometimes it hums softly which helps too. And it makes a great therapist, it listens and never talks back and looks at me with those deep loving eyes. Ohhh and of course as a hot water bottle, my feet get so cold at night it's nice having something soft and warm to put them on whilst I sleep, making sure the blanket isn't covering its face.

Thanks for reading, I hope this has helped anyone considering becoming a sex doll or taking on the responsibility of one of their own.

[bestiarium]

The Stronsay Beast [modern cryptid; globster]

In September of 1808, a strange marine creature washed ashore on a beach of Stronsay in the Scottish Orkney Islands (at the time, the island was called Stronsa). It resembled no known animal, having six arms, paws or wings, which were about 4.5 feet (1.4m) long and resembled plucked goose wings. When the news reached universities and scientific institutions, anatomists were called upon to visit the carcass and find out what kind of animal it was. Unfortunately, by the time these scientific men reached the ‘Stronsay Beast’ – as people had taken to calling it – the corpse was decomposed and weathered beyond repair. Few biological traits remained recognizable, so eyewitnesses were called upon to describe what the creature had looked like.

According to these eyewitness reports, the creature was about 55 feet (16.8m) long when it washed ashore and had a long and thin neck. At the end of the tail was something resembling an ear.

Scientists were puzzled, and some were of the opinion that this creature must have been a sea serpent, whose existence was considered plausible by many at the time. Spearheading them was John Barclay, a respected professor in anatomy at Edinburgh University who adamantly claimed that the carcass was the first solid evidence of the existence of giant sea serpents. His opinion was opposed by Everard Home, sergeant-surgeon and lecturer in surgery and anatomy at London’s Royal College of Surgeons. He did not believe in great sea snakes and claimed that the ‘beast’ was simply the torn and shredded carcass of a basking shark. He dismissed the eyewitnesses as unscientific and relied only on the shape of the bones that were found within the corpse.

During the discussions on the nature of the beast, reverend Donald Maclean entered the stage and claimed to have seen the creature alive in June, several months before it washed ashore, near the coast of the island Coll. The reverend claimed that the creature had a small neck with a broad, somewhat oval-shaped head that looked at his ship. Alarmed by the approaching animal, the boat was steered towards the shore. Eventually, the water became too shallow for the large creature and it returned to the open waters. The reverend also estimated that the creature was about 70 to 80 feet long (21 to 24m), which is much larger than the corpse on the beach. Additionally, he claimed to have questioned the crews of several fishing vessels that supposedly also encountered the creature. According to these reports, the monster had a head as big as a small boat with big eyes as large as plates. Although it looked terrifying, the creature did not attack.

Eventually, belief in the existence of giant sea snakes died out (at least within the scientific community) and Barclay’s conclusion was no longer taken seriously. Today, biologists agree with Home that the creature must have been a dead basking shark, or rather the damaged remains of one.

Source: Jenkins, B., 2022, The ‘Stronsay Beast’: testimony, evidence and authority in early nineteenth-century natural history, The Royal Society Journal of the History of Science, 0, published online. (image source 1: MechaDaveO on Deviantart) (image 2: Home’s drawing of a basking shark compared to a reconstruction of the Stronsay Beast based on eyewitness reports, on the same scale. Image source: Phil. Trans. R. Society of London, 99, 206-220 (1809).)

#cryptids #urban legends #aquatic creatures #monsters #mythical creatures

[lorenzobane]

Emotional Support Lizard

Summary: Julian is a bit upset, and Garak is determined to help.

(On AO3 Here)

Julian is actually, Garak thinks, fairly easy to care for emotionally. When his ego has been bruised, he wants someone to drink with and listen to him complain. When he's angry for some morally self-righteous reason, he wants to rant, rave, and be sanctimonious for a bit. When he's bored, you just need to run him like a riding hound. Garak's become an expert at random, lengthy, energy-draining tasks to keep in his back pocket for when Julian starts to fidget.

He's also honest, willing to just say what he needs when he's hungry or tired or wants a hug. Garak appreciates it more than he can express because trying to learn to be emotionally supportive of someone for the first time in his life at the tender age of fifty seems like a daunting task.

He reminds himself of this now because he's hit the one circumstance when Julian is not easy. He's upset, truly upset about something, though Garak cannot say what. Garak can tell because he's hardly spoken all night, pulling sharply into himself. He can also tell because Julian currently has three PADDs downloading what appear to be roughly 154 different journal articles. He isn't planning on sleeping.

Garak's tried everything, offered to get weeknight drunk on spring wine, to play a board game, sex (which Julian almost never refuses), and it had all been met with a bland, tired, "perhaps another night."

"My dear," Garak hesitates, watching Julian peck at his already light dinner with disinterest. "Are you... Are you alright?"

It burns him a little, being forced to ask so bluntly. He cannot help but be furious with himself at his inability to predict what Julian needs.

Julian gives him a glance and a fake smile. "Of course, love. I'm sorry; I'm clearly a bit distracted. I think I'm going to read in the library."

The library, as they called it, is more of an office that they sometimes used when they had urgent work that had to be done from home. The room was split into two sides, Garak's and Julian's, but they shared a broad catalog of leisure books that they kept in the same room.

Garak bites his lip, "you've hardly eaten."

Julian looks at his still mostly full plate. "I'll keep it in stasis and eat it later. I'm not hungry right now."

Garak nods and inclines his head, not sure what else to say when Julian takes his plate and leaves. As soon as Julian's turned the corner, he dropped his head into his hands. What could possibly be upsetting him this much? Was something wrong at work?

Or perhaps, a cold voice whispers in his ear, he's upset with you. Perhaps he's no longer happy in your home; maybe he regrets that lovely joining necklace on his neck. Maybe he's been thinking about a divorce, about leaving.

Garak feels the room closing in a bit around him and takes a deep breath, grounding himself in the feel of the chair under his lap and the sour-sweet scent of zabu stew. He's being irrational. It probably has nothing to do with him; when Julian is upset, it is nearly always work-related. All Garak needs to do is find out what.

Carefully puts his dish away, gets himself a cup of tea and his private PADD, and sets about hacking into the hospital's files.

Garak absent-mindedly flipped through Julian's most recent case files, taking a long drag of tea. Nothing so far, a few surgeries that went well, a bit of post-op care for others, nothing that jumps out at Garak as being unusually bad. He switches to security camera footage for the main areas of the hospital (there are no, Garak notes with irritation, cameras inside the hospital rooms). He scrolls through the footage at 2.5x the speed, watching Julian go about his day, casually flipping through medical charts and going from patient to patient before leaving to scrub in at the OR.

Garak ponders this and decides it probably isn't work-related. Taking a last stab, he checks Julian's message box. Mostly emails from Ezri Dax, Miles O'Brien, and Kira Nerys, with roughly 200 promotional emails from Quark's. He's about to give up hope when he sees an email Julian has marked as Important from South Rixx General Hospital.

Garak clicks it immediately and begins scanning the message. His eyes widen the further down he gets, and he quickly reads the rest of the messages in the thread. Once he gets to the end, he sits back heavily. Why didn't Julian just tell him?

It appears Julian's father, Richard Bashir had contracted a serious, potentially life-threatening infection while on Betazed a few months ago. Julian had been consulting with the hospital, trying to help. The last message, the one Julian received today, stated that Richard was responding slowly to treatment and the prognosis did not look encouraging.

As far as Garak can tell, Julian's relationship with his parents is complicated and emotionally fraught. He had met them several times, in fact. Both in person, when they've either traveled to Earth, or on Cardassia Prime when they've come to visit. They've even taken one incredibly painful family vacation to Ailsa IV. Julian calls them every two weeks, and they have a strained chat where Garak gets to see Julian do a phenomenal performance of Julian Bashir.

Despite how much Julian rages about his father and mother and how tense their relationship is, Garak knows they love each other. That is, in Garak's view, the precise problem.

He puts the PADD down and thinks. Garak would bet his left foot that those journal articles Julian was downloading, and is no doubt tearing through now, are related to his father's illness.

He gets up and walks to the library, "Julian, my dear?"

"Hm?" Julian replies, he has a PADD in one hand, and the other is tapping on the larger monitor running a calculation.

Garak hedges, "I'm worried about you."

"I'm perfectly fine, Garak," Julian replies a bit sharply.

"I'm sure you are, but still, you'll have to forgive me... This is all a bit out of character. Can you at least tell me what this is about?"

Julian sighs and rubs a beautiful hand across his face. "Just... A personal project."

"My love," Garak says, looking at him as sweetly as he knows how and pulling his lips into a soft pout, "you can tell me anything. Am I not, after all, your family?"

Julian's face softens, and he places a hand on Garak's cheek, "of course you are. Of course, speaking of family actually-- that is--"

Julian abruptly cuts himself off. "You already know, don't you?"

Garak licks his lips, "of course not. I haven't the faintest idea--"

"Oh, spare me," Julian spits. "You're trying to manipulate me into telling you something you already know. For what? A sense of accomplishment on this fine evening? Well, bloody, fine, my dad is sick, and I'm trying to fix it. Which you already fucking knew. Now please leave."

"What?" Garak gasps sincerely. "No! Julian, please. I am worried; I just want to be there for you. I wanted to help."

"You can't hack into my private files every time you want to help me! Some things are personal!"

"Too personal to share with me? Your husband? Who promised to honor and serve you for the rest of your life?" Garak says this a bit desperately, he knows, but it is nonetheless true.

"I needed time to process how I felt!" Julian takes a deep breath before whispering, "I would have told you, Elim. I would have. I wish you had trusted me to."

The room grows quiet for a moment before Garak stiffens up and coughs slightly. "Apologies, my dear. For overstepping. I'll leave you to your work."

Julian watches him steadily; he can feel his eyes on his back before Julian lets out a sigh. "Oh, come here then."

Garak turns sharply and is pulled into Julian's warm embrace.

"There must be something seriously wrong with me," Julian says, his voice a little softer and warmer. "But I suppose it is sweet how much you want to help. You're all sentiment under those scales, aren't you?"

Garak harumphs, "there is no need to be rude. I was simply--"

"I recommend you tread very carefully and remember that I am choosing to find this charming."

"I was simply being terribly, terribly sweet. An excellent husband."

Julian chuckles against Garak's ear. "Good choice."

"So," Garak asks, a bit softer. "Will you be coming to bed?"

Julian hesitates; his body goes slightly tense against Garak's before he relaxes again. "Yes, I will. Let's go."

Garak thrills a little at the victory, despite the minor stumble. Perhaps he can convince Julian that it was all a part of the plan.

#julian bashir #elim garak #garashir #st: ds9 #this is... hmm idk #it's something that demanded to be written #sometimes it do be like that #like it mugged me

[shepfax]

combo of day 3 and 4 post-op journal

this one has a photo in it of my body post-op so viewer discretion is advised. there is no blood, sexual content, or overall frightening imagery but it is "raw" so to speak in that it's actively healing flesh so it'll be under the readmore.

so yesterday (Jan 7th) I got to take a shower for the first time since surgery. this was my first chance to see my chest uncovered and when I tell you I legitimately could not be happier I mean it. my surgeon is apparently a fucking master human sculptor (my primary doc said today that she's typically on task for cis people's cosmetic procedures anyway) and she gave me a body that really, truly looks the way I always knew it should.

look at that. a fucking masterpiece. incisions lovingly shaped under my natural chest wall, nipples realistically placed, it's just organic enough to look symmetrical without actually being so, which is exactly how I wanted it for fear of looking artificial. it's soft, not flat, just like me, and it's mine. it's truly, honestly beautiful to me.

also I got a note that the pathology was normal on the tissue they removed and it confirmed that I lost 3.35 lbs of dysphoric meat. big win for me.

the showering itself was low-key awful though I'll be real with you all. removing the soft dressings from my bolsters and drains (which I was instructed to do I promise) made me all the more aware of them and while the bolsters are 100% numb the sensation of the drains made me almost faint it was so viscerally offensive. I sat in the shower and my wife helped me wash my head, arms, and back for as long as I could handle being out of the compression vest. putting it all back on was fine but then it was like. you know how you pack a suitcase perfectly before a trip and then you can never get all the shit you brought to fit the same way back into the suitcase? it feels kinda like that. ever since I unwrapped everything and re-wrapped it, I am suddenly slightly more aware of it's presence and it sucks ass. the drain outputs keep pinging me with a gnarly little itch of pain and the shower dressings I wore over the bolsters ripped out a bunch of my chest hair and those areas are itchy as fuck now. grrr

for physical activity I tried some of the neck/arm exercises the doc sent me and went with my mom to the grocery, picking up scar care gel for future use.

a friend of my family sent me not one, not ten, but a pack of 24 silly straws as a get well gift. I have aggregated 23 of them into a vase as the world's silliest bouquet and use one to stay hydrated.

today (Jan 8th) I took it very easy, with a small breakfast, a big hefty nap and a virtual appointment with my primary doctor for medication recheck on my hormones. she was very happy to hear about my experience with my surgeon and plans to recommend her to others in the future. big moment: I made myself lunch for the first time since surgery (literally just a banana cut in half with some peanut butter in the middle)! activity was only a short walk around the neighborhood with my dad, both because I was exhausted from poor sleep and because it was cold & windy.

tomorrow is my first post-op appointment with the surgical team and I believe it's the day I get my bolsters off but I could be wrong. we shall see what the future brings😀

#shep talks #surgery tag #top op journal

[popcornforone]

You’ve Not Lived, Until You Feel Alive

Chapter 2 of Is That All Mr Gutierrez series

Master List

Chapter 1

Thanks for the love for chapter 1 peoples, I know it was a little different to what I usually write but I need to character builds in this one. When we get to the smut it will be exactly what you all want.

Synopsis: Time has now passed & its 10 years since you had your first kiss with Javi. A lot has changed, & you’ve both grown, but your therapist is asking you to write a secure blog only they can see to get you to believe in yourself once again.

Word count:2500

Warnings: DO NOT READ IF YOU ARE UNDER THE AGE OF 18! THIS IS A VERY TRAUMATIC CHAPTER! I know this will not be for some of you, it gets dark, but I needed it too, I have to break the reader before they get to have fun. Death, murder, suicidal thoughts, violence, terrorists, cancer, shooting, blood, pain & suffering, angst, agony, anger, PTSD, mental health, nightmares. Pining, wanting, unrequited love not being returned, break ups, loss, sorrow. This chapter is done in a blog, journal format.

Again I am sorry if this is triggering or too much, but I needed to do this to character build. If you want to skip to chapter 3 that’s fine, it will be published soon.

Thanks for understanding peoples, it means a lot, & thanks for reading it’s always appreciated. Don’t worry the smut is on its way, I promise.

Secure therapy Blog post 18

I almost didn’t publish this. I really didn’t think anyone would want to hear what I had to say after the events but my therapist said I should just write when the day happened. Writings my therapy, it’s my creative outlet.

But today was the day the unimaginable thing happened….

My dad passed away & im not sure I can go on.

My dads been unwell for a while. We knew it was cancer & it disappeared about 4 years ago but then it came back, & it was incurable.

Nothing the doctors said… there’s nothing we can do… he’s got 6 months… go make memories with him… so that’s what my mum

& I have done.

My mum to have to go through another loss in her life. Another heartbreak, another good bye. I’m not ready to post about the other heart break yet, but I will do one day. It not mine that happened I don’t recall it.

But we have spent the last 18 months with my dad having the best time in the world. The Gutierrez wedding in Cuba for Javis older sister Luna was so much fun, my dads face as I danced with Javi after few too many drinks, thinking of what I could have had with Javi from my time as a teenager crushing on him. It was like time had frozen. My head buried into Javis neck, inhaling his scent for old time sake. The way his hand stroked my back, making me want more. Trying not to think that his fiancé was looking right at us. She knows I’m just his assistant & look after the legitimate side of the business. She has no idea the feelings I have hidden away from her soon to be husband. A pipe dream I had 10 years ago when I wrote my teenage diary.

But then we got home & dad took a downward turn. & he told me to be brave & go after my dreams & to always be true to myself.

When he was still with us after the 6 months the doctor originally told us, we took each day as a blessing. I don’t believe in god, but I know my dad does. Every night I asked my dads god for one more day with him. & obviously I asked for one too many.

Watching him pass was heartbreaking & but also soothing. He was no longer in pain. & what he did medically for the world to help & try & find a cure still astounds me. My dad went through awake brain surgery to see what happened when it was operated on & how it affects the body. He was so brave. If that procedure saves one life, my dads pain & death won’t have been for nothing.

The Gutierrez’ have told me to take as much time as I need. Javi has sent around a vase of black orchids, my favourite, he always says he sees my inner goth whenever he looks at them. He’s said the business can wait & that he can look after himself for a few days, but I am already missing that dimple & cheeky smile. Even now he has a calming influence on me. It’s just him, it’s just J. He will always be there for me. & yes it’s weird that one of my closest friends in the world is a drug lord & part of the mafia, but we run the legitimate side of the family empire. We run it well. & Javi knows a day will come when he has to run all of it. He’s not looking forward to that but he knows it’s his destiny. He & Sofia will raise an amazing family & have a fantastic life & I will watch by the side, maybe with a family of my own, watching them be happy & be glad I have a small part in their life.

My dad told me to be happy. & that’s what I’m going to do… be happy.

He wouldn’t want me to mope around & wait for life to happen.

So that’s what I’m going to do.

We will have the funeral, Javi Senior has said we can have the wake at their mansion, no need for us to have it in our hotel.

But then I think I need to take that gap year I’ve always promised I would do.

I want to see more of the world than just Spain & England. I want to experience life. I want to feel alive. That’s what my dad always said, you’ve not lived until you feel alive.

Dad I miss you.

I miss your smile.

Your kind eyes.

Your bad jokes.

& I miss that you will never walk me down the aisle or watch me grown into a woman. I know I am a woman but I have so many life experiences to come & you won’t be there to watch me grow & fail. Become proud of myself & who I become.

I love you dad…

I’m not sure I can do this without you…

Secure therapy Blog post 26

I’ve put this off

Everyone’s told me to type

Everyone asked me if I’m okay

I say I am

But I’m not

So here goes

4 months ago I nearly died…

even typing that feels like a weight has lifted off my shoulder

It was horrible

I should not be here

I can still feel the heat when I drop off to sleep

The dreams & nightmares are so vivid

Every day awake was already struggle & now my peaceful sleep is full of flashbacks of horrors or my worst nightmares

It’s pain like nothing else

I was in Rome, after seeing the opera, just on my own. I needed from space from mum, work & Javi. His break up was hurting him a lot & he’d been making rash impulsive decisions. It’s most unlike him. So I suggested I went away for a week, have some me time & so he can get over Sophia. The last thing we both needed was to be moody in each others presence.

So I flew to Rome, did all the sights & went shopping, hooked up with some guys & stayed in a nice hotel & went to the opera.

Then at 3am as I slept in bed I felt warm, it was September so the weather is to be expected. & then I heard the noise, & smelt the ash. A car had exploded outside our hotel & the front of the building had caught on fire. I grabbed my phone & keys & headed to the fire escape.

I could feel the heat surround me, my lungs desperately needing air, as this ash fog just coated my throat. I remember seeing some people pass out, lots of screaming & items on the floor that I did not register. I knew I had to make it out, I had to see everyone I cared for one last time

I know that in the last 18 months since my dad passed I’ve felt helpless & suicidal at times but I’ve always found strength & love from others, it’s got me though it. I needed to get out in one piece. I needed to be with everyone even if it is just to say goodbye.

But then I got to the lobby to make my way to the exit. This was not just a car crashing & exploding, this was a massacre. This was an attack on the hotel & its guests. Bodys burnt in front of my eyes, some people bleeding out, bullets & weapons across the floor. Death stood between me & my exit. How I had got to this part of the hotel still alive & not in pain was a miracle already. As I stepped across the lobby heading for the exit, I could just hear my dads voice like he was there going, you’re doing so well sweetheart, you’re almost safe, you can make it. A few more steps & the horrors will be over. You can almost smell the fresh night air, keep going.

Maybe there is an afterlife, maybe he was reaching out to me but I knew I had to make it across & get tho the exit. It took me a while but I stumbled eventually through the exit & gasped as the nights air filled my lungs.

But then the horror continued… but I have no recollection of it. All I remember is the high piecing screech & suddenly feeling warm as something hit me. Blood trickling & seeping through my sleep shorts. I had been shot. I know I blacked out but there was just one thing running through my mind before my face crashed into the hard cold concrete path. That i would was never get to apologise to Javi for telling him to man up after the break up, for not telling him that I knew Sofia was having an affair sooner, & for not telling him that he has been my true love from the moment I met him, aged 13.

27 of us survived the hotel siege. My mum said I had a face Picasso would have been proud to paint when I woke up. She was crying but her humour got me through it. She’s had so so much loss in her life. Losing me would have hurt the most, she’d have no one. We agreed one step at a time, keep things slow, but I keep having these nightmares from the day. I now know it was the police who shot me by accident thinking I was apart if the group storming the hotel & I am being compensated, I mean it is there job to protect everyone & not take any risks. But I was in my jammies how many terrorist siege a hotel in pjs?

Seeing Javi when I got back here on the island was perfect. All our anger & frustration with each other had gone. We hugged & cried & promised to never be mean or hide anything from each other again. & then he broke my heart just before I went to tell him how I really felt about him & that he helped get me through that night & how he was the last thing I thought of before I blacked out. He said I was his best friend & he knew we would always have each others back.

It still hurts much like the wound in my leg. It hurt deep. But if Javi just wants us to be just friends I can cope with that. I just want Javi to be happy that’s all. I want to watch him grow & flourish & live his best life. I want the world for Javi & if that means I’m just a friend, I hope I can deal with it.

I’m so glad I have a secure server to type on.

This has really helped me today, & so has looking back at all my old posts. Therapy has really made me not feel guilty, that I’m here & those people aren’t. Survivors guilt is real & it’s painful. I do still wish at times that I didn’t make it out but my dad was the voice in my head telling me to keep going & that I am strong. My mum will always have my back. & I know I can trust Javi to support me in everything as a friend, even if that’s all it is. But I do wish it was something more…

Secure therapy Blog post 32

It’s been a while… it really has

My therapist told me to write

She told be to be honest

She told me she would read this

She told me to say it

I am worth something

I am not defined by my recent trauma

& I am valid in my pain

Last week was not only the 2 year anniversary of my dads death but also the day I received my compensation for being shot & the findings report from the massacre were released on the same day, it hit me like a train & i seriously considered with all the emotions & conflict inside me, if my life actually mattered

My mums back in London, to complete the renovation of the new dinning room & kitchen of our hotel there, my best friend is on her honeymoon, & no offence to you my therapist, but I knew what you were going to say. I wanted something else or someone else to validate me.

I’ve been staying at Javis on Saturdays recently, he says that’s when he misses company the most & he usually has meetings or church on Sunday mornings. So I was just standing in the kitchen cooking us dinner, when everything just over came me, the knife in my hand looking so sharp & inviting, would anyone really miss me if I killed myself right now…

I didn’t even know Javi had entered the kitchen, but I knew the second I came out of my paused trance that the tingling sensation Within me was from his hand removing the knife from mine, putting it out of my reach. His other hand stroking my back going up & down my spine. I felt like I was actually breathing & being seen for the first time in almost 2 years.

& that’s when one of my favourite songs came on the playlist i was listening too. & I just rocked with Javi in silence, his arms tightly around me waist, squeezing the pain out of me but also filling me with love & purpose… the moment I finally turned my head to see him & his big puppy dog eyes, the lyrics sang “when nobody understands you, well I do” played. We both just softly smiled at each other no words being said.

When the song ended he asked me if I felt better & that I was always welcome & safe in his house or his parents villa if I need some space & didn’t want to go back to the hotel. I told him I knew that, he told me because that’s what best friends do we say nothing & we just understand don’t we…

I should have told him there & then that I was now sure I wanted more but the moment was so pure & perfect & gave me purpose again, that I didn’t want to ruin it with heart break for me if he rejected me. I couldn’t cope with that, not right now. So I’ll continue continuing on

I know my place

& I know Javi will always be there for me…

Chapter Three

#fanfic #my fics #pedro pascal #no minors #javi g #javi gutierrez #javi g fic #javi g fanfiction #the unbearable weight of massive talent #tuwomt #pedro pascal characters #pedro pascal character fanfiction #pedro pascal cinematic universe #pedro pascal fanfiction

[fatgumsurpremacy-remastered]

Hmhmhm very Self indulgent but engie and trans male reader smut. Reader fully recovered from bottom surgery and Engies giving them a lot of attention.

WOAH ANON YOU AND I ARE KINDRED SPIRITS

Tw: teasing, blowjob (tm receiving), anal, bottom I'm. Pet names

The heat of New Mexico was unbearable; the arid dryness of the area stung the prying eyes of passengers. No more so than you. You flippantly looked at your watch, counting the minuets as you stood in the dining room waiting. Days like this would have any man regretting their suit immediately, the starched collar of the white dress suit chafing the skin of your neck. Sweat built up as both anxiety and the heat got to you. You wondered if Dell would even come up here, no doubt he was hungry. You wanted him to see what you’d gotten him. Though with your luck you’d be met with 8 hungry mercenaries and a man hell bent on invention.

Your timer went off and you stood at attention. This marked the beginning of a week in heaven… or a vacation with your husband.

Two mercs aside from Dell knew of your relationship. Medic, and Scout.

You watched as the former walked into the room with an eager look on his face. He smiled and leaned against the entryway, a smug look clung to his features.

“Every time I look at you I’m reminded that I haven’t lost my touch!” He chirped, skipping in a manner that nearly gave him flight. You offered your hand to shake. The doctor caught it and instead held it above you, turning you around and back before clapping excitedly.

“You did lose your license though doctor, don't you remember?”

“Tit for tat boy, I see all is good. I was expecting some complications, but this is Wunderbar! With so little prior knowledge of these types of surgeries I never would have thought it’d go so well. At least-“ as he was moving around he turned his head back to you. You took the time to interject.

“Doctor, I’m afraid there’s no pus.”

His face fell, and brightened again as he piped for another.

“Nor are there blockages or swelling.” You opened your arms, chest heaved with pride in your appearance. “Im a changed man doc. And it’s largely in part to you.” You ignored the pout the man had at your lack of injury, and instead complimented his work. You knew well the doctors morals weren’t bound by any government. But you were damn grateful he stuck to some morals of medicine. He straightened again and sat down across you.

“You we’re a man without me! All you really needed was a-“ The man was cut off by the overlapping shouts of several other men.

“Yeah but Heavy was in the way! The hell was I supposed to do? Run through his legs, do a little dance around him?”

“You could’ve made it easier for me to get a clear shot. I signaled several times for you to move.”

“Well Sniper, you’re supposed to be able to uh- I dunno- AIM.”

You sent a knowing look at medic who rolled his eyes fondly at the bickering. No man coming through the door acknowledged you but Misha who sent you a smile.

“Hello Misha.” You said calmly as he walked to you, you opened your arms for a hug. One he gave to you in earnest. Nearly lifting you as he did. “You have not been here in long time.” He stated, almost concerned.

You shrugged, sitting in the chair behind you. “Haven’t quite gotten the chance. I’ve been down in Texas, writing for the journals. When you have the chance you ought to visit me. It gets incredibly.” You looked up right as Dell entered. Locking eyes, presumably, with his own.

“Lonely.”

He rocked on his feet, before kicking away an imaginary rock. You felt a fond smile appear on your face as he came closer. He walked to you as Heavy and Medic left. “Ain’t ya gonna make the effort?”

“I don’t get a kiss first?” He asked, a silly grin of anticipation welling on his face. You raised an eyebrow, crossing your leg like a mob boss and tilting your head to either side.

“Eh, I dunno if I can make that arrangement for Ya bud. You see-” you stood, crooking a finger under his collar and pulling him close. “You left me really, really lonely. So-“ you let him go, turning only to leave the table and adjust your suit to the other side. “I think you're gonna have to try just a tad harder.”

The man was aghast. He hadn't seen such a demanding side of you in a long time. He himself leaned against the table, weighing his options. “Mm. Sugar I think Id like my kiss first.” You grinned, walking over before bending at the waist and locking eyes with him.

“Earn it.”

He let out a shuddery breath before taking you into his arms and, out the door before anyone could see you. The rest of the mercs would be upstairs for a while, which meant the two of you had plenty of time. As he tripped down the hall with you his thoughts ran wild.

“You poor poor man, why hadn't you come down sooner?” Your look of playful contemplation told everything. “Oh dear! It's almost as if we both have jobs that the other one can't contribute to. Who knew?” Your sarcasm sent warm buzzes through your husband. A giddy smile crawled back up his cheeks. As he neared their quarters he fished his keys out, setting you down before fiddling with them.

“I've got a lot.”

“It's the red one honey.”

“The what?” you pointed at his keyring, but through his fiddling he didn't notice. “The red one love,” you reached out to grab it. As your fingers touched his you shared a soft look. He grabbed the key gingerly before shoving it into his keyhole.

“Imma treat you real nice tonight.”

“Aw yeah?” You asked, voice edging lower as you entered his room and removed your overcoat. “How are you gonna treat me big guy?” He bit his lip, unbuckling his overalls while advancing. “Cant give it all away.” He whispered as he leaned in for a kiss. You tilted your head away, earning an offended gasp from your spouse.

“Such a cold husband, be still my heart!” He moaned dramatically, leaning limp against his desk. You took the chance to throw your coat over him before walking back. “Don’t be a baby Dell, I’m just going to the-“ before you could finished you were tackled down for the bed by your brute of a husband. “You asshole!” You snorted out as he sat above you, his head pressed against your sternum.

You picked his head up and stared at his goggles, sneering slightly when he don’t take them off. “Generally humans make eye contact when we have sex Dell.” He hummed as if lost in thought. “Do they now. I figured they just turned over like this~” In a swift motion he flipped you over on all fours, pushing your shoulders down with it. He then leaned in close, the gravel in his voice sending shivers down your spine.

“And went on their merry way.”

You moaned softly as he placed a small kiss on your neck, his warm lips providing a sense of security. His hand rubbed circles under your shirt, pressing into tender areas. “Dell.” He hummed, noticing the undertone to it.

“You actually gonna do something or are you gonna make me wait?” He scoffed playfully and continued placing kisses around your back.

“Damn man, not lettin’ me have a moment are ya?” He bit back, humored at your impatience. You pushed your hips back, damn sure you made contact with his growing boner. You smirked back at him, playful response growing.

“Boy don’t you dare.”

“Erecting a dispenser back there Conagher?” You snickered before he pushed himself up from you: you heard him chuckling uncontrollably into his palms. Which allowed you to right yourself. From his neck to the top of his head he was a cherry red. You laughed right along with him. He covered his face with one hand and used the other to push you over.

Both of you were on separate planes of existence. Like two hyenas basking in bliss with one another, he eyed you with a glare. One which held no malice but all the misheif it could. “I will get you back for that!”

“For what?!” You exclaimed belligerently, “being funny?” You crawled over to him, doing your best to swing your aging hips over his lap. You steadied yourself with your hands on his shoulders, pressing your forehead against his own. He presumably looked into your eyes, and you took this opportunity to yank them off and throw them to the side. As you savored the look of playful shock you took his face in your hands, biting down on your own lip.

“Aww honey you ain’t got to get my attention like that.” He placed a large hand on the small of your back, large fingers feeling their way back up your side. You considered his statement with a buzz, rubbing the top of his head with your thumb. “I wanted a better look at those handsome brown eyes.”

He looked taken aback, then as a blush crept on his face he blew out. You snorted at the display.

“Let's cut out all this mess, ain't got too much time before the boys wonder where I'm at.”

“You just can't take a compliment egg head,” you remarked, pulling him by the strap of his overalls. “How bout you put that hand to good use?”

He smiled wickedly at the thought, his own body moving forward, caging you under him. He let his gloved hand slide up your shirt, unbuttoning it as he went. His eyes bore into yours, keeping you still as he went along.

“You're quite obedient when I've got you facing me like this. Ain't that a bit odd?” he teased, you shrugged.

“Only natural I assume. Wouldn’t want to give you too much trouble.”

He stopped his action to face you. Brows scrunched in confusion as he did so. With nary a word he removed your shirt, continuing once more. His impatience was clear in his actions, hands moving to grasp at the warm flesh under.

You moned deep at the sensation, so starved of the dull, expanse of his hands. You almost forgot how course and heavy his non metal hand was, gunslingers own, pointer form, covers by rubber. You placed a hand over his, moving it instantly.

He watched in quiet understanding, moving to adjust himself rightly. As your hand reached a stop his continued. He brushed along your stomach. Leaving a trail of kisses down. He never once broke eye contact.

As he grasped at the hem of your pants he smiled. His earnest look sent a surge of familiarity through you. You nodded, taking his arm in your own hand. “I’m good Dell. You can keep goin.”

“You sure? I wouldn’t want to overstep. ‘Ts been a while ‘n all.” You pat his forcep.

“I have been waiting for almost a year Dell Conhager. If you keep me waitin I’m filing for divorce.” He scoffed at the joke before shoving your pants, and briefs down in tandem.

He crawled over you, strong thighs caging you under him. His arm steadied by your head.

“You couldn’t leave me if you wanted to boy. I wouldn’t try.” You just winked before reaching up and letting his straps fall to his side. Taking the hint, he moved a leg to the inside of your own. Allowing you to grind against him as he undressed.

To say it was painful, seemed like an understatement to you. As you tried to get friction you could only feel the temperature around your tip. You whined in need at your husband.

“Give me just a second now love bug. These are harder to get out of than you’d think.” You nodded. And as he stripped you attempted your palms own sneaky decent past his line of sight.

It didn’t go unnoticed. As you were about to take your member in your hand Dell stopped you. Shirt off and overalls bunched around his waist.

“And what are you doin sir?” He laughs as he grabbed at your hand and pulled it to your face.

“I ain’t enough for you?” It was your turn to scoff, but this scoff was out of need. You pulled the bedsheets into your fist as you growled in need.

“Dell! Don’t tease me, cmon!” You looked up at the man who seemed to need more of an explanation. “Dell honey, you know it's hard for me to get off on grinding alone. Could you please, please give me a hand?”

He grinned stupidly, bringing your knees around his waist, he brought his face to your dick. With one hand he held your side and with the other he stabilized you.

He closed his eyes and he licked up your shaft. You felt the most sensation at the base, where you could feel phantom sutures at the site of surgery. You groaned and held the back of his head there. Eyes half lidded, pleasure bringing a haze to your eyes.

And he continued. No words, only quiet groans that were absorbed by your member. He kissed along it for a while, making his way up to the head in time. And then he took it in.

Your legs tensed, eyes fluttering closed as he was able to get around three inches down. He increased his speed, not pleased with the languid pace the session was proceeding at. His own eyes were closed. Focused on sensation.

You groaned into your arm. Biting down on a fleshy bit to keep quiet. He wanted nothing more than to pull your arm away at that moment. Would his base really judge him for pleasing his husband?

Well.

Some might.

He decided not to chance it, instead using spit that pooled from his actions to trace around the rim of your ass.

You gasped as a finger slipped in suddenly. You hadn’t felt this penetration in a while. You arched back against your will. Your body forgetting how much it loved the sensation. You gasped loudly. Panting at Engie to move them faster. To which he obliged.

He popped off of your member loudly, smiling with satisfaction as he stared at your wrecked state.

The man who came in so dapper before was trembling on his fingers. Sweaty and almost to the point of orgasm. Engie bent his posture over to the best of his ability. Back cracking a bit in the process.

His chest fell flush with yours, the skin on you both heating to such a degree it felt like you could melt into each other.

“You’d always been so handsome to me you know that? Always so so damn handsome.” You moaned, his fingers pushing up against your thick walls as he once again pushed through your hole.

“You’re so good, comin over here. Callin me, makin me smile. I wish-“ he said remorsefully. “I wish I could take a normal job for you.”

You gasped in accordance, attempting to pay attention as his hand sped once again. Without looking you could tell it was his gunslinger, you admired the instrument before but praised the damn thing now.

As you grew less responsive Dell could tell you were close. He offered a trail of kisses up your neck. Watching your semi lucid smile scrunch up. His free hand went back to your member, pulling firmly.

You scratched at his back from the action. Allowing your hips to guide his hand as you awaited your climax.

Dell whispered coercions into your ear, like a private prayer.

“Cum for me honey. I know you got it in you. Just give it to me okay?” You gasped for air you were already getting, feeling like all the breath was being used on something bedsides breathing. You nodded, whimpering pathetic noises as he grew sloppier in his own hand gestures.

“You’re gonna go soon ain’t you? We’ll go ahead. Do it, you’re so good just do it now okay?” With one more thrust of his fingers he sent you over.

But he knew better than to stop.

He slowed his movements, waiting until a little after you stopped twitching. He watched your chest rise and fall before removing his hand and laying beside you.

“I can get you cleaned up after this love.” He said, pulling you close as he could, and as he felt exhaustion course through his body he smiled. Kissing your forehead as you drifted off.

“Or we can wait till tomorrow.”

#engineer x reader #engineer x trans reader #engineer x trans male reader #engineer x reader smut #engineer x trans reader smut #engineer x trans male reader smut #dell conagher x reader #dell conagher x reader smut #dell conagher x trans reader #dell conagher x trans reader smut #dell conagher x trans male reader #dell conagher x trans male reader smut

[greatpain]

𝚂𝙴𝙲𝚄𝚁𝙸𝚃𝚈 𝚀 #𝟷  ...  𝚆𝙷𝙰𝚃 𝙸𝚂 𝚈𝙾𝚄𝚁 𝙱𝙸𝙶𝙶𝙴𝚂𝚃 𝙵𝙴𝙰𝚁? 𝙴𝙽𝚃𝙴𝚁 𝙰𝙽𝚂𝚆𝙴𝚁  ...  **********

𝚂𝙴𝙲𝚄𝚁𝙸𝚃𝚈 𝚀 #𝟸  ...  𝚆𝙷𝙰𝚃 𝚆𝙰𝚂 𝚃𝙷𝙴 𝙻𝙰𝚂𝚃 𝚃𝙷𝙸𝙽𝙶 𝚈𝙾𝚄 𝚂𝙰𝙸𝙳 𝚃𝙾 𝚈𝙾𝚄𝚁 𝙼𝙾𝙼 𝙱𝙴𝙵𝙾𝚁𝙴 𝚂𝙷𝙴 𝙳𝙸𝙴𝙳? 𝙴𝙽𝚃𝙴𝚁 𝙰𝙽𝚂𝚆𝙴𝚁  ...  * **** ***** *** ***** *******

𝚂𝙴𝙲𝚄𝚁𝙸𝚃𝚈 𝚀 #𝟹  ...  𝚆𝙷𝙰𝚃 𝙷𝙰𝚄𝙽𝚃𝚂 𝚈𝙾𝚄?  𝙴𝙽𝚃𝙴𝚁 𝙰𝙽𝚂𝚆𝙴𝚁  ...  ********** ** ***** **** *** ******

               𝚆𝙴𝙻𝙲𝙾𝙼𝙴 𝚄𝚂𝙴𝚁 𝙰𝙶𝙴𝙽𝚃𝚅𝙸𝚃𝙰𝙻𝙸𝚂

𝟶𝟶𝟷.   𝚂𝚃𝙰𝚃𝙸𝚂𝚃𝙸𝙲𝚂   ...

⋯⋯⋯   GENERAL DETAILS.

FULL NAME:   maxime d'aureville. NICKNAME(S):   max. ALIAS:  agent vitalis. AGE:   forty2. DATE OF BIRTH:   november 23. PLACE OF BIRTH:   a small little town in northern france. CURRENT LOCATION:   apex city, washington. GENDER:   trans man. PRONOUNS:   he/him. ORIENTATION:   who the fuck knows really. ROLE:   head of biomedical,  seventeen years with mercy. EDUCATION LEVEL:   doctor of medcine and phd (in pharmaceutical sciences, specifically regarding solaris) 

⋯⋯⋯   PHYSICAL APPEARANCE, ETC.

HEIGHT:   5'9. TATTOOS:   none. PIERCINGS:   none. SCARS: top surgery. STYLE:   medical professional core.  max and his patagonia jacket against the world.  turtlenecks,  cableknit sweaters,  slacks,  long jackets.  still wears his wedding ring on a chain around his neck out of habit.  DISTINGUISHING CHARACTERISTICS:   greyed early.

⋯⋯⋯   HEALTH.

ALLERGIES:   none. SLEEPING HABITS:   recently,  due to situations,  max has trouble sleeping through the night and will often forgo sleep all together.  he sleeps at his office,  not at home or in the on campus dorms.  EATING HABITS:   whenever he remembers.  is a good cook though. SOCIABILITY:   2/10.  will not speak to people if he doesn't absolutely have to. DRINKING / SMOKING / DRUGS:   sometimes,  enjoys wine   /   quit the habit when he started medical school,  picked it up again since separating from his husband   /   solaris. RADIANT STATUS:  pain manipulation. OTHER:   unexplained and undisclosed hand tremor and slight memory loss, chronic pain (pre-existing before solaris).

⋯⋯⋯   PERSONALITY.

LABELS / TROPES:   beware the quiet ones, byronic hero, cannot spit it out, child prodigy, full-name basis, the leader, perpetual frowner, properly paranoid, thousand-yard stare, feel no pain, mad scientist, self-made orphan. INSPIRATIONS:   caleb widogast (cr2),  victor vale (villains),  lee seolhwa (orv). TRAITS:   pragmatic,  analytical,  logical,  perceptive,  realistic,  evasive,  cautious,  paranoid,  contemplative,  grim,  forgetful (recent),  ambitious (previously), skittish (somewhat recent). LIKES:   rain,  white noise,  helping newer agents. DISLIKES:   talking about himself,  cold weather,  people standing in the kitchen when he was there first. WEAKNESSES:   strength-based combat,  de-escalation,  anything that involves talking to others for an extended period of time,  persuasion,  performance. STRENGTHS:   medicine,  dexterity-based combat,  planning,  readjusting upon complications,  perception,  endurance. FEARS:   fire,  abandonment. HABITS:   cracking knuckles,  keeping hands in pockets or otherwise hidden (recent),  fiddling with lighter,  clicking pen, calling people by either their agent name or full first name / doesn't often use nicknames. HOBBIES:   journaling,  caring after stray cats,  reading medical journals.

⋯⋯⋯   FAMILY, RELATIONSHIPS, ETC.

MOTHER:   anna d'aureville,  deceased. FATHER:   charles d'aureville,  deceased. SIGNIFICANT OTHER:   just divorced....  BEST FRIEND:   tba.  EXES:   ex-spouse (name tba).  SIBLING(S):   none.  CHILDREN:   none.  PET(S):   none, but he feeds the stray cats that linger around the hq and his home.

𝟶𝟶𝟸.   𝙱𝙸𝙾𝙶𝚁𝙰𝙿𝙷𝚈 / 𝙷𝙴𝙰𝙳𝙲𝙰𝙽𝙾𝙽𝚂   … 

born and raised in a little town in france by a couple who were both teachers. very normal life, very normal things. max always held an interest in the human body, medicine, pharmaceuticals, etc and did what he could to learn more. the d'aurevilles were literally the perfect family... kind loving caring etc etc.

[ parental death tw, fire tw ] when he was a teenager, he left a space heater on when he went out with some friends. unfortunately the wiring / circuitry in the house was old and not up to code and the whole thing ended up burning down overnight with his parents still inside. unfortunately they didn't make it.

maxime moved across the world to live with his dad's younger brother, wife, and their three kids in washington, usa. became incredibly reserved and closed off during this time for obvious reasons. through himself into his studies further.

ended up graduating top of his class in highschool, worked as an EMT during college (during which he was forced to confront literal fires quite a few times and never really was able to deal with that considering the guilt he's been carrying, but he trudges on!), and went to a very well ranked medical school for an md/phd program. particularly he was interested in solaris and the true effects of it on the human body. eventually this + the past he ran away from + his time as an emt + some other stuff i can't think of right now caught the eyes of mercy, and he joined as a junior agent while he completed his medical degree & residency.

after being placed in the biomedical division, he felt that it would be unfair of him to be administrating solaris without having taken it himself. there was no way he could anticipate what would happen, and while at times he regrets the whole thing, he understands that what he did benefits everyone around him as he is able to help relax patients and relieve their pain when needed.

met his husband, an agent in another division, when he was around 35. they hit it off pretty instantly and got married a little over a year later (read: they went to the courthouse and signed papers and called it a day. no one has time to fuck around with all that when theyre mercy agents). they were married for five and a half years, and have been divorced for some months now. while they both claim it was a mutual decision, it probably wasn't, but max isn't gonna say shit about it.

part of the reason max brought up separation was that he noticed some strange memory loss effects & a hand tremor for himself which was... disconcerting. he's the head of the department for fuck's sake, he has to keep it together. overall, pretty selfish of a decision, but it wasn't made overnight. he weighed the pros/cons and made a list (it took up approximately a quarter of a new journal) and came to the conclusion that it is more valuable for him to figure out why this is happening while balancing his duties as head than it is for him to worry about his husband whenever there's a mission. stupidest doctor you will ever have the displeasure of meeting.

skittish, evades questions like its an olympic sport. can get a little emotional pretty easily which is Not fun for anyone within his vicinity (see below). cares for cats more than he cares for himself. having a terrible fucking time always and it's obvious. practically lives in his office. does not want to be head of the department but alas, he still has the ambition he had when he was younger and is somehow determined to not let teenage maxime down.

𝟶𝟶𝟹.    𝚁𝙰𝙳𝙸𝙰𝙽𝚃 𝚂𝚃𝙰𝚃𝚄𝚂   ...

max can freely manipulate prexisting pain by increasing or decreasing how much pain he, or someone else, is feeling.  through practice, he has learned how to induce pain from nothing, but it's much more difficult, energy draining, and often overwhelms him with pain as well.  it is much more effective to amplify preexisting pain. no physical contact is required, as long as he has eyesight with the person / people he is effecting.  can transfer his own existing pain to others, but it's an unstable process.  is able to create a subconcious aversion to his presence, if he really wants to, by inducing very subtle amounts of pain within people around him. 

unable to control this while asleep or uncious, and nightmares or other such strong dreams can cause him to unintentionally induce a level of pain within anyone in his vicinity.  

can't permanently remove pain, but he can temporarily alleviate pain that a person is feeling.  often, he has to take that pain on himself.

hair went grey shortly after taking solaris because of the stress of the pain he was feeling as he wasn't able to properly control or understand his ability.

max attributes his hand tremor and moments of memory loss to his solaris intake / radiant status,  though he's told no one else about this and intends to keep it this way.

𝟶𝟶𝟺.   𝙲𝙾𝙽𝙽𝙴𝙲𝚃𝙸𝙾𝙽𝚂   ...

updated soon... prommy

#quick and messy background i am so sorry im half asleep #will be updated properly when i have brain #mercyorg:intro

[bitacrytic]

Why not?

Pol didn't leave Arm. Through two surgeries and several days dosed on painkillers, Arm woke up to find Pol at his side. Sometimes asleep, sometimes watching TV, other times staring right at Arm.

But the day before Arm's discharge, Pol was missing when he woke. They hadn't spoken about The Incident In The Metal Shop, for obvious reasons, but Arm was hoping Pol would bring it up, at some point. With him gone, Arm knew there was a surprise waiting for him.

Pol wouldn't leave for any other reason.

So when they left the hospital, and Pol arrived to wheel him back to his room, Arm's heart beat in anticipation. Because even though Pol was tongue-tied and shy, his mind was a gallery of romance and grand gestures. Arm had read the things Pol could think up when he put his mind to it.

As they got to his room, Pol smiled at him, opening the door before he wheeled Arm in.

"Tada!" he said, running before Arm to spread his arms to the room.

The anticipation simmered into disappointment as Arm took in the pristine, freshened room with new sheets and clean floors and hampered clothes.

Arm and his roommate weren't the most organised people so their room was almost always a mess. To think that Pol's big surprise was taking out the trash was... disappointing.

"Awesome," he said, smiling and looking around. "This is great." and so not what Arm had been expecting. "Thanks."

Pol frowned, looking from Arm to the room.

"You don't like it."

"Of course I do. Are you kidding?"

"You hate it." Pol shook his head and sat on the bed. "I was going to draw you a bath, or put petals around the room or some shit. But I thought you'd... fuck," he fell back on the bed.

Laughing, Arm got up from the wheel chair and crawled beside Pol, where he'd fallen on Arm's bed.

"I don't care about the room," he said, lying beside him. "But thank you."

"I had a whole speech."

"I don't need a speech."

He turned his head to look at Arm.

"I feel like I should say someth-"

Arm kissed him on the mouth.

Satisfied with it, he leaned back, resting his head on his hand as Pol stared at him, lips parted in surprised.

"OK," Pol gulped as his eyes scanned Arm's face.

"You were wasting too much time."

"I was working up to it."

"Six years, Pol."

"Well," he hesitated. "You wanted to kiss me too. Why didn't you do it sooner?"

Arm shrugged.

"I always imagined that you'd sweep me off my feet in some fucking extravagant way."

"Like a princess?"

"Fuck yeah," he smiled at Pol. "Why didn't you?"

"Well," Pol sat up. "I wrote it down in my journal." He shifted to the side-cupboard that belonged to Arm's roommate and opened it, pulling out Pol's journal.

"Why's your journal in Turred's cupboard?"

As he asked the question, Arm recognised the bed cover on Turred's bed. That wasn't Turred's bed cover. It was Pol's. And the harness hanging on Turred's desk chair was Pol's. And the shoes on the rack un the corner... Pol's sneakers and flip flops and...

"Where's Turred's stuff?"

"He's staying in my room. We switched."

"Oh my god," Arm said, getting up and pouncing over to Turred's- Pol's bed as he tackled Pol down, wanting to kiss him. But the movement hurt Arm in the stomach.

"Ow!"

"Arm," Pol said, worriedly. Grabbing Arm by the back of his neck and his waist, he gently turned them around, placing Arm on his back.

"You're my roommate," Arm said, happy even though he was in pain.

"That was the surprise."

"I thought the clean room was the surprise."

Pol pondered.

"Yeah, I can see how you'd think that given that you and Turred have horrid hygiene habits."

Arm laughed, but had to stop because movement was suddenly painful.

"I should call Dr. Top."

He tried to get up but Arm pulled him down again.

"Kiss me," he said. "No roommate's coming to stop us for a bit."

Laughing, enjoying the moment as much as Arm was, Pol kissed him one more time.

♧♧♧

♧♧♧

Read Another

#kinnporsche #armpol #the mansion of men #fanfic #This fic was supposed to be 200words a chapter #AT MOST #Yet #Here I am using -read more-

[ourhaileydavies]

Conservative Versus Surgical Management for Non-Traumatic Subarachnoid Hemorrhage: A Mini Review

Author By:  Johanna Stefany Canenguez Benitez

Abstract

Subarachnoid hemorrhage diagnosis is always a challenge for patients and physicians because it has different presentations. There are two main causes of subarachnoid hemorrhage: traumatic and no traumatic subarachnoid hemorrhage. Both groups share clinical characteristics, but not treatment. Therefore, it is essential to recognize the signs, symptoms, and types of presentation for proper management. The objective of this article is to inform our audience about the significant difference between conservative and surgical treatment for non-traumatic subarachnoid hemorrhage because it carries a high risk of morbidity and mortality, requiring emergency management and well-trained physicians to evaluate patients suspicious for the diagnosis. This article is a compilation of several articles that have been selected from different databases, International Journal of Emergency Medicine, and Journal of Neurosurgery. Traumatic subarachnoid-related articles were excluded from our search. There is no consensus yet about the approach of patients with non-traumatic Subarachnoid Hemorrhage(ntSAH) among experts worldwide, so SAH diagnosis is often overlooked due to the clinical manifestations and inconsistencies in individual findings, especially atypical presentation arrives at the ER. The most significant limitations of timely and aggressive management of SAH are the lack of clinical suspicion and the delay from the CT scan order until the CT scan report is ready. The most repeated cause of subarachnoid hemorrhage is aneurysm rupture. A timely aneurysm repair is considered the most critical strategy to reduce the risk of aneurysm re-rupture. Therefore, detection of the cause of bleeding and prompt management can make the difference between life and death.

Keywords: Subarachnoid hemorrhage; Surgical Management of SAH; Conservative Management of SAH; Medical management of SAH; Nontraumatic Subarachnoid hemorrhage

Abbreviations: SAH: Subarachnoid Hemorrhage; NTSAH: Non-Traumatic Subarachnoid Hemorrhage; GCS: Glasgow Coma Scale; DCI: Delayed Cerebral Ischemia

Introduction

The most common cause of patients going to the emergency room is headache [1]. As physicians, we must be able to recognize headaches that could be life-threatening. The medical history and the physical findings will allow us to differentiate a simple headache from those that can be deadly. "The worst headache of my life," this is the way how medical students and physicians can start thinking about subarachnoid hemorrhage, but not all the patients can recognize the worst headache in their life; some of them die before they arrive at the emergency room. There are many tools and strategies to approach and treat patients with severe headaches, and we must understand the strengths and limitations of each strategy.

The clinical presentation should be considered before proceeding with the different diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a CT scan must be requested. Subarachnoid hemorrhage diagnosis is always a challenge for the physician. Every second and minute will determine a poor or great outcome in each patient. There are multiple causes of subarachnoid hemorrhage (SAH), but we can differentiate two big groups: Traumatic and no traumatic subarachnoid hemorrhage. Both groups share some similar clinical characteristics, but not the treatment.

There are several scales to categorize SAH. The systems used to predict the patient outcome are the Hunt and Hess score and World Federation of Neurological Surgeons grading, and the Fisher grade helps predict vasospasm. In terms of patient-centered results and prognosis, specific scores were not performed better than the Glasgow Coma Scale (GCS). As we search into the diagnosis of SAH, it is essential to note that some patients with SAH, for example, Hunt and Hess lower grades are more commonly failed to see because the clinical presentation is mild, and they may have smaller aneurysms with scant subarachnoid blood. These patients do not necessarily recover or have less morbidity with rupture or re-rupture [1].

Accurate data is not available about the management of subarachnoid hemorrhage, but some of the Egyptian, Greek, and Arabic literature report some clues of earliest management in 1800. Unfortunately, the management is still controversial, especially when the discussion is between surgical and medical management of SAH. That is why reviewing many studies worldwide will allow colleagues to understand how to face this particular situation.

The most crucial strategy to reduce the risk of aneurysm re-rupture is timely aneurysm repair is generally considered. However, evidence for the ideal timing of treatment is limited, and it is undefined if ultra-timely treatment (within 24 hours) is superior to timely aneurysm repair (within 72 hours) [2]. A recently published retrospective data analysis that compares ultra-early treatment with repair performed within 24-72 hours after hemorrhage suggests that aneurysm occlusion can be performed safely within 72 hours after aneurysm rupture [2]. The American Heart Association/American Stroke Association suggests as a Class IB guidance that surgical clipping or endovascular coiling of the ruptured aneurysm should be implemented as early as achievable in most patients to decrease the risk of re-bleeding after SAH [2]. The treatment modality option between surgical clipping and endovascular coiling is a complex endeavor that requires an interdisciplinary team's expertise, including neuro-intensivists, interventional neuroradiologists, and neurovascular surgeons. The endovascular approach is superior for aneurysms to be considered equally treatable by both modalities, associated with better long-term outcomes.

Retrospective data on clipping and coiling in poor-grade patients suggests that surgical clipping and endovascular are equally effective. An early and short course of an antifibrinolytic drug, including tranexamic acid, started as soon as the radiological diagnosis of SAH is made and stopped within 24-72 hours, has been associated with a decreased rate of ultra-early re-bleeding and a non-significant improvement in long-term functional outcome. This approach remains controversial, and short-term administration of tranexamic acid to prevent re-bleeding is being studied in a multicenter randomized trial (Dutch Trial Registry number NTR3272) [3]. The avoidance of extreme levels of blood pressure is another medical intervention applied to prevent aneurysm re-rupture. The American Heart Association/American Stroke Association and the Neurocritical Care guidelines advise keeping the mean arterial blood pressure below 110mm Hg or systolic blood pressure below 160mm Hg (or both) in the presence of a ruptured unsecured aneurysm.

Serum biomarkers to detect the risk of delayed cerebral ischemia (DCI) are showing promising results [3]. Changes in serum protein S100B levels interacted with DCI status (presence vs. absence): F= 3.84, p= 0.016. Patients with DCI had higher S100B concentration level on day 3 than those without DCI (3.54±0.50ng/ml vs. 0.58±0.43ng/ml, p= 0.001). S100B concentration on day 3 following a SAH predicted DCI (p= 0.006). The multivariate logistic regression analysis has shown that impaired cerebral autoregulation and elevated S100B concentration on day three increase the likelihood of DCI [3]. Subarachnoid hemorrhage (SAH) is a medical emergency that requires urgent management. Around Eighty-five percent of cases of atraumatic SAH result from a ruptured aneurysm. Other factors such as arteriovenous malformation, Ehlers-Danlos disease can also be the cause [4].

The diagnosis of SAH ought to be considered in any patient with a severe and sudden onset or rapidly escalating headache. With many such patients presenting to the ED with a chief complaint of headache, differentiating those with a benign cause from an emergent etiology such as SAH can be difficult. Establishing the diagnosis of SAH, the most critical time-sensitive goals include confirmation of airway security and stabilization of hemodynamics. In the setting of a low Glasgow Coma Scale Score or the lack of ability to protect the airway, intubation should be undertaken, but care should be taken to mitigate increases in mean arterial pressure during the intubation process [5]. These therapeutic modalities should be addressed with the admitting neuro-intensivist or neurosurgery team. In addition, continuous electroencephalogram monitoring may be started in the intensive care unit.

It is essential to determine adequate management in every case, as this can be the difference between life and death. According to preoperative neurologic function, location, size of the aneurysm, the timing of the operation, severe initial bleeding, re-bleeding (usually within two weeks), and delayed ischemia were the major preoperative problems; ten percent died, and 13 percent deteriorated before surgery. Operative mortality was 5 percent, ranging from 1.6 percent of patients with normal preoperative neurologic function to 35 percent of severely disabled patients. Intraoperative complications (5 percent of cases) related primarily to the size and location of the aneurysm, postoperative delayed ischemia (minor and reversible in 10 percent and severe in 5 percent) related to operation timing and occurred primarily in patients afflicted within the previous ten days [4]. The outcomes of surgical treatment, including preoperative deaths, were better than the natural history of the illness. The difference became apparent after one month of observation.

Once a bleeding aneurysm is identified, the ultimate therapeutic goal is to secure it surgically by coiling or clipping. While coiling is the preferred method since it is less invasive than open surgical clipping, data is indeterminate as to whether long-term outcomes are better with either procedure, but protocols propose that coiling should be performed if both are possible [6]. In some cases, tortuous vascular anatomy or other contraindications to coiling make open surgery necessary. Timely treatment and securing the aneurysm are associated with a lower risk of re-bleeding. If surgical treatment is delayed, antifibrinolytics such as aminocaproic acid may be used for a short time to mitigate the risk of re-rupture [6].

Nine articles have been selected from Pubmed, Google Scholar, International Journal of Emergency Medicine, Journal of Neurosurgery, International Journal of Emergency Medicine, and other Databases. The articles were published within the previous ten years and written in the English language. The studies reviewed include review articles, clinical articles, systematic reviews, single-center, retrospective studies, prospective, multicenter cohort studies, cross-sectional studies, observational studies, and clinical trials. Traumatic subarachnoid-related articles were excluded from our search. The objective of this article is to inform our audience about the significant difference between conservative and surgical treatment for non-traumatic subarachnoid hemorrhage.

Discussion

There is no consensus about treating patients with hemorrhage (no traumatic Subarachnoid Hemorrhage) among expert clinicians within the United States and worldwide. Many concerns arise from an attempt to establish a protocol for the individual patient. However, at least in some areas, the wide variety of management practice testifies to a lack of agreement in the medical community. Therefore, we sought to design a survey that would highlight areas of controversy in the modern management of ntSAH and identify specific areas of interest for further research. Additionally, we performed a comprehensive review of the existing literature on several of these controversial subtopics in the management of ntSAH [7].

Although the timing of surgical intervention after SAH is controversial, it should be based on the clinical-grade, site of the aneurysm, and patient's medical condition. There are many factors to consider when treating patients with SAH, such as patient neurological condition and aneurysm location (Ex. Basilar aneurysms) aneurysms, unusually large or irregular aneurysms [8]. Patients with a non-peri mesencephalic SAH have an increased risk of a worse neurological outcome. Therefore, these patients should be monitored attentively. When an aneurysm breaks down, patients require a calcium channel blocker to reduce vasospasm risk due to ischemia. For example, The Mayo Clinic experience of 1,947 patients who underwent surgical treatment because of aneurysmal SAH or aneurysmal repair for about 20 years shows the results after a follow-up that 1,445 had an excellent outcome, 231 had an acceptable outcome, 171 had a poor outcome, and 100 died. Aggressive management can benefit many patients with severe neurologic injury after SAH by preventing rupture of the aneurysm, attenuating the severity and sequelae of vasospasm, and decreasing the surgical complications [8].

Clinically, subarachnoid hemorrhage diagnosis is often missed due to the various clinical manifestations and inconsistencies in individual findings, especially when atypical presentation arrives at the ER. In addition, there are several etiologies of non-traumatic SAH, such as perimesencephalic SAH, intracranial arterial dissection, pituitary apoplexy, mycotic aneurysms, reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, moyamoya, vasculitis, and even cocaine use [9]. When SAH is suspected, the best initial step would be a CT scan of the head or LP. Once the diagnosis of SAH hemorrhage has been made, it is essential to classify and grade the patient's risk to lead to the urgency of further management and prevent neurological consequences [9].

Subarachnoid hemorrhage carries a high risk of morbidity and mortality, requiring emergency medicine physicians to evaluate patients suspicious for the diagnosis cautiously. It is crucial to consider the restrictions of diagnostic modalities and early implementation of grading/scoring systems even in a nontraditional presentation. Giving the SAH complications, making a timely diagnosis, initiating management in the ED, and employing suitable consultations or admission for possible early intervention is crucial for care [9].

The two most significant limitations of timely and aggressive management of SAH are the lack of clinical suspicion from physicians and the delay from the CT scan order until the CT scan report is ready [8]. We suggest starting a SAH standardized protocol that includes the high priority of imaging studies (CT scan) to reduce the time from diagnosis and management. Performing a prospective cohort study using the protocol could lead us to better conclude aggressive and early management in non-traumatic SAH.

Limitation

This systematic review uses data collected in nine articles that included cohort studies, a cross-sectional study, and several observational studies and clinical trials. Given the nature of this investigation (secondary data review), the main limitation of this study is the lack of control over the desired study population, variables of interest, and the study design. Problems with secondary data could be that bias may have crept meanwhile obtaining the data; this bias will go unnoticed and may inadvertently affect the results.

Furthermore, the primary data may not include certain demographic information (e.g., respondent zip codes, race, ethnicity, and specific age) relevant to the study. For example, in the specific case of this investigation, age, availability of conditions to perform endovascular procedures, the severity of the SAH, and other variables could be ignored. In such cases, the data would create an aggregate pooled effect that may be misleading if there are important reasons to explain variable treatment effects across different types of patients.

In addition, secondary data analysis research cannot establish causality. This kind of investigation is limited to descriptive, exploratory, and correlational designs and nonparametric statistical tests. By their nature, they are retrospective, and the investigator cannot examine causal relationships (by a randomized, controlled design).

These significant limitations were addressed and minimized by:

1. Assuring that the correct type of studies was eligible for the review and guaranteeing that identifying all relevant information was comprehensive.

2. Considering publication bias.

3. Confirming that the methods used in each study were appraised and had an appropriate data abstraction.

Conclusion

Non-traumatic subarachnoid hemorrhage is a medical emergency. Early diagnosis and adequate management are crucial for a patient's survival. Therefore, conservative or surgical management should be promptly established. Intense headache is one of the most common alarm symptoms of non-traumatic subarachnoid hemorrhage that bring a patient to the emergency room; frequently described as “the worst headache of my life”. There are many tools and strategies to approach and treat our patients with severe headaches, and we must understand the strengths and limitations of each strategy.

One of the most frequent causes of subarachnoid hemorrhage is aneurysm rupture. This can be caused by certain conditions such as arteriovenous malformation, Ehlers-Danlos disease, collagen deficiencies, uncontrolled high blood pressure, uncontrolled Diabetes Mellitus. A timely aneurysm repair is considered the most vital strategy to reduce the risk of aneurysm re-rupture. However, evidence for optimum timing of management is insubstantial, and it is unclear whether ultra-early actions to resolve the subarachnoid hemorrhage (less than 24 hours) are superior to early aneurysm repair (within 72 hours) [2].

Retrospective data on clipping and coiling in low-grade patients suggests that surgical clipping and endovascular are equally effective. Early detection of the cause of bleeding and prompt determination of management can make the difference between life and death, as it requires prompt and adequate management.

#spine surgery #Head and neck surgery #spine #Juniper Publishers #open access journals

[tapedsleeves]

for the WIP game, tripped and fell on you if you haven't done it already (if you have, haunted max AU, I always love the imagery you post for that one!)

hiiiiiii, I haven't done any of them yet so you're good gonna put them under a readmore so ppl don’t gotta scroll

tripped and fell on you - the hookup to enemies to lovers 6167 (Mark Stone/Max Pacioretty) au where!!! for some reason, the summer before Mark gets drafted, he hooks up with max for like. three days straight, and THEN they have their whole like. thing where they're rivals (mutual rivals, even) and then they both end up in Vegas.

Mark is 18 in this fic and Max is about 21:

But Max isn’t storming off in a huff, rolling his eyes and muttering like the other people who have decided he wasn’t worth their time have done before. He’s dragging Mark along, hand warm and firm on Mark’s wrist. He doesn’t look angry - well, more angry than strong eyebrows and a serious face does in general, anyway. It’s a serious face, Mark thinks, but no less pretty for it. His lashes are long and dark, fanning over his cheeks when he blinks. 

Max looks over, acknowledging Mark’s attention with a small upturn of his mouth. Mark thinks, a little stupidly, that he’d probably follow Max anywhere, right now. 

Max doesn’t drag him all the way back to the parking lot, instead stopping short at the narrow opening between two buildings. He stops abruptly, so Mark almost topples over him, but Max reroutes his momentum and pushes him into the narrow alleyway. 

Before his mouth can form any protests, Max has him pressed against the brick wall, rough against his t-shirt. Max lets go of his wrist, and instead moves to put one hand behind Mark’s neck, and the other on his shoulder. He looks at Mark, almost eye to eye. 

“Uhm.” Mark finally says. His brain stalling out on what Max’s plan is. Mark’s blood is thumping through his brain, a one word refrain - kiss kiss kiss. 

and, just for kicks: the haunted max au! (titled tentatively, no home for a hollow man) I have so so little of this one actually written. it's mostly just vibes in my head lol. (a 6167 hanahaki/half amnesia (part of the surgery to remove the flowers also erased the memories of the person Max loved) heavy on the angst! Max thinks, very truly, that he's haunted. This part is from where Max reads Mark's journal, and then, later, after they become nameless pen pals.

Mark’s Journal, excerpted, page 6, undated. 

It’s all supposed to be fine, you know? It’s always been fine before. People come and go, good people, bad people. Exceptional people. It’s never felt like this, though. Like a hole in my chest. Like a blind spot that I don’t even remember is there until something hits. Or doesn’t. 

I hate it. 

There, I admit it. I know Kelly is my friend, but he made a stupid decision. A series of them, culminating in the dumbest decision of them all like a big avalanche of shit. 

And the only person I want to talk to is the one person I can’t talk about.

– 

Max looks at the letter, holding the paper in his hands. He can see where M had scribbled something out - can feel the indentations on the paper, and read what had been written underneath. 

“I love him. I know he’s right there, but he’s gone. And I still love xxx him.” After that, the letter had picked up back where it left off, talking about the Vegas Powerplay, and how it seemed to be limping along. The part that was marked out with x’s was impossible to make out, the paper so saturated with ink it had warped and almost torn. 

Max thinks about that crossed out line, and grabs a pen. 

I don’t know you, which makes this easier to tell to you than anyone else: It feels like I died, but my body kept going. Am I even here? I must be, because I’m writing this letter. But am I the same as I was? I’m not even sure what happened to me. Every time I try to think about it, all I can see is how I am now, like a two-way mirror. Is he on the other side watching the things I do? Does he look at me and see the way that I am? Is this what he wanted? Does he know why I feel so empty? Did he feel whole? 

Was he happy? If he was, why am I like this now? 

The doctors say everything looks fine, normal, good. Every time they say that, I see the pity in their eyes. Poor Max, he survived. That’s not how it usually goes, I don’t think. 

I hate not knowing how things were and still missing them.

#hrpf #6167 #ask meme #aaaa thank youuuuuuu #this made me actually uh. touch them again which was fun!! #hockey rpf

[blenderchildren]

February 1st. National Serpent's day.

Surgery tomorrow after the snake bit me that I wrote about in a previous journal entry(3 or 4 days ago) on one of my pages, inducing my current stay at the hospital.

If I find it, I'll repost it after I eat lunch.

I don't read into this sort of subject as a bad thing from the artist or the divine.

Dragonlord - Lamia

First it feels like you're wearing a rubber suit, or made of elastic netting, trying to pull you down, gradually getting worse, until you lay down.

(The whole lay down to make the tension subside makes me think of some pecking order of weakest link in the chain of natural order, or of life-force ideal. i.e.-a life is born, so a life is removed from the cycle or specific tree of life)

I myself curled up with my knees to my chest. The snake bite was sort of like attaining nirvana. White serpent wrapped around my spine same as a cadeuces medical staff and curled around my neck and slowly worked its way up over the jawline, then covered my scalp like a stocking cap, then lifted out and then bit my neck and penetrated the base of my neck like a corkscrew to get inside. It then spread through the inside of my head and could not feel anything, as it washed over the back of my eyes, bright and blinding me. Then I felt a snap of a fiber strand on my neck. I had to tell myself to move my head and assess my body to make sure everything was still connected. I could not feel anything from head to toe. Once I could sit up, I called for paramedics. I was afraid to stand up because I didn't want to tear my inside body tissues, arteries, and veins, organs and nerve fibers that are affected by marfans.

That was last weekend. Today is Feb 1st, Serpent's Day. I go into surgery tomorrow. My stepmother's birthday is tomorrow.

I was moved to a different hospital between the time of my 911 call and my surgery a week later, and I don't remember anything during my stay there, with the exception of a kind nursing staff member who played a song on his ukulele for me. I also don't remember a thing about my transfer to another hospital or going into surgery, during that week.

#Youtube

[rsrsbabe420]

[auditionmarcboulet]