Author Question: Surgery for Shrapnel to the Abdomen

Naomi Asks:

My protagonist is a surgical resident at large hospital, and I want to write a scene where she is in the OR treating a piece of shrapnel entering the patient’s large intestine with no exit wound.

It took quite a long time to get the patient any sort of medical attention and he has multiple myeloma. I’ve read from my research that myeloma can cause increase inflammation and compression of blood vessels causing coagulation and lessening internal bleeding.

A few questions:

I want to know the chance of my character surviving the surgery. I’m aware since there was no exit wound, and the piece of shrapnel didn’t hit any vital organs, that it would be high chance. However, since he received medical attention rather late (perhaps between half an hour and an hour) I want to know the chance of him actually surviving.

What would be the role of the surgical resident in this scenario? I don’t necessarily just want her to be cleaning up, but I want this to be as accurate as possible.

How long will it take to recover from this surgery?

Are they any complications that could happen during the surgery? If so, please list the major ones.

Jordyn Says:

For this question, I went to one of the best OR types I know . . . my friend Kim Zweygardt who works as a Certified Nurse Anesthetist (CRNA).

Kim Says:

First of all, let’s talk about length of time.

If the shrapnel missed all vital organs and major blood vessels, the length of time to treatment is minor. Are you talking from time of injury? If so, it takes some time for EMS to get to the scene, stabilize the patient, and get to the ER. It takes time in the ER for the nurses to start IVs, for the ER doctor to assess the patient, and get lab and radiology studies to diagnose. It takes time for the surgery to be scheduled and the OR crew to set up for the case.

In a large teaching hospital, is there an OR open or do they have to wait? If the patient isn’t bleeding out, it’s urgent but not life and death. It’s unlikely for the patient to be in the OR from time of injury in half an hour or even an hour.  For instance, in a stat C-section with the patient and crew in house, it’s supposed to be decision to incision within thirty minutes and it’s sometimes difficult to hit that timeline. It takes time to transfer the patient and get the OR ready so I wouldn’t be concerned with that time affecting the outcome in this scenario.

Chances of surviving the operation? It’s kind of a misunderstanding that lots of people die in the OR! Your chances of surviving something is very good in the OR because everything and everybody is there to help you survive— all ways to stop bleeding, medications to resuscitate, etc.

The biggest risk is if the shrapnel was close to major blood vessels that could be nicked by the sharpness during removal.  Most likely scenario is if it’s embedded in the bowel then they would just resect the bowel. In other words, remove the piece of bowel damaged along with the shrapnel. That’s normally done using a special stapler and then reconnected.

It’s possible depending on damage that they’d do a temporary colostomy. Let the bowel heal and go back later to reconnect it.

Biggest worry is infection. Normally when you resect the bowel you do a bowel prep so the colon is empty of stool. The shrapnel itself is dirty but having to resect an unprepped colon— risk of infection is very high and serious enough to cause death. But it’s not an immediate thing. They’d put him on antibiotics but within 24-48 hours he’d have symptoms if infected.

Role of the resident— depends on how advanced they are in their training. If early in residency, assisting. Holding retractors. If more advanced they could do most of the case. In all cases, if an attending surgeon is there, the resident will be left to close the surgical wound, write the orders for post op, and follow up on the patient in the ICU or PACU (Post Anesthesia Care Unit). What they wouldn’t do is clean things up! That is left to the nurses and techs.

His recovery time? If no infection then three to five days if healthy and their bowels are moving to where they can eat, drink, go to the bathroom, etc. With infection recovery time could be weeks or even a month or more.

Hope this helped and best of luck with your story!
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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com.

This Is US: Jack’s Needless Death

This television episode caused more people to reach out to me over any other. This Is Us has been building up to Jack’s death for eighteen months. It needed to be big. It needed to be dramatic. Can you tell I’ve been watching the show? It was really none of those and medically— well, just weird to be honest.

If you haven’t watched the episode then don’t read this post because it will reveal his cause of death . . . like right now.

Jack’s ultimate demise? A heart attack called the widow maker caused by the stress of the fire.

Jack is in intense smoke and heat for several minutes. He emerges and is first checked by EMS. He is being given oxygen and a dressing to his arm for “2nd degree burns”. The EMS person says she can’t treat the burn and he is seemingly refusing transport, but she does encourage him to be seen. Also, giving oxygen is correct, but it is not the right type of mask. A note on burns. Burns will evolve over the next several days so you don’t really know how severe a burn will be for a while.

Jack does eventually go to the hospital to get his burns checked. The doctor is initially giving him instructions on burn care.  The doctor says, “I’d like your heart rate to come down.” and glances at the monitor— which doesn’t have any readings on it. No waveforms. No numbers. He then says, “There’s soot in your airway so we’ll have to run some tests. The swelling is minor.”

That’s about it. The doctor tells Jack he basically dodged a bullet and seems none too concerned about his potential airway damage.

Just as I mentioned above, airway burns from smoke inhalation are similar to skin burns in that they evolve over time. Smoke inhalation and the potential for upper airway swelling is taken very seriously. There is a nice overview here. At the very least, there should be discussion of admitting Jack to the hospital. As quoted from the article, “Studies have shown that initial evaluation is not a good predictor of the airway obstruction that may ensue later secondary to rapidly progressing edema.” If there is concern about significant injury to the airway then the patient is electively intubated until the airway injury heals. It’s VERY difficult to intubate someone with a lot of airway swelling.

Shortly after this consultation, Rebecca decides to make a phone call and get a candy bar from the vending machine. In that, perhaps under two-three minutes passage of time, Jack codes and dies. Even though she is just outside the ER nurses station, she never hears a code being called. Doesn’t see the commotion.

The doctor approaches her and says, “One of complications of smoke inhalation is that it puts a terrible stress on the lungs and therefore the heart. Your husband went into cardiac arrest. It was catastrophic and I’m afraid we lost him . . . Mrs. Pearson, your husband has died.”

After a few exchanges she goes to Jack’s room where there is a spotlight shining on his chest with a cursory ambu bag at the head of his bead . . . but no other equipment. I’m telling you in two minutes, a code has barely just begun and is never called so hastily . . . like ever. Later, explaining the event to Miguel, Rebecca says he had a widow maker’s heart attack.

The widow maker is a real term for a heart attack. It generally refers to occlusion of the left main coronary artery that feeds the left side of the heart. It is the same heart attack celebrity trainer Bob Harper had and survived. The reason the widow maker can be so devastating is that the left ventricle is the largest, strongest pumping chamber. If it dies . . . well, you’re hosed.

There would be no realistic way the doctors would know it was specifically this kind of heart attack as shown in the episode without an autopsy. Presumably, Jack went into one of the lethal heart rhythms, v-tach or v-fib, at the time of his code. In the time frame given on the show, the medical team would have barely started CPR and given the first line treatment which is electricity. A 12-lead ECG can be a strong diagnostic tool for this type of heart attack, but they never did one. Had they done that early on, they probably would have seen the changes.

Also, he would likely have some signs and symptoms. Chest pain. Nausea. Left arm pain. Sweating. Demonstrating these might make the scenario seem more believable. Having Rebecca witness the code would have been more dramatic.

Also, it would make more sense that he would suffer this cardiac event while he is actually under duress— such as during the rescue of the children and the dog.

The only way to truly know that this is the type of heart attack Jack suffered as presented in the show would be to conduct an autopsy.

This Is Us— thanks for killing off a beloved character in a totally lame way— at least from a medical standpoint.

A Real Doctor’s Thoughts on The Resident

As you know, last week I did a couple of posts on Fox’s new television show The Resident. You can find Part I and Part II by clicking the links. Shortly after this post, I came across a You Tube video by Dr. Zubin Damania who runs a series of entertaining and informative videos on healthcare under the name ZDoggMD.

I’ve found Zubin’s videos fun. Some are satirical in nature, but others tackle very serious healthcare issues. Zubin does for the general public what I try to do for writers. As a note, some of his videos do have some salty language.

So, it was with interest that I viewed his thoughts (serious ones) on The Resident to see if we agreed on the same things. I was somewhat shocked in some of the things he thought were spot on as far as medicine goes and I must say I’m relieved we’ve worked at different hospitals. To be fair, I’ve never worked on a surgical floor or in the OR so my expertise is not in that area. You can view his thoughts in the posted video.

One thing he found more truthful than I did was the cover-up of the doctor who shouldn’t be performing surgery anymore. That something like that wasn’t as blatant as it appeared on television, but was much more subtle— but does happen.

It was interesting to see the differing opinions between a physician and a nurse. The lead female character— I think is a resident because she wears a long, white lab coat. Nurses typically don’t wear this unless they are nurse practitioners. He thinks this same character is a nurse who seemingly works in every unit of the hospital. What’s clear is it’s not clear what her job is. This is also one of my major complaints about medical shows in general— they don’t realistically show the true nature of the job.

I appreciate ZDoggMD— particularly his support of nursing. It has not gone unnoticed by me. Keep up the good fight, my friend!

9-1-1 S1/E3: Evaluation and Treatment of Overdoses

In Episode 3 of 9-1-1, the story opens with officer Athena Grant, played by Angela Bassett, finding her daughter unconscious from taking hydrocodone pills as seen in the trailer below. The daughter, who appears to be between twelve and fourteen, is whisked off to the hospital and admitted to the ICU in short order. One, did they treat this ingestion (or overdose) correctly? Two, would this type of ingestion warrant ICU admission?

It’s stated in the episode that the daughter took “six to seven” hydrocodone pills. Hydrocodone is a combination of acetaminophen (Tylenol) and a synthetic type of codeine. It comes in many different preparations with different amounts of acetaminophen and hydrocodone. Where do we start to evaluate whether or not the ingestion is worrisome?

1.  How is the patient? What signs and symptoms do they have?  The EMS crew in this situation is lucky. The mother knows exactly what the daughter took. She presents unresponsive with slow breathing. Number one treatment in this situation after assisting with her breathing? Give Narcan which this crew absolutely does not do. Narcan is a reversal agent for opioids. It can be given via a mist up the nose so you can generally reverse the sedative effects of the drug without even starting an IV. It is a life saving measure because it is the not breathing part that will kill you first. This is the medication they should have given first.

In absence of knowing exactly what the patient took, we can look at clusters of signs and symptoms called toxidromes which might point us in the right direction.

2. What did the patient take? When did they take it? How much did they take? Many drugs have multiple components and we have to evaluate EACH component and whether or not this could prove harmful to the patient. The opioid  (once reversed with Narcan) is probably the least concerning. The amount of acetaminophen ingested is our next priority and we would calculate how many milligrams per kilogram she took. We know for acetaminophen that when you start to get between 100-150mg/kg that there could be a potential for liver damage. There is a reversal drug for acetaminophen’s damaging effects on the liver called Mucomyst, but there is a window in which this can be given to be effective. Usually, a poison control center will help us manage these types of patients.

In this case, let’s say she took six pills of Lortab 7.5/500. From this we know that each pill has 500mg of acetaminophen. Assuming the average 12-14 y/o is about 100 lbs (converted to 45 kg) then she took about 66mg/kg of acetaminophen. A four hour Tylenol level (measured four hours after the ingestion) would be checked to ensure she wasn’t toxic, but in this case likely not.

3. Will this patient be admitted to the ICU? It might come as a surprise, but ingestions of medications are most often not admitted to the ICU. Most are managed and observed in the ER. In this case, the girl should have been given Narcan by EMS. We would continue to watch for the somnolent effects of the opioid and evaluate the risk of the acetaminophen.

Also, it’s generally protocol that an aspirin level is measured as well even if the patient denies taking any. We can’t always depend on the patient being truthful about what they took and aspirin can have very devastating effects as well. Other labs depend on the medication ingested and what parts of the body if affects. This patient would likely not be admitted to the ICU.

Also, if we get a toxic ingestion within an hour we can give activated charcoal (that literally looks like black sludge) that will bind the medication. This is not always done for several reasons. One is the risk of the charcoal ending up in a patient’s lungs during administration. Usually this is done under the recommendation of Poison Control.

4. Do we notify Child Protective Services? In this episode, Child Protective Services conducts a mental health exam on the teen. In the real world, this evaluation takes place through mental health providers not associated with the state. State involvement is generally reserved for what we would consider a risky home environment. A teen getting into their parents medicine cabinet for some pills would not fall into that category. What would? A two-year-old ingesting crack cocaine that was lying around the home. Each case is handled very individually, but this case presented in 9-1-1 would not rise to that level in my opinion.

As a side note, parents are not separated from their children during medical treatment. Can we please stop perpetuating this myth?

What do you think of 9-1-1?

Fox’s The Resident: Everything Stereotypically Bad About Hospitals (Part 2/2)

Today, I’m continuing my review of Fox’s new medical drama The Resident and all that is bad about it. You can find Part I here.

Let’s continue our list.

THE RESIDENT: L-R: Manish Dayal, Emily VanCamp, Shaunette RenŽe Wilson, Matt Czuchry, Valerie Cruz and Bruce Greenwood in THE RESIDENT premiering midseason on FOX. ©2017 Fox Broadcasting Co. Cr: Justin Stephens/FOX

Bargaining with IV drug users for drugs. In one scene, the younger protege is seen bargaining with an IV drug user so that she’ll give into his demands and it becomes a bartering of sorts like buying food in an open market. Hands down, the physician should decide what his bottom line is and not waiver from it.

Effective CPR is “until the ribs crack”.  Effective CPR is just the amount of compression depth it takes to generate a pulse that can be felt. It is a risk factor that the patient’s ribs can break, but it is not the clinical guideline we shoot for.

An environment of “no questions asked” is dictated. The senior resident gives his junior resident this mantra: “Do what I want you to do. No questions asked.” Again, this type of environment is intolerable in the hospital setting and should never be dictated . . . like ever. A questioning environment has been shown to increase patient safety and smart hospitals are encouraging this very thing. Most hospitals also have a mechanism in place to go above the bedside medical team if family concerns are not being addressed.

A surgical resident get first dibs on the new, bright, shiny, robotic surgical wonder. Need I say more?

The attending surgeon pretends to do a surgery. Remember the new shiny surgery robot? Remember the attending from Part I that has obvious hand tremors and should not be doing surgery? Did I mention this attending surgeon is an ego maniac (he even leaves positive medical reviews for himself)? Well, since no one has ratted out this well . . . rat . . . it must be him that first uses the machine. However, physically, he can’t do it. So he sets up a ruse where it appears he’s doing the surgery where in reality his uber smart, highly capable resident is. I cannot tell you how ethically bad this is on so many levels.

There are several issues that surround a lengthy medical code in the ER. The IV drug user that bargains for drugs in the beginning codes related to a heart infection. She is coded for nearly 30 minutes— the junior resident keeps it going for that long because of his emotional connection to the patient. Of course, just as he decides to call it, the patient gets her pulse back.

The senior resident is mad at him because he’s just revived a “vegetable”. Honestly, it is the senior resident’s job to watch their underlings. There would have eventually been an attending doctor overseeing this code. So, the person least responsible for the length of this code is the junior resident. Everyone higher up on the totem pull has the ability to stop the code.

Hospitals keep vegetative people alive for money. This is so patently false it’s laughable, but is probably more believable for the general public because many think hospitals will do anything to meet their bottom line.

I’ve been in nursing twenty-five years this May. I first started in adult ICU nursing and in that unit in Kansas there was avid discussion of clinical pathways to put people on to withdraw unnecessary (futile) care. In fact, I would say I’ve seen the opposite— at times a push to take people off of life support sooner then may be warranted from both the family and/or medical providers.

A resident taking it into their own hands to discontinue life support. Because the patient has no hope for life and he sees that the family is in no hurry to stop life support, the resident decides to turn off the machines. Fortunately, he is caught by a fellow resident and quickly turns back on the life support and the patient suffers no ill effects. Again, highly unethical. How about . . . having some hard conversations with the family about the viability of their daughter and helping them come to this decision? I know this is painted in the episode as a merciful thing for this doctor to do, but it would have been murder if he succeeded. He does not have permission to discontinue life support and cannot do so on his own accord. Period.

Also, there is no reason to be dumping a bucket of ice cold water onto a patient’s face . . . like ever.

I guess I should be thankful to The Resident for giving me all this blog material. It’s the only thing good about the show.

Tell me what you think of The Resident? If you’ve seen an episode, will you keep watching?

 

Fox’s The Resident: Everything Stereotypically Bad About Hospitals (Part 1/2)

Seems like this television season there have been quite a few new medical dramas hitting the airwaves. I’ve done a four part series on The Good Doctor (Part 1, Part 2Part 3, and Part 4) and 9-1-1. Newest onto the small screen is Fox’s The Resident.

It will make you hate hospitals and everything about them.

There are a few that say to me, “Why try and correct all this misinformation? Most people know it’s not factual.” It might actually surprise you how many people view what they see on television as real and true. The recent demise of crock pots everywhere after an episode This Is Us led the company to release a statement about their safety.

The Resident highlights every horrible hospital stereotype . . . literally on the planet. This is pretty amazing for a show to do in one hour.  The show centers around two residents: the senior resident Dr. Conrad Hawkins and a new bright and shiny resident, Dr. Devon Pravesh. One big problem . . . it’s not even clear what type of residents they are.

Hawkins is the gunslinger. The medical doctor who knows everything under the sun and bucks corruption (and common sense) at every possible turn. He is brash, arrogant, and needs a few classes in mentoring and bedside manner. Well, not just him, but really the entire cast of doctors from the senior attending with tremors who shouldn’t be doing surgery anymore to the wicked smart surgical resident who, in a room full of people (and on the fly by no less) states to a family that the result of their loved ones surgery was “Prescott’s dead.”

Sweet.

I don’t even like this show a little bit. As it stands now, I personally find nothing redeeming about it. Not only medically, but socially as well.

Here is just a short list to get us started on what’s wrong with The Resident.

An open appendectomy. Appendectomies are mostly done laparoscopically. In this patient, it’s even commented that it hasn’t ruptured so it should be the easiest of all appendectomies. However, this patient has a heinously large incision and the attending physician (the one with the horrible hand tremors) nicks an artery and the patient dies.

A short surgical code. It is true that surgeons don’t like deaths to occur in the actual OR. Considering that, the surgical code (compared to a medical code later) is laughingly short. Like big shrugs around the room after a few minutes— golly gee, our patient is dead.  Not sure how we treat hemorrhage.

The cover-up. I can’t say with one-hundred percent certainty that no bad medical outcome is hidden, but I will say that the climate is definitely supporting the truth coming out in the hospital setting. In this television episode, it’s plainly clear that this attending surgeon has a reputation for bad outcomes and the staff has been covering this up for a while. After the patient dies, they develop “the story” to cover up the surgeon’s negligence. Hands down, this puts too many careers at risk and most people aren’t willing to take that chance. This is beyond “playing along”. Most hospitals have corporate compliance hotlines where concerns can be left anonymously. Honestly, it would increase the tension of this television show to have someone trying to expose him.

Next post, we’ll continue our discussion on the medical inaccuracies of The Resident.

 

Radiation and Spiderman

So pleased to have back our radiology expert Shannon Moore Redmon.

Welcome back, Shannon!

When in elementary school, our teacher rewarded good behavior with an episode of Spiderman. The thought of a once nerdy boy turned superhero, gave all the kids in class grand ideas of swinging from tall buildings and capturing bad guys with web like nets. Thankfully, no one ran out and searched for spiders to bite them.

However, when humans are truly exposed to radiation, we do not acquire superpowers like our wonderful Spidey, but overdoses of radiation lead to a variety of sickening symptoms or cancer, depending on the size of the dose.

Peter Parker’s symptoms do not demonstrate the real effects of radiation exposure.

  • Peter is bitten by a radioactive spider.

First, a radioactive spider does not contain the ability to provide humans with special powers. Peter’s hand develops a large boil on the area of the bite, but instead of going to the hospital, the teenager goes home and lies down.

This is science fiction, but wouldn’t a normal teenager at least tell the grownups living in the same house of his insect bite and go see a doctor? My boys would.

  • Peter feels the results of the radiation in his body and his DNA changes.

Some real world medical tests use radioisotopes or expose patients to radiation, but the small dosage rarely manifests into any biological changes. We receive more radiation exposure from our televisions, microwaves and cell phones we use every day then we do from medical tests.

Nuclear Medicine is a radiological modality where small doses of radioisotopes are given to patients to discover diseased areas within the body. These scans can detect cancers, non-functioning organs or other medical conditions, such as Alzheimer’s disease.

Fluoroscopy, another radiology modality, uses live x-ray beams to study the stomach and intestines. Technologists and radiologists must protect themselves with lead aprons, gloves, and thyroid shields. They also wear dosimeter badges to record their exposure.

  • Peter wakes up no longer needing glasses and his body has evolved into a buffed-up physique.

If only radiation exposure was that transformative. We’d all be rushing to our local x-ray departments for the latest dose of tummy tightening effects.

Larger doses of radiation are destructive, but in the case of a cancer patient, the damaging exposure can be helpful. Medical facilities use therapeutic radiation to attack malignant tumors, shrinking or eliminating them.

According to the NCBI, there are two types of radiation exposure, acute and late onset disorder. If you want your character to die quickly, then review the following symptoms:

Acute disorder:

Alopecia – hair loss
Skin erythema – redness of skin
Hematopoietic damage – destruction of blood cells
Gastrointestinal damage
Central Nervous damage

Late onset disorder:

Cancer
Non-cancer disease
Genetic effects

So, for now, Spiderman fan’s need to steer clear of those radioactive insects. But if your character has a medical condition that requires a dose of radiation, the positive effects can be as life changing as Spiderman’s.

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Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.