Month: June 2012

A Minor Detail: Heidi Creston

/ Jordyn Redwood / Leave a comment

Handling the medical treatment of a minor can be tricky. Heidi Creston is back to discuss some of these special circumstances.

Welcome back, Heidi!

I work in L&D, and by far, dealing with family issues is more demanding of my time and energy than anything else. There is one issue that continually pops up and more and more I am finding it in the books I’ve been reading as well. I’m not an expert but I’d like to toss my two cents in for whatever it’s worth.

There are three primary condition that will emancipate a minor WITHOUT a court order:

1. Marriage
2. Joining the Armed Forces
3. Reaching the age of 18

Marriage or enlistment in military service by a minor brings about a new relationship of obligation and responsibility between the child and someone other than the parents. The severing of the child-parent relationship in this manner constitutes as an implied emancipation.

Substantiated reports of desertion, abandonment, non-support and other conduct of the parent may constitute reasonable circumstances for implied emancipation of a minor depending on the age and maturity level of the minor.

Pregnancy, in most states, does not constitute for implied emancipation. The pregnant minor is MEDICALLY emancipated, meaning they can make medical decisions for themselves and their baby only. The best option is to research the emancipation laws in the state that your are writing about because regulations vary from state to state.

Some states are pretty liberal with their emancipation procedures and a judge can sign off on it without a hearing if all parties involved are in agreement. So if you are planning some animosity within your story with those teenagers, take a quick peek at the laws first.

Marriage is another minor detail as well. Some states, like Wyoming, the legal age of marital consent is 19, not 18. So there is good reason said boy had to talk to girl’s dad first.

Jordyn here: I did a series as well on HIPAA issues that you might find interesting. Several aspects of this law are violated by authors frequently. Check these links for further information.

1. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-13.html
2. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-23.html
3. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-33.html

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.

Author Question: The Pesky Reporter and the Wildfire

/ Jordyn Redwood / Leave a comment
Charise’s question is very pertinent particularly with so many wildfires burning in my home state of Colorado right now. How does EMS handle it all?
Charise asks:

I’ve got a forest fire happening and a news photographer out trying to get the best shots. She’s walking around recently scorched areas. Her car is parked on black top.  It’s still pretty hot and smoky but she is there without an air tank so it can’t be too crazy. 

I need her car to be inoperable but nothing too crazy like exploding. Is it possible that parked on asphalt, the tires would blister or begin to melt (but a person could still be okay walking around on the dirt)? It seems the way heat is conducted in the earth vs. pavement makes this plausible?

Also, I know animals flee a fire but do they get caught sometimes? Is it possible she’d come across a dead deer?

After she leaves the area, it’s normal she’d have some smoke inhalation problems? Coughing, hacking, etc? Does that require medical treatment or would she be left alone since she’s lucid and otherwise healthy?

Dianna says:

My first thought is that rescue personnel (fire, EMS, law enforcement, haz-mat, etc.) form a perimeter (boundary circle) of three areas: the hot zone, the warm zone and the cold zone.
Hot zone is where the actual emergency event is occurring (in your story case, the forest fire). Warm zone is the surrounding area next to the hot zone; it’s for rescue personnel to enter and exit the hot zone and for decontamination. Cold zone is the area beyond the warm zone and is the only area okay for civilians, including the media.
That said, your character wouldn’t be allowed in an area that her car would experience the damage you stated. Now, of course, sometimes the media and other civilians enter a restricted area like the warm zone (they wouldn’t enter the hot zone unless they’re willing to die). So, you could certainly add that into your story, but she would have charges brought on her, so your story needs to reflect that.
It sounds like you have your reporter character staying with rescue crews, and that’s not accurate. We “deal with” the media this way — we tell them exactly where they can stand and set up their equipment, we keep them informed and updated, and we monitor their whereabouts, but we don’t hang around with them since our job is to work the scene (not watch it unfold), and we certainly don’t allow them to travel around with us at a scene. Sure, we talk with the media, even joke around and share information as appropriate (sometimes just to emotionally handle intense situations), but it’s kept to a minimum and very professional. Good conflict for fiction, though, would be for a rescue personnel to deviate from this, but make sure that person has strong reason for doing so.
It’s highly unlikely she wouldn’t be caught (the boundaries are well monitored), especially since you say she suffers with respiratory issues, so the authorities would know she entered the warm zone (we’d hear her coughing).
As for the medical issues she’d experience, it depends on where exactly she traveled at the scene and it depends on her signs and symptoms. She wouldn’t be covered in ash unless she was actually in the hot zone. If she does experience any respiratory distress, she’d be unwise not to seek medical treatment, and the treatment we’d provide is oxygen therapy, IV, possibly meds and a CPAP depending on her signs and symptoms, and we’d definitely hook her up to our cardiac monitor and evaluate her vitals. This is my thinking: If she’s “covered in ash” then her respiratory system was definitely compromised and she needs medical treatment from EMS.   
So, make medical information fit into your story (not the other way around) by simply keeping things within the possible and changing little things in the story as needed. For example: If a character suffers a head injury and you don’t want that character to go to the hospital on scene, then simply have the character well cognizant with minor signs and symptoms, and later on that character could develop serious signs and symptoms if that’s what you want. Another thing: all patients are different, so how one patient’s body responds medically isn’t the same as another patient’s body; meaning, there are a ton of ways to write medical aspects in fiction.              
As for animals: Sure, all types of animals are caught in all kinds of disasters, so anything there is possible.

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After majoring in communications and enjoying a successful career as a travel agent, Dianna Torscher Benson left the travel industry to write novels and earn her EMS degree. An EMT and Haz-Mat Operative in Wake County, NC, Dianna loves the adrenaline rush of responding to medical emergencies and helping people in need, often in their darkest time in life. Her suspense novels about characters who are ordinary people thrown into tremendous circumstances, provide readers with a similar kind of rush. Married to her best friend, Leo, she met her husband when they walked down the aisle as a bridesmaid and groomsmen at a wedding when she was eleven and he was thirteen. They live in North Carolina with their three children. Visit her website at http://www.diannatbenson.com

Author Question: Will the ER do DNA test?

/ Jordyn Redwood / Leave a comment
Marion asks:

Will the ER do an emergency DNA test to establish familial relationship?

Jordyn says:

I actually have this scenario in my forthcoming second novel, Poison, releasing 2/1/2013. I needed to prove a woman was related to garner custody. Between my ER docs and my brother who works for a large sheriff’s department– we figured out a plausible solution.

The ER is not going to run this test on an emergent basis and I don’t know of many hospitals who even have the capacity in house to accomplish this. So, the lab would be a “send out”.
What will happen is that the ER will contact social services (in house and whatever county the child is in– this might be known as department of family services or DFS) and make arrangements for the test to be performed. Turn around time for a private lab (maybe the family volunteers to pay for the test) may be 1-2 days. Something done through the state is going to take longer– my brother quoted 7-10 days.
During that time, the child can be admitted into the hospital (but again, this will depend on how full the hospital is and may be unlikely if the child is not ill.) Or, the child will go into foster care until the test results become available and social services examines the home the child is going to. In my book, the child went into short term foster care– this can always add conflict to your ms.

Forensic Issues: Determining Time of Death

/ Jordyn Redwood / Leave a comment

Determining time of death is important for criminal prosecutions to narrow down the list of suspects. Some things that can aid narrowing down this window are forensic terms you may of heard of: Algor Mortis, Livor Mortis, and Rigor Mortis.

I was fortunate to hear a local coroner speak several months ago. And she reviewed these terms and what they meant.

How fast does a body cool? In a 70 degree room the body will cool 1 degree an hour if maintained at a steady temperature. Issue being, how often are the deceased found in a perfect, unchanging, 70 degree environment? They can be found in temperature extremes, exposed to the elements, or buried in differing depths. All these will effect determining time of death.

Algor Mortis: Reduction in body temperature after death. There is generally a steady decline until is matches the ambient temperature of the environment. Problem being if the body is found in a much hotter area like a house with little air conditioning in a hot, humid environment.

Livor Mortis: Dependent pooling of blood when a person dies. This can be helpful in determining the position of the body at death and if a body has been moved. For instance, let’s say a nude body was found face down, yet their buttocks, heels, shoulder blades and posterior scalp are purplish. This would indicate a change in the position of the body. It starts 30 seconds to two minutes and becomes fixed in 8-12 hours.

Rigor Mortis: Stiffening of the muscles. Starts in small muscle groups first. Begins 2-4 hours, fully developed in 6-12 hours and disappears in 36 hours.

Things that can speed up or slow down these time frames are: the environment, fever, and whether or not the body was buried. Considering the long time frames, an exact time of death is hard and the best hope is to narrow down the time frame.

Here’s a good overview and includes additional discussion of the process of putrefaction.

http://www.deathreference.com/Py-Se/Rigor-Mortis-and-Other-Postmortem-Changes.html

Have you written a scene using any of these concepts?

Forensic Issues: Collecting a Rape Kit (2/2)

/ Jordyn Redwood / Leave a comment

Last post, I covered some generalizations about how a sexual assault victim is managed in the ED. Today, I’m going to get into specifics about how a rape kit or Sexual Assault Examination (SAE) kit is collected.

Herald Times Online

The sexual assault victim is a crime scene. Medical needs always come first. If the victim presents with life threatening injuries, these will be managed first above everything else. Collection of evidence will come at a point when the patient is stable.

In the kit are generally some large paper drapes. On the ground, we’ll lay out two large bed sheets with the towel on top. The patient (assuming she is wearing the same clothes at the time of the attack) is asked to undress in the middle of these sheets and then given a gown to wear.

Each piece of clothing is bagged in a different paper bag and labeled. I do a piece of clothing, time, date and my initials. Plastic bags are never used. Moist things in plastic will mold and disintegrate and this can damage valuable evidence.

Once the clothes are bagged, each of those sheets are bagged individually as well. This is done in hopes of collecting trace evidence that may have dropped off the patient as she unclothed.

Next, it is important to know the details of the assault as this will dictate what pieces of evidence are collected.

Mouth swabs are collected. They do need to dry before being placed in either an envelope or small cardboard box designed for these swabs.

Fingernail scrapings are collected and fingernails are also trimmed and collected as well.

The pubic hair is combed and any debris is collected in an envelope. The comb is placed there as well.

Probably one of the most humiliating parts of the exam for the victim is that known hair samples need to be collected from their head and pubic area. These must be pulled from the victim. The hair cannot be cut. The point of this is to get the hair shaft that contains DNA so this can be compared to other DNA samples that are combed off the victim.

Blood samples are collected.

A pelvic exam will be conducted by either the ED doctor, ED Nurse Practitioner or the SANE nurse. This would be outside the scope of practice for a bedside ER nurse to do but she is able to do all the other parts of the kit.

If residual fluids are left behind, these are swabbed as well. Any place where the victim may have been bitten will also be swabbed.

Remember, all swabs need to be air dried before they are placed in an envelope or cardboard container. This takes time.

Photographs are taken.

The patient will likely be prophylactically treated for sexually transmitted diseases and pregnancy (if they choose). Counseling will be done in these areas. Some STD’s require follow-up testing– like HIV and a follow-up medical plan will be provided for the patient as well.

For additional information on collection of a rape kit, check this source: http://www.enotes.com/forensic-science/rape-kit.

Forensic Issues: Collecting a Rape Kit (1/2)

/ Jordyn Redwood / Leave a comment

ER nurses need to be familiar with the collection of a rape kit or Sexual Assault Examination (SAE) kit. This is good information for a novel that involves a rape victim or a character working as an ER nurse. I’m going to cover this in two parts, the first being some generalizations to consider and then I’ll move into specifics for the second post.

Sexual Assault Nurse Examiners (SANE) are nurses who have received specialized training in the collection of an SAE kit. It is not a simple one day class but multiple classes and clinical hours before the certification can be earned. It is not required that a SANE nurse be the one to collect the SAE kit. SANE nurses are not available at every hospital though you are likely to find them in major metropolitan areas.

The ED staff and police work in conjunction for the victim.

There is not a “national” standardized SAE kit. Each police jurisdiction may have their own of what they want collected.

The location of the crime is important as this will dictate what police agency handles the crime and evidence. The location of the hospital doesn’t play into this. If the crime occurred four hours away– that police jurisdiction will have to send an officer to our location.

The victim needs to give consent for collection of evidence and pictures. The victim can refuse and though we will encourage them to think about this differently, they do have the ultimate say. It is preferred that kits are collected within the first 24 hours though can be done up to 72 hours. After that time, one may still be collected but those involved may be concerned about how much evidence could be recovered and whether or not it will benefit the victim to be put through the exam.

Crime photographs are mostly managed through the police department CSI folks. Though, again, this may change in smaller, more rural locations. If you are writing specifically about a known town and a “real” hospital, it will behoove you to talk to someone there to get the details right.

If available through the police department, a victim’s assistant will come to the hospital to help the victim to understand the process. The nurse may have to advocate on behalf of the patient and ask the police if one is available. Often, these are a team of volunteers that support the police, especially during the night and weekend hours. They also receive specialized training sponsored by the police department. Smaller departments may not have one available. In that instance, an option would be to have the bedside nurse ask a chaplain to come and support the patient.

Next post we’ll talk about specifics of the kit.

Shock Me To Death

/ Jordyn Redwood / 2 Comments

There’s nothing like watching a TV show and seeing medical personnel come in with the paddles (even these are rarely used) to shock a patient. Many people say this is “jump-starting” the heart and this is really the wrong clinical picture to give as far as medical accuracy is concerned. The use of electricity on the heart actually stalls it.

What?!?

How could that possibly be helpful to a patient?

Heart cells are very unique, cool little contraptions. Each cell in your heart can generate a beat. Yes, that’s right, every little teeny one. Most often, the normal conduction system of the heart overrides this unique property of heart cells, and the electricity flows from the AV node to the SA node so the heart contracts in a normal, orderly fashion.

Heart Cells: Douglas Cowan, Children’s Hospital Boston
The heart’s normal beat is important because when the top (the atria) contract, it pushes the remaining blood that doesn’t flow via gravity when the valves open into the ventricles. When the ventricles contract, it pushes blood out to the rest of the body.

The purpose of blood flow is really oxygen delivery to the cells. Of course, there are other functions but this is primary. Without oxygen delivery to the cells, cells will die. Lack of oxygen delivery to the cells is called shock.

We’ll talk more about shock in later posts.

Defibrillation (or unsynchronized cardioversion) is only used in a few arrhythmias. Ventricular tachycardia and ventricular fibrillation. These arrhythmias appear when something has affected the heart’s normal conduction system– such as a heart attack, electrical injury, lack of oxygen. They are more common to the adult population than to the pediatric.

In these arrhythmias, the heart’s normal conduction system is no longer working properly and other cells in the heart become active in an attempt to keep the patient alive. The problem with these arrhythmias is that they do not produce a pulse.

No pulse is clinical death. So, we must get back the patient’s pulse back in order for them to have a chance at survival.

What defibrillation actually does is stop the heart by briefly terminating all electrical activity in hopes that the heart’s normal conduction system will begin to work and a palpable pulse will then ensue.

Important note— there must be some electrical activity for defibrillation to work. So, it is not indicated for the treatment of asystole or when the patient has “flatlined”. This is done often in television shows and is a clear medical inaccuracy.

Electricity is also used in another condition called supraventricular tachycardia (SVT). Supra means above. So this rhythm is a very fast rhythm generated somewhere in the atria. Sometimes, when the heart beats incredibly fast, it doesn’t have enough time to fill with blood. When it fills with less blood, it pumps less blood out. Less blood out means less oxygen delivery. The patient can have signs and symptoms of lightheadedness, dizziness, sweating, chest pain, and difficulty breathing to name a few. They still have a pulse though it may be weak and thready.

The goal of using electricity in this instance is again to disrupt this pathway by stalling it in hopes that the heart’s normal conduction system will take over at a much slower rate.

There is also a medication that can be given that will chemically stall the heart, too. It is called adenosine and is used in the stable patient presenting with SVT. It is used in instances of fast rhythms to slow the pulse down.

Does this change your impression of how defibrillation really works?

Author Beware: Delusional Diagnosis (2/2)

/ Jordyn Redwood / Leave a comment

Last post, I discussed the issue of heart palpitations and how, in isolation, they can be benign and not representative of heart disease.

The line in this particular published novel that did get my ire up is shortened as follows: “Any experience terrifying enough to cause a panic attack, in extreme circumstances, causes an arrhythmia. That’s a heart attack.”

Really? No. There’s a lot medically wrong with this sentence.

First, in very general terms, a heart attack is caused from lack of oxygen to the heart muscle, generally from a clot in an artery that feeds blood to the heart– your coronary arteries. When the heart muscle is not getting oxygen, it becomes irritable. One interesting thing about your heart is that each cell can generate an electrical current that will contract heart muscle. It generally does not do this due to the over-riding normal pacemaker. However, when oxygen is cut-off and the heart cells become irritable, they can begin to fire outside the normal conduction system.

When this happens, the medical team begins to see aberrant beats. But see, the heart attack itself generally causes the arrhythmia, not the other way around.

Let’s stay on track with this character. A healthy, college age woman. The incidence of actual heart disease is going to be low. What causes chest pain during a panic attack? Generally, the heart rate may be faster than usual. However, the truly rapid heart beat of SVT (more on that later) I would say is rare and would point away from the mind and more to the conduction system in the heart.

The last thing to consider is that people who have true heart arrhythmias, may have structurally fine hearts. Meaning the muscle, valves, and coronary arteries are good. Just the conduction system is a little funky.

My advice for authors– don’t make blanket medical statements. Just like they taught you in school– sentences that have all, every, etc… are likely the wrong answer.

Author Beware: Delusional Diagnosis (1/2)

/ Jordyn Redwood / Leave a comment

There’s nothing I hate more as a reader than to be happily reading along a novel that I really like and come across a medical issue that begins to pull me out of my snow globe of a story bubble. It’s even worse when it begins to keep me up at night and I dream up a whole blog series about this issue.

That means things are really bad.

This happened recently. The story is actually quite good. Solid, interesting premise. Had it not been for this medical issue that was a thread through the entire story, I’d easily give it a five star rating. But, because of this medical issue and how it was painted, I downgraded my review just for that reason.

It made me wonder if the author had talked to someone in the medical field. And if they did, who it was. I mean, the 125 year-old retired dermatologist may not be the best resource. For dermatology– yes, absolutely. Otherwise, just sayin…

And I love dermatologists by the way. But if I’m dying– please find me a cardiologist!

The issue surrounded palpitations. The author began to write about how the lead character was having palpitations and how she was concerned this represented a major heart issue that would ultimately lead to her not being able to pursue her ultimate career goal. The author painted it as a major event in her life.

I’m going to ease off a little here as patients are often this way. They worry that a minor symptom represents a major life-ending disease. Happily, this if often not the case. So, it’s okay to do that… in the beginning. I’ll cover the major down side of this book next post.

Let’s cover what we know. What are palpitations?

Palpitations are merely the sensation of your being aware of your heart beating. Normally, you can’t feel that muscular pump busily working in your chest. Is doesn’t keep you up at night with its never-ceasing beating nature.

Palpitations are often skipped beats. When your heart skips a beat, sometimes blood doesn’t flow out as it naturally would and this fullness can be felt. Normally, these skipped beats aren’t anything too concerning if they happen every so often. More worrisome is if it is happening all the time and/or associated with chest pain and/or shortness of breath.

Palpitations can also represent rapid heart beats or irregular heart beats. These can be a little more worrisome.

However, some people with palpitations do not have heart disease or an arrhythmia. This character happened to be a young, healthy college student which makes these diagnosis more unlikely.

Come back for Part Two of Delusional Diagnosis next time.

Determining Brain Death: 3/3

/ Jordyn Redwood / Leave a comment

Last post, we talked about the use of apnea testing to determine brain death after the patient meets certain criteria.

There is one additional test that may be done to determine brain death and that is a brain perfusion scan.

This procedure is done in radiology which can make it very difficult. Imagine taking a ventilated patient through the halls of the hospital along with several IV pumps giving medication that are keeping the patient alive. That in itself is not a fun excursion.

Once the patient is in radiology, they are given an injection of a radioisotope—something that will trace where the blood is flowing. After the injection, photos are taken of the patient’s brain. If there is no blood flow to the brain, and this must include the brain stem as well, then the patient is said to have “brain death” and is clinically dead at that point.
This You Tube video provides a very good explanation of these concepts.

After brain death is determined, the patient is not immediately withdrawn from life support but a conversation will ensue with the family that the patient has died and they will be encouraged to discontinue life support.

Generally, families are given a lot of time to come to terms with this decision. Anywhere from 1-3 days is reasonable. They may want to fly in additional family members to be present when life support is discontinued. I’ve never been part of a situation where, when the finding of brain death were fully explained, where families chose not to discontinue support.

This is not to say that the patient may not proceed to circulatory death despite receiving life support. Once the brain has died, it does become very difficult to keep the body functioning.

Does this change your mind about how brain death is determined?