Care of the Burn Patient

Linda Asks:

In my middle grade novel my main character’s dad was a fireman in NY.
He was present during the collapse of the World Trade Center buildings.
He was burned severely and is in the hospital – near death.

My main character remembers his last conversation with his Dad in the hospital right before he dies.

The dad is hooked up to all kinds of beeping machines and is wrapped in white gauze.
After he talks to his son for the final time, he pushes a button for more morphine.

Questions:

Do they still wrap burn patients in gauze?
Is morphine used on severely burned people?

Jordyn Says:

From the point of view of your character– yes, burns are wrapped in gauze. They are specialized dressings, but a character aged 10-13 could perceive it as gauze only.

Yes, morphine is still used for pain.

My only concern is this character having a conversation with his dad. You don’t describe the nature of how he was burned, but a severely burned patient, particularly one close to death, is likely on a breathing machine and, therefore, unable to speak to his son.

You could change the scene to be that he’s so sick that they are getting ready to intubate the character’s father, and the medical team gives them a few moments to talk before they put the father on the breathing machine. He could still die quickly after from his injuries.

The Use of Hypothermia Post Cardiac Arrest

Emily Asks:

I am playing around with one of my character’s being shot life threateningly, but of course it’s gotta be something he recovers from with time.

This character is in his late 20s and in good health before the incident takes place.

At first, I was toying around with the idea of making the gunshot wound similar to what Kate Beckett had in the show Castle at the end of season three. The trouble is, I do not know how medically realistic her wound was, as you have pointed out Castle’s medical inaccuracies before. If you have possibly seen the episodes in question, could you give me some feedback on the medical aspects of Beckett’s shooting?

In relation to this, her heart supposedly stopped twice during the whole ordeal. I have been researching induced comas, and while they seem to be used for patients having more of a direct injury to the head, in the case when a victim’s heart stopped twice and is resuscitated both times, would there be any reason to keep them in an induced coma for a time due to lack of oxygen to the brain?

Then, after researching, I am playing around with giving this guy a collapsed lung from the bullet, which is small caliber.

1. In what hypothetical cases would this kind of injury require immediate surgery?

2. Are there any complications that could be serious enough for the said character to have to go back into surgery at a later time?

3. My character happens to be a bass singer for an acapella band. Would a collapsed lung affect his career at all even after he made a full recovery?

Thank you for taking the time to read and respond to my questions!

Jordyn Says:

Beckett’s Gunshot Wound:

I had to go back and find some videos that were related to this. Shockingly, I found this scene pretty medically accurate. I found one that showed her coding one time. Though I definitely could have missed some. The determination to put someone in therapeutic hypothermia or targeted temperature management (as now termed) related to their heart stopping is dependent on whether or not they wake up immediately after their code.

A patient that wakes up spontaneously and quickly after a pulse is restored has intact neurological function. Those that remain comatose have a concern for neurological injury related to oxygen loss to the brain during the resuscitation and therefore the medical team could choose to put the pt in a “hypothermic” state to try and prevent this neurological injury.

This is slightly different from a medically induced coma that patients with traumatic brain injury might be placed in to prevent brain swelling. The difference is actively cooling the patient. I have not seen the use of hypothermia in the traumatically brain injured population (though this does appear to be an area of study), but use of medically induced comas, yes.

There are definite guidelines that the American Heart Association has put out that outline this course of treatment. You can find one such article here.

If your character codes and doesn’t wake up– then this would be a reasonable course of action medically, but written under the guidelines in the article.

In regards to your specific questions.

1. It’s more likely than not that a gunshot wound to the chest would go to surgery, particularly if the patient presents with any abnormal vital signs especially low blood pressure. There’s just so much there that could be damaged. The heart. The lungs. The blood vessels.

2. Yes, there could be a number of scenarios where the character could require more surgery such as a blood vessel that’s leaking that’s not found the first time during surgery and continues to bleed. Infection– specifically some sort of abscess formation could be another reason, but that would take some time to develop.

3. I don’t personally foresee a problem with his acapella career after his lung is healed. It would take time to get to the point where he was. If you wanted to affect his career, a patient who is intubated (placed on a breathing machine) can develop vocal cord damage as a rare complication.

Best of luck with your story!

Criminal Minds: Can a Patient be Admitted for Psychological Distress?

In a recent episode of Criminal Minds, a woman was nearly shot and killed by a madman operating a drone. She is saved and uninjured, but is admitted to the hospital just in case she begins to suffer some psychological distress.

Can this really happen?

The situation as portrayed on television— no.

When admitting someone emergently for a psychiatric problem, one of two things needs to be a concern. Either the person is a threat to themselves, to another, or both. You might hear a provider ask, “Is the person expressing HI or SI?” which stands for suicidal ideation or homicidal ideation.

If a person is expressing either or both of these concerns then a couple of things happen. The patient first must be medically cleared by a physician to ensure that there are not any coinciding medical concerns. Once this takes place, they then are put through a mental health evaluation.

Once a mental health evaluation is complete, it is decided what type of psychiatric services the patient may require. Sometimes, it is admission under an involuntary hold. Other times, the patient may be connected with outpatient services.

Think about the many events that have happened just in the US where people will be suffering psychological distress, but are not expressing suicidal or homicidal thoughts. The  devastating hurricaines. The mass shooting in Las Vegas. Put simply, if we admitted every patient that we were concerned for the potential of psychological distress outside of expressing HI or SI— we’d quickly run out of hospital beds. Plus, patients expressing these concerns should not be placed on a medical floor unless they also have co-existing medical problems that they need treatment for. Also, in that case, they require one on one observation.

Although a nice thought, you do have to have a mental concern other than psychological distress from surviving a potentially life-ending event to be admitted into the hospital.

Kardashian Style Ultrasounds on Reality TV

Critics who say reality TV is fake must not watch the ultrasound scenes on Keeping Up with the Kardashians. On a recent episode, Khloe Kardashian visits an infertility doctor with her sister, Kim, and receives an ultrasound of her uterus and ovaries.

Instead of being like most Hollywood scripted shows, KUWTK portrays this scene with spot-on accuracy. Watch the video below… (Caution: Some adult language is censored during this scene).

What KUWTK did right

We can all see that this doctor’s visit is legit. Maybe it was scripted, but at least they recorded the ultrasound as true to real life. Here are the things they did right and something Hollywood needs to study for future TV shows.

1) The physician has the machine turned at the appropriate angle. It is facing the physician and pulled down where he can reach the dashboard. The camera still is able to give him plenty of TV time while Khloe and Kim can watch the scan on the wall monitor.

2) Khloe is pretty much covered with a paper sheet during the scan and the physician or sonographer inserts the probe. This is a very accurate scenario for a real life internal vaginal ultrasound. Sonographers and physicians who scan make sure the patient is comfortable and covered while the scan is being completed. We utilize vaginal scanning to view the uterus and ovaries and also first trimester babies. We scan on top of the belly for second and third trimester pregnancies or other types of imaging.

 3) The machine is relatively quiet. The only noise heard in the background is the cooling fan on the system. No heartbeats or added sound effects are slipped into the scene to make it seem more authentic. Finally, TV got this detail correct.

4) The physician uses the appropriate probe and the appropriate anatomy is shown on the screen. The images we see on the monitor are the uterus and ovaries.  Many times, shows present anatomy on the screen that doesn’t match the discussion they are having or the sounds coming from the machine.

5) The ultrasound equipment is a top of the line GE ultrasound machine. No ancient relic from the 1980s being thrown into a scene because it’s the only thing in the props room. Hollywood must think no one will know the difference. This physician uses modern ultrasound technology to do his job.

Reality TV might get a bad rap for not being truly “reality”, but this scene was the most accurate ultrasound example on TV to date. Maybe Hollywood films and television directors need to learn from Keeping Up with the Kardashians as an example of what to do when filming an ultrasound scene.

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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.

Treatment of Car Accident Victim with a Brain Injury

Leslie Asks:

My character has been in a car accident and sustained head damage (swelling to the brain)— is there a medical term for that? Also, the swelling becomes so bad the doctors have to remove part of her skull— is there a name for that? How long does that swelling usually take before it goes down so they can replace the skull? Does the character regain consciousness? I have her in an induced coma which I want her in for a while.

Jordyn Says:

Upon further clarification of this question from the author, she says there is not a significant description of the motor vehicle collision in the manuscript and the scene is being told from the POV of a nurse.

The brain swelling is called cerebral edema. Usually, if it’s a significant car accident then there is usually bleeding as well. This is why I ask about the car accident. It should be pretty serious.

A nurse will use language that a family can understand. So, I might actually avoid a lot of medical terminology when speaking to the family unless I also clarify what the words mean.

I might say something like, “Your mother (or whatever relation) has a lot of swelling in her brain as a result of the car accident. We call this cerebral edema.”

A craniectomy is where they remove a portion of the skull.

Peak brain swelling is generally 48-72 from the time of injury and diminishes from there. Induced coma is a reasonable medical scenario here.

Whether or not this patient regains consciousness is up to you as the writer. Statically, the odds are pretty low for her to be the same person she was before. If she does wake up, she’ll have extensive rehab needs for sure– but you could write it either way.

Best of luck with your story!

The Good Doctor is Bad Medicine Part 3/3

This is the third part of a series examining the medical aspects of ABC’s new medical drama called The Good Doctor which highlights the struggles of autistic surgical resident Shaun Murphy. You can read Part I and Part II by following the links.

Episode 2 has so many issues it’s taking me two posts just to cover it.

The other issue in Episode 2 is the care of a young girl with abdominal pain. Everyone but Dr. Murphy thinks this belly pain is caused by the girl’s parents’ divorce.

Issue #1: Ordering proper medical tests. One of the easiest things I feel like a medical show can get right is ordering the proper tests. Any medical consultant worth their salt should be able to assist the writing staff in this. For this patient, a child suffering abdominal pain, he orders a D-dimer, lactate, and amylase. Together, these tests make little sense. A D-dimer is used to look at blood coagulation. A lactate at how acidic the blood is. A lactate isn’t crazy, but a more applicable test for this girl would be what’s called a BMP or CMP— both of which are metabolic panels that look at the function of several organs in the abdomen. An amylase is okay as well— but drawn with other tests that make more sense. How about just a plain x-ray of her abdomen while we’re at it?

Issue #2: Going to a patient’s house. Despite the inappropriately ordered, fairly normal lab tests, the results bother Dr. Murphy so much that he goes to the patient’s house and insists on examining her. I cannot emphasize how much this would be frowned upon and I have personally never seen this happen. How would this be handled? First, simply a phone call to the family and request they come back to the hospital for further studies. If the situation is deemed serious enough, and the family cannot be reached by phone, involving law enforcement to help would likely be the next step.

Issue #3: Not calling an ambulance. When the girl is checked on, she is unresponsive and has vomited in her bed. Instead of calling an ambulance, Dr. Murphy insists that they take her by car. In an urban setting (in absence of a mass casualty situation), this is highly irresponsible. EMS response is generally very good and medical care can be started more quickly than driving a patient to the hospital. The episode proves my point when the girl becomes clinically more sick on the drive to the hospital and Dr. Murphy starts CPR. If EMS had been called to the house, this could have been prevented.

Issue #4: When to start CPR? In pediatrics, generally CPR is not started until the heart rate is under 60 beats per minutes. In this case, Dr. Murphy starts CPR for a weak, thready pulse. Looking up American Heart Association guidelines for pediatric CPR would be an easy way to figure out when CPR would be indicated.

Issue #5: Inaccurate medical portrayal of shock. When the 10 y/o girl arrives to the hospital, Dr. Murphy states, “Patient is a ten-year-old female with hypovolemic shock and bradycardia.” Hypovolemic shock is shock related to fluid losses, but seemingly this patient has vomited one time. Really not enough to set in shock in the older child. Also, the body’s response to hypovolemia is to increase the heart rate. The patient should be tachycardic. A pediatric patient can become bradycardic, or have very slow heart rate, in relation to shock, but it is a very late sign and I don’t think the medical history given on this girl is enough to warrant a code.

Issue #6: A surgical resident taking a patient to the OR. Keep in mind, Dr. Murphy is like on day #2 of the first year of his surgical rotation, yet he orders an OR, takes the patient to surgery, and is only interrupted by his attending when he’s about to make his first incision. Just no, no, no.

I think overall The Good Doctor has good intentions in looking at how people with special needs can operate in certain professions. However, don’t look at the first two episodes as any representation of good and accurate medical care.

There is always a way to maintain tension and conflict while still being medically accurate.

The Good Doctor is Bad Medicine Part 2/3

I’m continuing my evaluation of ABC’s new medical drama The Good Doctor. You can find Part I here. The series follows first year autistic surgical resident, Shaun Murphy, as he navigates his surgical residency.

The second episode sees Shaun begin his duties and he’s been accepted into the program, albeit with some outward disdain from some of the attending surgeons.

In the opening scene of this episode, a middle-age woman has had a CT of her abdomen that shows a large mass.

Issue #1: Morphine dosing. The patient’s initial dose of morphine is 10mg. This is a little on the high side. Generally, we’ll start with lower doses and work our way up. However, they distress the patient with news of her medical diagnosis and so the attending surgeon says to the resident, “Give her as much Morphine as she wants.” So the way we deal with patient distress is by overdosing them on narcotics? I don’t think so.

Issue #2: Reviewing medical tests in front of the patient. Two surgical residents and the attending surgeon pull up the CT results in front of the patient without having reviewed them first and the test shows a very concerning exam. Dr. Murphy diagnosis her with cancer, in front of the patient, based on this scan. This is reason #1 why you know what the patient is dealing with before you go talk with them. Nothing should be hidden from a patient, but also should the information be presented in a compassionate, informative way.

Issue #3: The definitive diagnosis of cancer can only be made by biopsy. Are some radiology studies highly suggestive of malignancy? Yes, absolutely. But always, the cells must be looked at for definitive diagnosis, which means a biopsy.

Issue #4: Supposedly, Shaun Murphy is crazy uber-smart despite his communication difficulties related to his autism, but he seemingly made it out of medical school without an understanding of what “scut work” is. Sure.

Issue #5: Nursing as boss. In one scene, a nurse is placed as Shaun Murphy’s “boss” to keep him from ordering unnecessary medical tests. Put simply, this is not nursing’s responsibly.  It is a nurse’s responsibility to protect patient’s assigned to her from unnecessary medical testing (or at least question the physician about tests that seem out of bounds), but never would a nurse be assigned to follow a resident around all day to keep tabs on him. This is the responsibility of the surgical hierarchy and they need to keep tabs on this resident. Also, this nurse seemingly works every area of the hospital from the ER to the PACU. This is also unrealistic.

Issue #6: Nurses are called by their first name— not “Nurse” and their last name. Again, can we get rid of this stereotype?

Issue #7: Lab delay in pathology results. Lab works very closely when surgeons are waiting for results with a patient on the table. These would be considered “stat” reads and would not be placed in the normal milieu of other lab tests.

Issue #8: Threats of violence are taken very seriously. Shaun’s response to the lab personnel not immediately reading the pathology slides is to verbally threaten to throw a rock through their window. This is completely unacceptable behavior, regardless of the autism diagnosis of the surgical resident, from any member on a hospital staff and would not be treated with a kind response (as in she smiles and concedes to his demands.) A statement made like this would receive disciplinary action.

Issue #9: These amazing medical centers cannot do amazing surgery. In this episode, the surgical team decides they must cut out the kidney in order to get a better look at the tumor. Fine, great. But why not reimplant it once the surgery is over?

There are so many issues with this one episode of The Good Doctor it deserves a Part III.