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.

The Good Doctor is Bad Medicine Part 1/3

The Good Doctor is a medical drama that’s first season just started airing on ABC. Of course, anytime a new medical drama hits the airwaves I get messages from people curious about my opinion.

The drama focuses on first year surgical resident Shaun Murphy who has autism. I’ve watched the first two episodes and though the premise of the drama is mildly intriguing— I don’t find the medical aspects or interactions between the medical staff worthy enough to keep watching. Unless, I keep analyzing episodes for this blog. We’ll see.

Episode 1 features the fight of a hospital administrator to get him accepted into the program. On Murphy’s way to the hospital for seemingly his first day, of course, he saves a life at an airport.

A teen is showered with glass and suffers life-threatening injuries to the neck and chest. An older male, who identifies himself as a doctor, begins to render aid by putting pressure on the wound. The doctor says, “His jugular vein has been cut.”

Issue #1: Placement of direct pressure. Murphy chastises the older doctor for holding direct pressure improperly (for a pediatric patient) and for occluding the patient’s airway because of it. The doctor adjusts and the patient begins to breathe again. Truthfully, there are differences between the adult and pediatric airway, but I’ve never heard of adjusting pressure d/t anatomy. You have to put pressure on what’s bleeding. If that causes problems with the airway, then the patient requires intubation to protect the airway.

Issue #2: Doctors having sex in the call room. Can we please just get rid of this stereotype? Please, just please. There is never as much rampant sex as portrayed on TV in hospitals. In my almost 25 years of nursing, I’ve heard ONE rumor.

Issue #3: Airport Security. I cannot believe in this day and age that, regardless of what someone says, hospital security would allow anyone to grab a knife and run wildly through the airport without being arrested— even if a patient’s life is in danger.

Issue #4: EMS response. Considering this is an airport, the EMS response time is laughingly long.

Issue #5: Chest tube. Of course, Dr. Murphy places a chest tube in the patient as well as makes, MacGyver style, a chest tube drainage system. Once this is done, he triumphantly raises it above the patient and the patient dramatically improves. Just, no. Drainage systems should always be level or below the patient to drain. Never above. Like never. You can check out this nifty nursing video that explains just that.

Issue #6: Direct OR admission from the ambulance. The now stable patient is met by a surgical resident and goes straight from the ambulance to the OR. No, just no. First of all, why does a stable patient need to go to the OR? Secondly, everything first to the ER. The ER attending will make a decision to consult surgery and a plan will be made to take the patient to the OR.

Honestly, there’s more in this episode. Can we talk about the language the doctor uses to get consent? I’ll spare you until next post where I examine episode 2.

 

Pediatric CPR: When to Stop?

Nothing probably tugs at the heartstrings more than thinking about a child dying. It’s not the way things are supposed to happen. We expect life to follow the natural order of things— the old die first. Parents should never bury their children.

Sadly, we know this reality is not true. The pediatric nurse understands and confronts this reality more often than most. Particularly nurses who work critical care, ER, oncology, and hospice.

A reader of this blog posed this question to me: How long will a nurse or doctor perform chest compressions on a pediatric patient? Is forty-five minutes too long or would they try longer?

This is a tough question and not so easily answered. There are really no hard and fast rules as to when CPR should be stopped and it depends a lot on the reason for the code (if known) and what types of signs the patient is giving us. For instance, just because a patient doesn’t have a pulse, doesn’t mean they don’t have electrical activity in the heart muscle. Some causes of a code are reversible, but it takes time to do so. Hypothermia might be a good example of this.

I’ve worked in both adult and pediatric critical care. What I’ve found generally is providers will run pediatric codes longer than adult codes even when chances are small to get a pulse back. No one wants to see a kid die— health care providers are no different. Plus, culturally, we resist death at every turn even though it is the course each of us will journey to.

However, I did come across this article that begins to address this concern. If we can teach how to resuscitate patients— should we also not teach providers when it is reasonable and ethical to stop such efforts?

1. Are there clinical features present prior to the code that are predictive of poor survival? For instance, in the adult patient some of these from the article included pneumonia, metastatic cancer, and low blood pressure. For pediatric patients, kidney failure and use of a continuous infusion of epinephrine are mentioned.

In the emergency department setting, we want to know what the patient’s initial heart rhythm was. If there was no electrical activity in the heart (terms such as asystole, flat-line, ventricular standstill) then chances of getting back organized electrical activity AND contraction of the heart muscle are low.

2. Is the patient receiving high quality CPR? This might seem like a no brainer. Of course, if the patient codes in the hospital, they must be receiving excellent CPR. What research shows is that this is not true and it is a big drive of many institutions to simply improve the quality of CPR. If I can ease your mind, many hospitals are improving CPR basics through high fidelity code labs, more frequent CPR check-offs, mock codes, and computer based CPR training that measures effectiveness of CPR and coaches the participant on how to improve .

What are some CPR pitfalls? Initiating CPR in a timely manner. Compressing deep enough and at the right rate. Not over or under ventilating the patient (both can actually cause problems). CPR is what we call a high risk, low yield procedure— meaning we don’t do it very often, but when we do we have to do it right. What you don’t practice frequently you don’t become adept at. CPR is no different.

Considering this, we look at how long the patient’s down time was. This refers to the time when the patient’s heart stopped beating to the time they got CPR. Trouble is, this might be relatively hard to determine. When was the patient last seen? Is the patient cold to the touch? Are their pupils fixed and dilated?

The good news for the writer is there is a lot of leeway in this area as far as how long a medical team might “work” on a patient. Factors can be given for both short and long resuscitation times.

The most important part is getting those factors medically correct.

What about you? Have you written a resuscitation scene into a work of fiction?

 

Author Question: Motorcycle Injuries

Tory Asks:

I’m currently writing a fan fiction and the two main characters get in a motorcycle crash. The female just found out she was pregnant. I have three (very unrelated) questions. Could the crash send her into cardiac arrest? Would the male (who was driving) be able to survive with just a broken arm and a sprained ankle? And would the baby survive?

Jordyn Says:

Hi, Tory. Thanks for sending me your questions.

1. Yes, a motorcycle crash could send someone into cardiac arrest.

2. Could the male survive with just a broken arm and a sprained ankle? Sure, this is possible, but I don’t know if it’s probable. When looking at accidents, medical people always look at the injuries of the other people involved to determine how serious everyone’s injuries might be.

If the female in the accident suffers a cardiac arrest, it would be surprising that the male walks away with just, essentially, a broken arm. You could make it more believable in the description of how the accident happens. For instance, the female is thrown from the bike, but the male is trapped underneath it. You could also have them differ in the type of protective equipment they’re wearing (helmet, jackets, etc.)

3. Would the baby survive? Again, it depends on a lot of factors. How far along is she in the pregnancy? Cardiac arrest— how long is she pulseless? What other injuries does she get in the accident? The sicker she is from her injuries, the more likely she will miscarry the pregnancy. The body will defer energy and resources to the mother over the pregnancy. Then again, some women have maintained a pregnancy through terrible injuries so you would have some leeway as an author here.

If the mother is far along in the pregnancy (at least 22-24 weeks along) and in cardiac arrest the providers might consider C-section to save the infant. So, without more details as to the nature of the accident, her injures and the state of her pregnancy, it would be hard to say if the baby would likely live or die.

Good luck with your story!

5 Tips for a Character’s Stroke

Even some famous authors get medical details wrong.

In a New York Times bestselling novel, the author presented his main character’s mother with a stroke. Almost all the details were accurate, except for the origin of the blood clot in the mother’s leg. This is where the author needed more research and clarification.

For example:

If the blood clot broke loose from the arteries of the leg, it travels to the toes and become lodged in the tiny capillary vessels, never reaching the brain.

If the blood clot broke loose from the veins of the leg, it travels to the heart, out to the lungs and becomes lodged. This obstruction can be fatal and is called a pulmonary embolism, not a stroke.

Therefore, when giving your characters a stroke, let’s get the details right by asking the following questions:

What kind of stroke does the character have?

There are two types:

Ischemic Stroke occurs when blood vessels in the brain become blocked by a moving obstruction that has traveled to the brain and lodged within the vessels, cutting off oxygen supply. These moving obstructions or emboli and most often come from the heart or carotid arteries.

Hemorrhagic Stroke occurs when excessive bleeding in the brain, either from a ruptured blood vessel or from trauma, places pressure on the brain tissue. This cuts off the oxygen supply in that area.

There are two types of hemorrhagic stroke:

Intracerebral – located inside the brain
Subarachnoid – located outside the brain

What are the characters risk factors for a stroke?

Characters need to exhibit a pre-existing condition that contributes to a stroke. Such as:

High blood pressure
High cholesterol
Smoking
Heart Disease
Head Trauma
Drug Abuse

What are the characters symptoms?

Think FAST:

Facial drooping
Arm weakness
Speech Difficulty
Time to call 911

Strokes on the left side of the brain will contribute to symptoms on the right side of the body and vice versa. If the stroke affects the cerebellum or brain stem, then symptoms can affect both sides of the body.

What is the characters treatment?

Ischemic Stroke: t-PA therapy is provided by licensed medical professionals and needs to be administered within three hours of onset symptoms.

Hemorrhagic Stroke: Blood thinner meds are halted and blood pressure meds are administered to decrease bleeding.

What types of medical procedures are provided for a character experiencing a stroke?

Ultrasound of the carotid arteries may be performed to determine blockage in the arteries carrying blood to the brain.

CT or MRI scan of the brain to identify the cause and location of the stroke

For an Ischemic stroke, an angioplasty or endarterectomy is performed to open the narrowed channel and provide blood flow to the brain again.

For Hemorrhagic stroke, a procedure may be performed to place a coil, clip or glue in the affected area to try and stop the bleeding.

Follow these tips and you’ll be thinking FAST in no time!
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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.

 

Forensic Question: Testing a Blood Sample for Pregnancy

Jordyn Asks:

Can you test a blood sample to see if the person who left the blood behind is pregnant?

Amryn Says:

For most traditional tests, it would require a fair amount of blood be left behind in order for perform a pregnancy test. The blood would also need to still be in liquid form rather than dried.

It’s not something that would be done for a variety of reasons, not the least of which is that samples are usually conserved as much as possible for forensic testing. So while it’s possible with the right set of circumstances, it likely wouldn’t be done since the blood would be used for DNA testing rather than diagnostic testing.

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Amryn Cross is a full-time forensic scientist and author of romantic suspense and mystery novels. Her first novel, Learning to Die, is available on Amazon. The first book in her latest series, loosely based on an updated Sherlock Holmes, is available for pre-order on Amazon. Look for Warzone in January 2015. You can connect with Amryn via her websiteTwitter and Facebook.

 

Author Question: Unconscious Teen Struck in Head by Baseball Bat

Ari Asks:

Hello and thank you for this blog. It’s a brilliant resource and I’m grateful to have the opportunity to reach out to a professional in this setting.

I have two scenarios in a novel I’m writing that I could use your help with.

First, a teenage boy is struck in the head with a baseball bat. He is knocked unconscious and falls into a coma. When he arrives in the ER, I would like some compelling dialogue between the first responders to convey his condition, rather than just typing it out in the slug lines. What are some of the measures that nurses and/or doctors would take in responding to this injury? Also, what type of jargon or verbiage would make this scene convincing to someone in the field?

Second, is the scenario where the doctor informs the parents of the same boy about his condition. In what setting would he/she do this? Or for that matter, who would be the person to inform the parents to begin with?

Thank you for taking the time to help writers do your profession justice.

Jordyn Says:

Hi, Ari. Thanks for reaching out and all your compliments regarding the blog. I’m glad you’ve found it helpful.

Typically, when a patient arrives to the ER via EMS, they give a report on their patient when they get to the assigned room. In this case, it might be something like this:

“This is John Doe, age 17, struck in the head with a baseball bat at 1600 today. Pt with immediate LOC (loss of consciousness). Was unconscious upon our arrival. Responds only to pain. We started an IV, drew labs, and started normal saline TKO (to keep vein open). His Glasgow Coma Score is eight (this is bad). Vitals signs are as follows: Heart rate 100. BP 124/62. Respirations 16. Pulse ox 100% on 100% non-rebreather. Parents are here. No chronic illnesses. No drug allergies.” 

The ER team will place him on a monitor, assess the status of his IV, and do a thorough physical exam of the patient including an extensive neurological exam. I would follow the link above and do some reading on the Glasgow Coma Scale and how it’s scored.

A Glasgow coma score of eight or less will likely lead to the patient being intubated because there is concern that he would not be able to maintain his airway.

Taking into consideration this patient’s mechanism of injury and the fact that he is unconscious, he would receive an expedited CT scan of his brain to look for injury— likely bleeding in this case.

Past this, it would be hard for me to talk to you about all the things the medical team would say. It’s your scene. If it is a compelling scene in the novel, I’d have a medical person review it.

Keep in mind the POV character you’re writing the scene from. If it comes from a medical person’s perspective, then the use of technical terms, etc is more warranted because they should sound like they know what they’re talking about. If the scene is from a lay person’s POV— then you can write more generally about the medical things being done.

Who informs the parents about their son’s condition? These days, parents are generally not separated from their child, even in instances where the child has lost their heartbeat. The parents likely followed the ambulance and would be updated upon arrival in the patient’s room. A nurse or a doctor can update the parents and give them the medical plan of care as outlined by the physician.

Hope this helps and happy writing!