Author: Jordyn Redwood

The Movie Unsane is Insane in its Portrayal of Mental Health Care

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A recently released movie, Unsane, starring the remarkable Claire Foy, highlights the plight of Sawyer Valentini after she’s been involuntarily committed into an inpatient psychiatric hospital.

This post does contain spoilers to the movie so stop reading if you don’t want to know more about the film.

The crux of the story is that Sawyer believes her stalker has made his way into the psychiatric unit where she is a patient— whether or not that is the case is the mystery.

Unfortunately, the way that psychiatric care is highlighted in the film is disturbing at best. At worst, I hope it doesn’t deter anyone from seeking mental health treatment if they need it.

Problem One: Not disclosing to a patient why she’s being admitted. The genesis of Sawyer’s admission into the psychiatric unit stems from a visit with a counselor where she discloses at times she thinks about hurting herself. She’s left unattended (a no-no if you think someone is suicidal) and the next scene is a nurse escorting her into an intake room. The nurse never fully explains to the patient the reason for the admission and leaving it out doesn’t really increase the drama of the scene— it just makes the nurse look mean and uncaring. Simply, a nurse could say, “Your mental health provider has placed you on an involuntary hold because she’s concerned you’re going to hurt yourself. ” Then the heroine can argue with her about why she feels the admission is unnecessary.

Problem Two: Having the patient undress but allowing her to keep her bra. A bra is considered a ligature risk and patients can’t have anything on their person that they might use to hurt themselves. Hair ties, piercings, and other jewelry are all removed.

Problem Three: Drug injection sites. Emergency drugs for agitated patients are usually given IM (intramuscular) and not IV (intravenous) to the neck or arm. Can you imagine trying to start an IV on an agitated patient? It’s much easier to land a needle in a large muscle group then to try and finesse a tiny IV catheter into a moving target.

Problem Four: Leaving a patient alone in restraints all night. There are very specific regulations around restraints and significant documentation that goes along with it. Patients in restraints are continuously observed by a staff member and circulation to their extremities is checked often. Also, the patient must be offered bathroom breaks at a minimum of every two hours and you can’t deny them food as punishment. The goal is always to get patients out of restraints as soon as they can be safe— and that doesn’t always imply that they are calm.

Problem Five: A mixed gender open unit. Need I say more?

Problem Six: That psychiatric care is an insurance scheme for money and that patients are intentionally kept until their insurance money is exhausted. This is a large crux of the movie to the point that one of the patients is actually an undercover police officer trying to uncover the scam. This is the most disappointing aspect of the film. There are so few mental health beds around the country right now that it is not difficult to fill them. Here’s a news article here, here, here, and here— which all posted within one week. Trust me, mental health facilities can keep their beds full without perpetuating insurance schemes.

Overall, an interesting movie, but portraying the current state of mental health care in this country would have only increased the tension and drama for this film.

Video on Treatment of Excessive Bleeding

/ Jordyn Redwood / 1 Comment

Since I get LOTS of questions regarding bleeding, I thought this would be a nice instructional video to post regarding treatment of excessive bleeding.

The post is mildly political at the beginning and does contain some profanity (bleeped out), but at the end it is a great discussion of controlling bleeding— particularly use of tourniquets.

Thanks ZDogg, MD for the great information and keep up the good fight.

911: Let’s Provide Some Medical Care

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In the Season Two/Episode Eight airing of the FOX television show 911— there was a great scene on how to really provide no medical care.

The setup: A gay couple is getting ready to go on a bike ride. Much time is spent in a musical montage showing their lives together. It’s clear they have had a loving relationship and remain deeply in love. One gentlemen goes to load a bike onto a SUV when, in a series of unfortunate events, he gets pinned by the SUV to the entrance gate— akin to Anton Yelchin’s accident (though they do show in the episode the SUV was placed in neutral).

He is discovered by his partner who then calls 911. Upon arrival, there isn’t much done for his lover. He is essentially declared dead on arrival.

Then, the gentleman who discovered his partner, goes unconscious while a firefighter has his back turned. Literally only a few seconds have expired when the firefighter discovers he’s passed out. They provide one and a half cycles of CPR and kind of shrug their shoulders declaring that he’s died, too.

This is unacceptable management of this patient. It’s essentially a witnessed arrest so they were correct to start CPR immediately, but at the very least, he should have been connected to an AED for rhythm analysis and probable defibrillation. A very common reason for sudden collapse are arrhythmias that will respond to electricity. There’s no reason why this gentleman’s treatment  should have been so sparse. It would have increased the drama and the tension of the episode to have this patient get a full resuscitation.

Lifetime Movie Killer Twin: Killing Nice People Needlessly

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As with all television networks these days, the Lifetime Channel could use a good medical consultant as well. In a recently aired movie, Killer Twin, not only (Spoiler Alert!) does the main character, Kendra, have an maniacal unknown twin sister trying to end her life . . . the writers aren’t helping her out too much either.

There will be spoilers for this movie in this post so you’ve been warned.

The plot revolves around the heroine, Kendra, whose life is perfect. She was a twin, but the adoption agency didn’t disclose that and she was adopted as a single child, leaving her twin sister to suffer in the foster care system. Now her twin wants her life and wants Kendra dead.

The main attempt to do this is to expose Kendra to poppy seeds, of which she is deathly allergic to, via a conveniently delivered fruit basket— oh, and steal her epi pen so she can’t save herself.

Thankfully, Kendra’s mother is with her and calls 911, but the attempted murder plot lands her in the hospital.

Here are the following problems with this scenario.

Problem One: Twins aren’t necessarily allergic to the same thing. Can they be? Sure, but it would have to be proven out. For instance, if a mother were to tell us in the medical sphere that a patient’s twin sister is allergic to penicillin, but the patient has never had it, we would still give it a try. It’s presumptive in this movie to assume that because evil twin has the allergy, so would the good one.

Problem Two: Unnecessary Hospitalization. It’s actually very rare for a person having an anaphylactic reaction (which is life threatening if untreated) to land in the hospital. Most of the time, they are observed in the ER for several hours and sent home with medications to take over several days. I’ve outlined the treatment for anaphylaxis in this post. Also, the heroine, who is six weeks pregnant, is told that the medical team admitted her overnight because “a lack of oxygen and toxins could hurt the baby.”

First, let me mop up the blood that just shot forth out of my eyes.

Poppy seeds are not a toxin. They’re a food item. There’s no evidence given in the movie that the character stopped breathing and therefore suffered a loss of oxygen. If you claim this— let’s at least put the character on a monitor to watch her oxygen levels. Lastly, you can’t monitor a baby at this point in any way and isn’t a justification for staying in the hospital.

Problem Three: Killing people with the wrong IV solution. The picture on the right shows the IV solution they were “running” on her (explained in the next section) which is sterile water. Flat out, this will kill people for reasons I won’t go into here. It is never used as an IV solution.

Problem Four: The IV tubing goes into the pump. Honestly, if you’re going to park a piece of medical equipment at the beside, and have a nurse check on it, then know how to use it. As noted in the photo, the IV tubing is not loaded into the IV pump.

Sadly, sweet Kendra doesn’t need her evil twin to kill her, the writers are doing their best on their own with this medical set up.

 

Modern Family: S10/E7 Disclosing Pregnancy Results

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This blog post does contain spoilers for episode seven/season ten of Modern Family— you’ve been warned!

On a recent episode of the wildly popular ABC series Modern Family  (which I personally thoroughly enjoy) it was disclosed that Haley Dunphy is pregnant. However, the way her pregnancy was disclosed was a violation of patient privacy.

In the episode, Haley and her boyfriend, Dylan, are playing bumper cars when he playfully rear ends her while she’s applying lipstick (yes, in the bumper car). The end of the lipstick gets shoved up her nose and breaks off leading to a trip to the ER.

Evidently, Haley was given anesthesia to remove the piece of lipstick from her nose. They also x-rayed the nose (at some point) because they tell her it’s not broken. There’s some witty banter about how the injury happened and that she and Dylan want to remain childlike as long as possible which is when the doctor says, “Oh, we did a pregnancy test prior to your anesthesia and you’re pregnant.” This was done via a blood test.

Problem One: There’s really no reason to give anesthesia in this case. We remove foreign objects from pediatric noses all the time and never give anesthesia. Anesthesia is reserved for the OR. Sometimes, a patient might need a little something to chill them out for a procedure, for which we would use nasal Versed or Fentanyl. You don’t need to start an IV and recovery is not too long.

Problem Two: Not even sure why they needed to do an x-ray for a broken off end of lipstick in the nose. I don’t think the mechanism of injury warrants even thinking the nose is broken. Lipstick is soft after all.

Problem Three: A blood test used to determine pregnancy. This is rarely done and would be used more specific to determining pregnancy where problems in early pregnancy might be the concern— such as ectopic pregnancy or early pregnancy miscarriage. In this case, a urine test would suffice.

Problem Four: These days, disclosing pregnancy results must be done very carefully. As healthcare professionals, we don’t know who the male is at the bedside and if the patients wants that male to know about the pregnancy or not. The doctor should have asked Dylan to step out of the room as she disclosed the results to Haley. Then it’s Haley’s decision about whether or not to tell her boyfriend. The same is true if we discover a teen is pregnant in the ER who might be there with her parents. The parents are asked to step out and we’ll tell the teen. It’s up to her whether or not to disclose the results to her parents. We as healthcare professionals will encourage her to do so, but it is ultimately her decision.

I think the best way to have handled this situation would have been to perform the pregnancy test prior to her getting an x-ray of her nose, but even this would be a little outside the norm because shielding her abdomen would have been easy in this scenario.

Treatment for Partial Thickness Burns

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Robin Asks:

I have a question regarding burn care. The main character in my novel is burned in a house fire and receives second degree burns to his back. How long would the wound be oozing? If it’s second degree burns, would he require skin grafts? What is the general treatment for second degree burns? What pain medications would be ordered?

Jordyn Says:

With burns to the back, it would really depend on what percentage of his back is burned. Burns are always calculated in percentages so it’s hard to know exactly what the treatment would be without knowing that number.

However, in general . . . second degree burns are now called partial thickness burns in medical terminology. Usually, to qualify as a partial thickness burn, the skin is reddened with blistered areas. These will probably ooze quite a bit for a few days.

Current treatment is to slather the burned area with triple antibiotic ointment, generally leaving blisters intact. After the ointment is in place, the burn is covered with something that won’t stick to the leaking fluid (called serous or serosanguinous fluid) like non-stick gauze pads and then roller gauze is applied around. This is why not knowing the burn size is problematic.

If the burn is large, covering most of the back, then the torso may need to wrapped to keep the non-adhesive barrier/dressing in place. The goal is to leave blisters intact. Blisters can be popped if they are problematic in size but the skin may be left over top because it provides a protective barrier. Exposed raw skin is the most painful. Blisters are also left intact because they provide a barrier against infection.

These dressings would likely be done until the skin heals which can take up to two weeks. As far as home pain medications, once the wound is covered it usually decreases the pain dramatically because the raw, exposed nerve endings aren’t coming in to contact with air anymore. These days, the patient might be sent home with a few doses of Lortab or Percocet (three days is becoming more common) with the patient instructed to take Ibuprofen on a schedule as well for pain control. I don’t think this is a situation where skin grafting would be required.

Hope this helped and best of luck with your novel!

The Good Doctor S1/E6: Killing Patients

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At some point in every medical person’s career, we face a time when we think or may have altered the course of someone’s life either by a medical error causing serious harm or death.

Truth is, it’s a team effort to keep patients from suffering from these complications. We are all responsible for looking out for one another regardless of scope of practice. For instance, if an EMT sees something the doctor (or new resident) is doing wrong, they should speak up to prevent harm from coming to the patient.

In this episode of The Good Doctor, the staff is dealing with an MCI or Mass Casualty Incident. A bus full of wedding guests has crashed. After several of them are treated, it is discovered that a woman is missing at likely still at the crash site.

A resident leaves with an EMS crew (this in itself is highly unlikely) and finds the missing woman. On scene, the resident diagnosis her with a flailed chest and subdural hematoma (a collection of blood on the brain).

What is a flail chest? It’s when two or more consecutive ribs are broken on the same side creating a free floating segment of the chest wall. This can inhibit the patient’s ability to breathe and also puts the patient at a higher risk of having a pneumothorax (or air collecting outside the lung inhibiting the lung’s ability to fill with air.)

The resident chooses to intubate and then drill a bur hole into the patient’s head for the swelling. Upon arrival to the hospital, the ER doctor notices that the patient’s oxygen level is low (like in the 70s— normal of 90 and above) and pulls back the tube and the oxygen levels increase.

When someone is getting intubated, it’s natural to push the tube in too far and because of the anatomy of the lungs, it will pass into the right lung. It’s later noted in the show that because the resident intubated the right lung and that’s the side that had the failed chest, the patient suffered from persistent hypoxia (or lack of oxygen) and her brain died because of that.

Was this patient’s death preventable?

Putting aside that this patient could have been hypoxic during the time she laid for an extended period of time in the ditch, this death could have been preventable if the EMS crew, who would have been monitoring the patient’s oxygen level (and so should the resident if involved in transporting the patient) had spoken up about the dramatically low level.

When a person is intubated, these are the following checks that happen to ensure the tube is in the right place.

1. Does the chest rise and fall equally. In this patient’s case, the right side of the chest would not have risen that much if several ribs were broken and the lung was deflated which should prompt the doctor to do number two on this list.

2. Are the breath sounds equal? The patient’s lungs are auscultated (listened to with a stethoscope) to determine this. They should be equal. If not, then there is a problem with that patient’s lung (one is deflated, etc) or the tube is in the wrong position. At that point, the tube could have been adjust. If the patient’s breath sounds were severely diminished on the right side (especially after trauma) then a need decompression should have been done on that side as a rescue measure to try and reinflate the lung some.

3. Are the patient’s vital signs improving? This would be primarily the oxygen level. It can take a few second to a few minutes for the patient’s oxygen levels to reach normal but they should improve. If not, then something is wrong with the tube and it should be evaluated.

4. Is there the presence of carbon dioxide measured as end tidal CO2? There are quick measure devices in the field to check that carbon dioxide is coming up through the tube. This also ensure the tube is in the right place. In the hospital setting, we will watch this number continuously.

5. Ultimately, in the hospital setting, an x-ray is done to confirm proper placement in the field but if the above items or done, the tube (or endotracheal tube in this case) should be in the right position.

If the EMS crew would have spoken up and/or if all three of the crew members had been performing their job correctly by monitoring the patient’s oxygen levels (which is a very basic thing to be monitoring) then this patient’s death could have been prevented.

It’s up to every member of the healthcare team to ensure patient safety.

9-1-1 S2/E1: What Can be Diagnosed in the Field?

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Fox’s 9-1-1 series is beginning Season 2. The series is enjoyable, but there is some definite leeway the series takes when making certain field diagnosis.

In the first episode of the season, a man gets hit with an old artillery shell in his leg. As noted on the picture on the right, by simply shining a flashlight into the wound, the paramedic declares that his femoral artery has been severed. This could be more believable if there was even some mild pulsatile bleeding, even with a tourniquet in place, at the site which is characteristic for arterial bleeding.

Later in the episode, a picture of the wound is shown with a “live” shell in the anterior thigh. The fact that it is a live shell is made by a firefighter who is former military based on the color. I can’t comment on whether or not that’s true— I’m not military— but the team does make a decent choice (since the patient is stable) to not take him inside the hospital.

When the bomb squad gets there, they are able to take this sweet x-ray in the field. It is a plain, diagnostic x-ray. There is no way for an EMS crew to take an x-ray like this. Can the bomb squad? Yes. So the show is doing it’s due diligence by having the bomb squad perform this task. However, the bomb squad would not need the military to diffuse this— my law enforcement brother who used to work with the bomb squad verified this.

What other things have you seen shows diagnose in the field that they wouldn’t be able to do?

Tension in the Ultrasound Room

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There are many ways to add tension and conflict to medical scenes without making them over the top or unrealistic.

Today, we’ll focus on how to add tension and conflict from real-life scenarios in the ultrasound department.

1) Family members – most patients have a family member with them when they get an ultrasound performed. But when a patient shows up with eight people in tow, things can get tense quick. This often happens with obstetrical ultrasound patients. Everyone wants to see the new baby and mom drags the three-year-old toddler who would rather pull the cords on the expensive machine than watch the monitor quietly (will come back to the toddler angle in a moment).  Here are the reasons why it might be best to leave Grandma and Grandpa at home too.

Ultrasound rooms are usually small – Most departments think they can roll our machines into the tiniest closet possible and save larger spaces for radiologist’s offices. While this does not make for a fun workday, having a crowd of people shoved into this small space makes for great tension in a story.

Too much talking – When family members gather, excited about the new addition to their family, they want to discuss and ask questions. The Sonographer however has about a hundred pictures needed to image for a complete exam. The scanner investigates every nook and cranny of the baby and mother for  syndromes and defects in the brain, heart, abdomen, chest and extremities of the baby. All structures on the baby are tiny and our sweet unborn model does not hold still for our pictures. When a multitude of questions bombard our thought process, this distracts from the most important goal, imaging the baby. However, for a story, a family peppering the Sonographer with questions could add tension and humor to the scene.

Young children – Sonographers are not babysitters and most toddlers are not interested in their sibling inside momma after about the first two minutes. Kids, however, love the really expensive machines that cost about a hundred grand. They want to pull on the cords, press the buttons and possibly put themselves in grave danger. The ultrasound room is not a safe environment for a toddler. However, Sonographers are constantly dealing with patients who let their children run around the room like it’s their own personal playground. Great for adding tension to the moment.

2) Doctors – Most Sonographers try to provide great images for their doctors to read, but when scanners don’t see an abnormality on an exam, then it is likely the doctor won’t either. When a pathology is missed, doctors are not happy. When adding a scene like this to your story, the author must be careful not to make the Protagonist appear incompetent. Perhaps, the doctor and employee disagree about what the protagonist sees. Many firm discussions take place in the real world when a Sonographer is convinced of an abnormality, but the doctor does not agree.

Also, make sure to give a variety of personalities to the doctors in the story. While a few doctors have the stereotypical arrogant attitude and can be difficult, most are nice and want to be a part of the team.

3) Other Sonographers – Some coworkers work well together, while others are lazy, sloppy or control freaks causing conflicts within the department. I have yet to be in a department where there is not at least one person stirring up trouble on a daily basis. Add tension to the story with arguments between coworkers.

4) Patients – we get a variety of personalities in our departments, from drug-addicted mothers to shackled felons with guards in tow and everything in between. I’ve rarely had anyone try to hurt me, although when I was an x-ray tech, some of the alcoholics we had to image, did try to hit me. In ultrasound, not so much.

Our job becomes difficult when we find abnormalities on a patient. When we find severe pathology, we realize our patient’s lives are about to go downhill. From finding cancer to blocked main arteries or a heart defect on a baby, these diagnoses create tension within the sonographer.

These are just a few ways to add conflict into an ultrasound machine. If you find you have more specific questions about this modality, then feel free to reach out to me – www.shannonredmon.com.

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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.

How Fast Can Someone Bleed Out? A Real Life Example with Video

/ Jordyn Redwood / 1 Comment

I get asked often as a medical expert and host of this blog how fast someone can bleed out from a variety of injuries. When I say fast, I think many people are doubtful. I’ve said many times that all bleeding can lead to death if not controlled, whether venous or arterial.

Recently, Bo Johnson,  a friend of mine who is an ER nurse and avid outdoors man had a very close call with nearly bleeding to death. This story does have a happy ending (thank heavens.)

Bo was riding his bike to his children’s school while carrying a razor scooter in one hand. The scooter became caught in his bike and when he fell, his neck landed on the edge of the scooter, severing his right internal jugular as well as a large muscle. What follows is video of the bleeding before surgery that Bo graciously gave me permission to post here. WARNING: The following video is a graphic representation of active bleeding.

Photo Courtesy of Bo Johnson

Keep in mind, this is a large vein, and not an artery. However, the bleeding is still quite brisk and if uncontrolled would be deadly. If it had been arterial, the blood would be a brighter red in color and would spurt from the wound, and would be more difficult to control.

Bo spent two hours in surgery to repair the injury. The jugular vein could not be repaired so was tied off. The jugular vein on the other side of the neck will hopefully compensate. He spent one night in the hospital and should be back to work helping to heal others in about a month.

All who know Bo are so thankful that he is going to be okay after this freak accident. I personally publicly thank him for allowing me to share his story, video, and photo with you so you can see just how significant bleeding can be.

Speedy recovery, my friend.