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?

 

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!

Author Beware: Inaccurate Ultrasound Scenes Part 2/2

Today, we’re concluding Shannon’s series on how to write medically accurate ultrasound scenes. You can find Part I here. Today, Shannon is covering tips #3-#5.

Welcome back, Shannon!

Tip #3: Sonographers scan in the ultrasound department most of the time.

Most scans are performed in the designated ultrasound department for their exams, unless they are in active labor, in the ICU or for some astronomical reason, cannot leave their room. Even in the emergency department, if the patient can be transported to the department, then they will be.

Portable ultrasounds are performed on serious cases when the physician does not want the patient moved for some pertinent reason.

 For Writers: If your character needs an ultrasound exam, is conscious, can move well, or sit in a wheelchair, send them to the ultrasound department.

Tip #4:  Sonographers like top of the line equipment.

One television scene at a top-rated hospital showed a tiny little ultrasound machine from the 1990’s being used for the exam. Seriously?

Get rid of the outdated equipment. The machines in top-rated healthcare systems are the best of the best, large and full-sized pieces of equipment.

Modern portable systems look like laptops, are smaller, and are taken to the inpatient rooms or ICU.

Some facilities provide their ER and L&D doctors with tiny devices the size of a cell phone to carry in their pocket for quick peeks, not full anatomy exams.

For Writers: When describing the machine look at top of the line equipment with GE, Philips, Samsung or other manufacturers. This will give you a good idea of what is being used in the real medical world.

Tip #5:  Sonographers know where to place the probe.

Make sure the anatomy showing on the screen matches the location of the probe and the anatomy being discussed is displayed.

One television scene I witnessed had the actor place the probe in the middle of the abdomen, but a kidney presented on the screen. Sonographers know the kidneys are located on the sides of the abdomen, not in the top middle.

If you’re listening to the baby’s heart on a second or third trimester baby, then the heart will display on the screen. Not the brain, fingers, and toes.

If investigating the liver, then the probe needs to be placed on the right side of the abdomen. With the spleen, move the probe to the left side.

If it is a first trimester scan, then a vaginal exam will be performed. If the baby is in the second or third trimester, then the probe is placed on top of the abdomen.

For writers:  Research anatomy and physiology on the internet or in books before writing the ultrasound scene. Make sure the location is correct and the disease process is represented accurately. If unsure, then find a nurse, physician or medical professional to ask or connect with Jordyn and me.

When researching a specific topic, perform a google search, but select a credible source. Choose sites that end with .edu, .org, or .gov. Those tend to be most accurate. Sometimes I will use others, but always back it up with a healthcare system education site like Mayo Clinic, Cleveland Clinic, or the government site (ncbi.nlm.nih.gov).

Don’t be like one famous author, whose patient’s venous blood clot, located in the leg, traveled to the brain and caused a stroke. However, in real life, strokes most often come from the carotid arteries and heart. Venous blood clots in the legs kill when they break off and travel to the lungs.

Shannon, thank you so much for this valuable insight. I know I learned a lot.

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Shannon Moore Redmon writes Romance 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.

 

Author Beware: Inaccurate Ultrasound Scenes Part 1/2

Redwood’s Medical Edge is pleased to host Shannon Moore Redmon, an ultrasound sonographer, and she’s offering her insights on how to write ultrasound scenes accurately. I know I’ve learned a few things for sure. Today, we’ll cover tips #1 and #2.

Welcome, Shannon!

Americans love to watch medical television shows, like Grey’s Anatomy, ER, or House. We buy up the latest medical thriller and discover the scientific world of healthcare.

What many fail to recognize are the glaring inaccuracies associated with the ultrasound profession and the exams being performed on the television screen. Such scenes contain incorrect anatomy, probes placed in wrong positions, or actors who need more camera face time and scan patients backwards.

Doesn’t Hollywood consult experts when they use ultrasound to determine an abnormality of a baby or find cancer in a patient’s liver?

As a registered diagnostic medical sonographer for over twenty years and an instructor who teaches others to utilize this amazing modality, here are five tips to make those ultrasound scenes more accurate.

Tip #1:  Sonographers perform the majority of scans.

Whether in a hospital setting, an outpatient center, most OB/Gyn offices, vascular offices, and general imaging facilities, registered sonographers are the ones who perform the majority of ultrasounds on patients . . . not doctors.

In my experience, sonographers scan the patient first and sometimes are the only one who take the images. If a patient is high-risk OB, a sonographer will scan her first, then a maternal fetal medicine doctor will scan after to confirm the diagnosis.

When abdominal or vascular ultrasounds are performed, sonographers scan these patients and the reading physician or surgeon may come into the room to discuss with the patient. More than likely, they will read the images from a digital archiving system located in their office down the hall, then attach a report to the patient’s medical record.

Most episodes on television have a doctor performing the exam. Where have all the sonographers gone? Having lunch together down by the river?

For writers: When writing your ultrasound scenes, let the sonographer take the images and discuss the case with the reading physician. If you want to ratchet up the drama, then let them have a heated discussion over what the sonographer believes she sees versus what the physician thinks he knows.

Great radiologists and reading physicians will critique a sonographer’s images and call them out on sloppy pictures. Sonographers will defend their opinions and their patients when a doctor minimizes the seriousness of the findings with a list of differential diagnoses or refuses to discuss the diagnosis with the patient. This happens in real life.

Tip #2:  Sonographers turn off the sound of the heartbeat.

In the famous Doritos commercial, granted the scene is a comedic parody, but if you listen close during the entire exam, the heartbeat is playing in the background and there is no Doppler technology activated. This is also the case in many television scenes, depicting actual exams.

In real life, the heartrate sound does not play during the entire exam. Sonographers know the heart rate plays only when we turn on the Doppler technology, drop the gate into position and hit the update key. We listen for a few seconds, acquire a heartrate strip along the bottom and then turn the sound off.

For writers: If there is background noise, it comes from the cooling fan on the machine.

Next post: Tips #3-#5.

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Shannon Moore Redmon writes romance 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.

Author Question: Nurse Comforting Orphaned Child

Erynn Asks:

First Question: What’s the protocol when a child is brought in after a traumatic event (like being the sole survivor of an accident) while waiting for next of kin if they’re not local? I had originally written a scene where a nurse was comforting him, but I feel like I remember a reader telling me they wouldn’t be allowed to hug or hold a child . . . .even if they’re alone. Is this correct? Are there nurses who wouldn’t care and would do it anyway?

Second Question: Would CPS (child protective services) necessarily be involved? The child in question has an adult sibling and a will exists that will show that he should be the guardian. Would there be any hoops for him to jump through before they let him take him home?

Jordyn Says:

I’ve worked as a pediatric ER nurse at two different large pediatric medical centers and have never been admonished to not hug or hold a child if that’s what they emotionally required. I actually find that utterly shocking any hospital would tell their nurses not to do this— though obviously understand why.

A pediatric nurse will always provide age appropriate care. Infants and toddlers usually need to be held to be comforted. With a school age child or older we would go based on the child’s cues. We would probably ask, “Do you need a hug?” or “Can I sit with you?” Sometimes, open ended questions are hard for kids who are dealing with traumatic events to answer. Questions like, “What do you need right now?” probably won’t elicit much of a response so the nurse will ask very pointed questions.

Who else could assist the child? An ED tech. A volunteer. A child life specialist.

I think you’d need to place close attention to where this novel is set and the hospital would need to match your setting. Community ER’s (common in rural areas) are more comfortable dealing with the adult patient so they might approach this situation very differently and not have as many resources available.

Child Life specialists are generally not staffed 24/7 so I would keep that in mind. I also haven’t found them outside pediatric hospitals. Same with chaplains– may not be available 24/7. Depends on the type of hospital.

As a pediatric institution, we also would probably not involve Child Protective Services though probably social work consultation would be advisable in this situation. In CO— we generally reserve CPS for concerns for abuse.

If the adult sibling could prove legal guardianship in the case of the death of the parents than the child would be released into their care. Even in the case of lack of paperwork, the child would likely go to next of kin, of which it sounds like would be this sibling.

Happy writing!