What is the Glasgow Coma Scale?

Often times on television and in movies, you’ll hear a medical character exclaim, “His GCS is 5!” or some other variation. What is this score? What does it mean for the patient?

The Glasgow Coma Scale (GCS scale) is one way to gauge the significance of brain injury. There are three components to the measurement. Eye Opening. Verbal Response. Best Motor Response. In general, the highest score is 15. The lowest score is 3. You can be dead and still score a 3 so the higher the score the better.

Eye opening looks at four components and each is given a score:
4: The patient opens their eyes spontaneously.
3: The patient opens their eyes after being spoken or shouted to.
2: The patient opens their eyes to a painful stimulus.
1: No eye opening at all.

Verbal response looks at five components:
5: The patient knows person, time and place.
4: The patient can speak but is not oriented.
3: Speaks unintelligibly.
2: Moaning.
1: No verbal response.

Best motor response looks at six components:
6: The patient can obey a two part request such as touch your nose and then your shoulder.
5: The patient moves to push away a stimulus. For instance, if I’m starting an IV in your left hand, you take your right hand to push it away. This is called localizing pain and the patient usually needs to move across their midline or above their clavicle (if the stimulus is placed to the head) to score here.
4:  Pulls extremity away from pain.
3: Abnormal flexion.  Also referred to as decorticate posturing.
2: Abnormal extension. Also referred to as decerebrate posturing.
1. No motor response.

Initially, we might look at the overall score to determine whether or not a patient needs to be placed on a breathing machine. Generally, a score equal or less than eight is used as a cut off point. The lower the initial score, the more likely the patient will be intubated. Over the long term, the GCS can be used to trend improving or worsening neurological status.

Have you ever heard this scale used on television or in a movie?

Should You Videotape a Healthcare Worker Without Their Consent?

Recently, I became aware of a story that broke my heart. Perhaps you heard of it, too. A WWII veteran called for help multiple times and when the call light is finally answered, the nurses delay giving him lifesaving measures and are even seen laughing at his bedside. Two nurses, appropriately so, lost their licenses. You can view the video and read about the story here. Also, this case that just aired on ABC news within the last few days of elder abuse by nursing staff  caught on hidden camera as well.

This is a very touchy subject and I don’t necessarily have a strong statement to make, but I do have a cautionary tale. I understand both sides and I’m glad these nurses were caught so that no other patient suffered needlessly. However, I also know that I would feel completely violated if I was videotaped or recorded without my knowledge.

When I worked as a Pediatric ICU nurse, a family chose to videotape the staff without their knowledge. The family was critical of the staff in general and it really was a no win situation. Then news came out that they had been videotaping the patient’s care. Our managers at the time approached them and requested they stop. In all the footage, and I don’t know how much there was, the staff wasn’t seen doing anything inappropriate.

In writing fiction, we always talk about increasing tension and conflict. I can tell you from personal experience that this will definitely do it.

In real life, if you or a family member make a decision that this is a necessary step to take, I would ask yourself why you’re making this choice. Considering this means you already think something is wrong. If that’s the case, is this the right doctor or hospital to be working with?

Taking this step is very serious. At the very least, it will likely destroy any trust between you and the medical staff. Sometimes, that’s hard to get back. Legally, you should discuss whatever option you’re considering (secretly recording a conversation, etc) with a lawyer. Different states look at this issue differently. There might be a hospital policy in place against. There are patient privacy concerns (the recording picking up another patient’s information). Also, it might actually have the reverse effect. When medical people know they are being more scrutinized, the added stress can make it more likely for them to make a mistake.

I think several things can be done before this to allay or address a family’s concerns. Any good hospital will take a family’s concerns very seriously. If they don’t, then there are places to go with your concern. For instance, concerns for elder abuse can be reported to state regulatory boards.

Here are my thoughts if you’re concerned your family member is not being taken care of appropriately.

1. A family member should be at the bedside 24/7. I know this may not be feasible for everyone, but having a family member at the bedside does keep staff on their toes. Ask questions. Keep notes. One problem I do have with the current state of medicine is that the providers don’t seem to read one another’s notes so important facts may not be shared. I had a personal experience with my husband with this very thing. If you can’t find someone to sit at the bedside, check in a couple of times per shift via phone with your loved one’s bedside nurse and try to be there in the morning when they make rounds.

2. Tell your nurse that you have a problem right when it occurs. State it clearly. Plainly. Rationally discuss what your concern is. If the response from the bedside nurse isn’t satisfactory, then ask to talk to the charge nurse. If that doesn’t help, ask to talk to the unit manager or nursing supervisor. You can speak to a patient care representative. If it’s a concern about the doctor, your bedside nurse should be the one who will advocate for you in that situation. Do not stay silent about your concerns. Big or small— please speak up.

3. You can request alternative staff to take care of your loved one. This is easier on the nursing side. Sometimes, your personality and the nurse’s personality don’t mix. That’s life. We don’t get along 100% with everyone. Is it a personality issue or do you think the nurse is providing bad care? Making a distinction between the two will help the charge nurse or supervisor decide what the best action is to take. For instance, a conflict of personalities, maybe it’s not best to put the same type of nurse in there.

4. Pay attention when you are admitted to the hospital about calling an RRT. An RRT stands for Rapid Response Team. Usually they are made up of a team of ER doctors, ICU doctors, and critical care nurses who will come to the bedside an do an independent evaluation of the patient and suggest a treatment course. Bedside nurses can call these, but many hospitals are making sure families know they can do this as well. The time to use this is when you feel your family member is getting sicker, but the bedside staff isn’t listening to your concerns in a way that makes you comfortable. It allows another set of eyes and ears on the patient and more medical opinions can be discussed.

5. If you’re a medical provider, you should report sub par staff to that person’s supervisor. This is all of our responsibilities. If you feel you can’t do that, then leave an anonymous message to your organization’s corporate compliance hotline. As they say, document and report.

What do you think about videotaping medical staff without their knowledge? Are you for it? Against it? Why?

Flatliners: The Real MRI Story

As followers of this blog know, I did my own medical review of the recent movie version of Flatliners here and here. I thought there was something off about the MRI scenes, so I asked our resident radiology expert, Shannon Moore, to watch the film and give her thoughts.

Welcome back, Shannon.

I’m a huge fan of the 1990’s version of Flatliners. Kieffer Sutherland and Julia Roberts were brilliant outside of his Lost Boys role and her Pretty Woman phenomenon.

In 2017, an updated version of the Flatliner’s movie was released with Ellen Page. Of course, I had to watch and give my opinion. The movie was as enjoyable as the first one and held my interest and nerves through the entire film.

However, some flaws invaded the magnetic resonance imaging (MRI) scenes.

MRI Magnets

MRI machines contain a highly charged magnet thousands of times beyond the magnetic field of the earth. Metal objects become projectiles when they are close to the machine. Just to give an idea of this device’s strength, click on the link or search You Tube for MRI accidents after reading this post.

With a magnet so powerful, how can these students use a defibrillator right next to the scanner? The metal paddles, as well as other components in the device, would have become projectiles and caused damage not only to the equipment, but also to the people in the room standing next to the system. An MRI safe defibrillator is being explored, but so far not approved or on the market.

Even the argument they turned off the magnet is not logical. To “quench” or shut off an MRI magnet is not as simple as flipping a switch. In a hospital setting, MRI magnets are only “quenched” in case of a fire or if someone is pinned to the machine. Neither of these happen in this movie. The reason the magnets stay on constantly is because the shutdown process demands a release of helium and causes days of down time. The magnet could be damaged from the quenching process. Therefore, the magnet remains active on a daily basis or in this movie’s case, during their experiment.

The residents use the defibrillator to stop and restart the heart with the person on the MRI table. Real-life cardiac arrest procedures, with the patient in an MRI scanner, is to remove the patient from the scanner and place them on an MRI safe stretcher. They are removed from the room and provided life-saving measures.

Other metal objects in the movie’s experiment room are Courtney’s laptop computer, the heating blanket, laryngoscope, etc. – all containing metal objects and life-threatening projectiles.

MRI Images

 When the residents are gathered in her apartment reviewing the images on a laptop, bolts of lightning or electrical currents appear on the scans—that is all Hollywood.

The type of scan they were showing on the screen was a Diffusion Tensor Imaging (DTI). This scan is a type of functional MRI that tracts the diffusion of water molecules in the white matter fibers of the brain. The colors in these images are assigned based on orientation. Front and back are usually blue, right to left are red and interior to exterior are green. Recorded electrical pulses are not shown on real MRI images. To be accurate the lightning bolts should not have been added and the actors could have pointed to the areas they were discussing.

MRI Brain Coils

The final inaccuracy is with the brain coil placed on the resident’s heads. It was dainty and petite showing the entire face of the actor.


Here is a real brain coil:


Quite a bit different from what was shown in the movie. In real life, there are a couple of coils to show the face, but they would have hindered the actor’s ability to intubate which again would not be done in an MRI Scan room because of the metal Laryngoscope used.


Overall, the movie was entertaining and interesting, but the MRI scenes need some resuscitation.
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.

Author Question: Long Term Coma

Tina Asks:

I’m a self-published author who has written two books from a YA fantasy series (The Arid Kingdom) and am now working now on a modern fantasy action novel.

I’d be really grateful if you could help me with some medical advice regarding this scene:

There is an accident during a concert. A girl who was singing on the stage has her head hit by a stage lamp. She falls unconscious and remains so for eight months.

1. Some other character with an open injury (a dagger injury) will be in the same hospital. Will they be in the same ward?
2. After she wakes up, will she have some memory problems?
3. I expect her to have some mobility issues after staying in a lying position for such a long time, like she’ll have to learn to walk again. Will her arms present similar issues?
4. How long does the recovery stage last and how is that done?

Jordyn Says:

Let’s first tackle the character who is in a coma for eight months.

What a lot of authors don’t consider is that humans eat, poop, and pee so all of these things need to be provided for in the unconscious person. If she has perpetual unconsciousness, she would need to be fed by a tube. Also, she’ll still need to poop and pee and since she can’t walk to the bathroom then she’d be placed in an adult diaper (or a catheter placed for urine drainage especially in the beginning). There are other things medically we consider in a perpetually unconscious person– most importantly– can they breathe adequately. Some can, but most end up with a trach.

When she wakes up, will she have some memory problems? You have some latitude here as a writer. Could go either way. She’ll probably be fuzzy until she figures out what happened but as far as her retaining her past experiences/memories you can decide.

This character would have whole body muscle atrophy from being bedridden for eight months. So yes, arms will be weak as well. She would be easily fatigued. Even something basic like brushing her teeth will be taxing.

Once she does wake up and is considered stable, she would be transferred to a rehab center and then transitioned to outpatient therapy. How fast and well a person does in rehab can be largely up to them. If she works hard, has a positive spirit, etc she could progress quickly if she has no other injuries. However, considering her length of unconsciousness, I’d imagine rehab would take months. Maybe eight weeks on the short side. I consulted with a physical therapist on this and he agrees. Could easily be longer. Two to four months as a range.

The character with the dagger injury would likely not be on the same ward. The unconscious person would likely initially be admitted to the ICU. The dagger injury, could even go home if not surgical. If surgical– then a regular surgical floor unless extenuating circumstances required ICU admission. Depending on the hospital, some ICU’s are split between medical and surgical.

Hope this helps and best of luck with your novel.

Medical Review of the Movie Flatliners 2/2

I’m continuing my review of the movie Flatliners that released last year which is a reimagined redux of the original 1990 movie.

In the movie, a group of medical students intentionally put one another into cardiac arrest so they can have a near death experience (NDE). Let’s examine medically whether or not their method would work.

The plan is to anesthetize the inductee with Propofol (which is a short term anesthetic), cool their core body temperature, and then defribillate them with electricity causing them to flatline. Keep in mind, asystole means there is no electrical activity happening in the heart. You can read a post I did here on how electricity or defibrillation really works.  Amazingly, in this medical center’s basement in another fully functional hospital with a very expensive MRI to be used during a disaster.

Issue #1: A medical center has a fully functional part of the hospital with an expensive MRI that is doesn’t use. Any empty, unused space in the hospital is a drain on the budget. Especially an expensive piece of radiology equipment. No sane hospital anywhere would be leaving that piece of equipment unused in a basement.

Issue #2: What they show is not an MRI. MRI scans take a long time and can never be done in 60 seconds.

Issue #3: Trusting a fellow medical student to resusciate you. Need I say more?

Issue #4: Knowing that they are going to put someone in cardiac arrest, no one really bothers to hook up a resuscitation bag.

Issue #5: During one code that begins to run several minutes, one of the students orders another to put the cooling blanket back on because “she’s too warm”. This flies in the face of every resusciation protocol there is. There is a somewhat well used phrase that you must be “warm and dead”. Suboptimal body temperature makes resuscitation more difficult. They are only making their job harder.

Issue #6: Endotracheal tubes have a balloon on the end that must be inflated to stay in place and deflated to take out. No one seems very concerned about this.

Issue #7: You cannot deliver electricity over clothing. Bare skin only. Also, paddles are really not used any more for a variety of reasons. Most hospitals have transitioned to patches. The paddles are used as a back-up.

Issue #8: Propofol is a distinctive milky white substance. Seems easy enough to draw up some milk in your syringe for the movie to simulate this.

Issue #9: You cannot shock a heart that is in asystole into a normal rhythm. You can see my post above for that. Can you shock someone into asystole? There is a rare possibility that you can shock someone and stop their heart. However, the common rhythms a person would go into because of this is V-tach and V-fib and not asystole. The movie depending on this rare event for every flatline is unrealistic.

Issue #10: You can tell when a shock is delivered to a patient because generally they have quite a few muscles contract. Patients never come up off the bed as dramatically as on film or television. In fact, I’ve never seen a patient come up off the bed at all.

Have you seen Flatliners? What did you think of the medical aspects?


Love Matt Czuchry, but The Resident Needs Help

As you all know, I’ve been taking my own jabs at The Resident which you can read here and here. Today, our resident radiology expert Shannon Redmon offers her insight of some of the show’s inaccuracies.

Welcome back, Shannon!

As a huge fan of Matt Czuchry since his Gilmore Girl days, I must say that his new show, The Resident, is quite entertaining. Too bad several episodes include inaccurate medical information.

For example, two MRI scenes have aired on this series and both are misrepresented as to what happens in a real hospital.

In the first scene, Drs. Conrad and Pravesh are viewing an exam in the MRI control room. No one else is around. No technologists, radiologists or even patients. The reason this is out of character is because most surgeons view the images from their workstations or with a radiologist in their office, not in the technologist control room.

Digital radiographic photos can be accessed from computers all over the hospital. All doctors need is their login and the patient’s name to access any record in the system. Why would both surgeons trek all the way to the MRI room to look at the images? They can pull them up right from where they are sitting and in the operating room before surgery.

The second MRI scene shows Nic, the well-rounded nurse, marching into the MRI room to confront a billing lady who convinced a doctor to order an MRI on a patient with a penile implant – a metallic based penile implant according to the dialogue in the scene. When nurse Nic enters, the patient is already in the machine. She stops the exam because the patient has a metal penile implant which could be “ripped out” by the powerful magnet.

If this patient were going to have any issues from the MRI, then the damage would already be done. MRI magnets are always activated. The patient with a metal implant would not even be allowed in the room. MRI technologists have strict vetting procedures in place to conduct on all patients. These policies keep at-risk patients from harm and are emblazoned into the brains of all technologists. They would have been the ones to prevent the test from being completed, not the nurse from an outside department. This scene makes the MRI tech seem inept.

Also, where does the billing consultant get so much authority? If any employee confronted physicians and nurses the way she did, she’d be tossed out on her head. No surgeon is going to stand there and let a consultant from billing tell them what to order or how to treat their patients. This woman strongly encourages all staff to upcode patient exams for more money. Without proper documentation or a legitimate reason, upcoding is illegal and hospitals can be highly fined for healthcare fraud in violation of the False Claims Act.

Although I cringe when I see such inaccurate scenes, I will continue to watch for two reasons. Because I love Matt Czuchry and … I love Matt Czuchry!
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.

Author Question: Surgery for Shrapnel to the Abdomen

Naomi Asks:

My protagonist is a surgical resident at large hospital, and I want to write a scene where she is in the OR treating a piece of shrapnel entering the patient’s large intestine with no exit wound.

It took quite a long time to get the patient any sort of medical attention and he has multiple myeloma. I’ve read from my research that myeloma can cause increase inflammation and compression of blood vessels causing coagulation and lessening internal bleeding.

A few questions:

I want to know the chance of my character surviving the surgery. I’m aware since there was no exit wound, and the piece of shrapnel didn’t hit any vital organs, that it would be high chance. However, since he received medical attention rather late (perhaps between half an hour and an hour) I want to know the chance of him actually surviving.

What would be the role of the surgical resident in this scenario? I don’t necessarily just want her to be cleaning up, but I want this to be as accurate as possible.

How long will it take to recover from this surgery?

Are they any complications that could happen during the surgery? If so, please list the major ones.

Jordyn Says:

For this question, I went to one of the best OR types I know . . . my friend Kim Zweygardt who works as a Certified Nurse Anesthetist (CRNA).

Kim Says:

First of all, let’s talk about length of time.

If the shrapnel missed all vital organs and major blood vessels, the length of time to treatment is minor. Are you talking from time of injury? If so, it takes some time for EMS to get to the scene, stabilize the patient, and get to the ER. It takes time in the ER for the nurses to start IVs, for the ER doctor to assess the patient, and get lab and radiology studies to diagnose. It takes time for the surgery to be scheduled and the OR crew to set up for the case.

In a large teaching hospital, is there an OR open or do they have to wait? If the patient isn’t bleeding out, it’s urgent but not life and death. It’s unlikely for the patient to be in the OR from time of injury in half an hour or even an hour.  For instance, in a stat C-section with the patient and crew in house, it’s supposed to be decision to incision within thirty minutes and it’s sometimes difficult to hit that timeline. It takes time to transfer the patient and get the OR ready so I wouldn’t be concerned with that time affecting the outcome in this scenario.

Chances of surviving the operation? It’s kind of a misunderstanding that lots of people die in the OR! Your chances of surviving something is very good in the OR because everything and everybody is there to help you survive— all ways to stop bleeding, medications to resuscitate, etc.

The biggest risk is if the shrapnel was close to major blood vessels that could be nicked by the sharpness during removal.  Most likely scenario is if it’s embedded in the bowel then they would just resect the bowel. In other words, remove the piece of bowel damaged along with the shrapnel. That’s normally done using a special stapler and then reconnected.

It’s possible depending on damage that they’d do a temporary colostomy. Let the bowel heal and go back later to reconnect it.

Biggest worry is infection. Normally when you resect the bowel you do a bowel prep so the colon is empty of stool. The shrapnel itself is dirty but having to resect an unprepped colon— risk of infection is very high and serious enough to cause death. But it’s not an immediate thing. They’d put him on antibiotics but within 24-48 hours he’d have symptoms if infected.

Role of the resident— depends on how advanced they are in their training. If early in residency, assisting. Holding retractors. If more advanced they could do most of the case. In all cases, if an attending surgeon is there, the resident will be left to close the surgical wound, write the orders for post op, and follow up on the patient in the ICU or PACU (Post Anesthesia Care Unit). What they wouldn’t do is clean things up! That is left to the nurses and techs.

His recovery time? If no infection then three to five days if healthy and their bowels are moving to where they can eat, drink, go to the bathroom, etc. With infection recovery time could be weeks or even a month or more.

Hope this helped and best of luck with your story!

Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com.