Author Question: Drug Injection Scene

Kiri Asks:

I really hope you can help me. I feel like I’ve reached out to half the medical community and still haven’t gotten an answer.

I have a protagonist who suffered a ruptured aneurysm two years before the story starts. The aneurysm caused a stroke. Presently, he is mostly recovered, though he still suffers migraines and some memory loss. I have a scene where another character catches sight of yet another character giving my protagonist a shot in the arm.

Originally, I had the intramuscular injection be a vasopressor to help with his blood pressure, but then someone told me this would only be done in a hospital.

I would really like to keep this injection scene. So I changed it to an anticoagulant, though I’m having trouble verifying that this is anything someone like him might need. (Did I mention he has another blood vessel wall bulging and ready to burst, this one inoperable?)

I also have him taking beta blockers for his migraines and he later uses these to try to commit suicide by taking an entire bottle. An ER nurse told me this would certainly be dangerous. I could change it to another drug.

Any thoughts are much appreciated.

Jordyn Says:

First of all, you have two competing medications. A vasopressor raises blood pressure and are typically given IV in the ER and ICU setting. The beta blocker used for his migraines can (and often does) lower blood pressure.

Unfortunately, I don’t see either of your two options as feasible for an intramuscular injection scene— either as an anticoagulant or a blood pressure medication. If the character’s blood pressure is too low, the first thing would likely be to give him some IV fluids and just stop the beta blocker.

Some patients do go home on subcutaneous (SQ) anticoagulant therapy, but usually it’s when they have a known clot— not simply to just keep the blood thin. There are too many excellent prescribed oral medications to do this on an outpatient basis. If you wanted your patient to have a clot in the leg (deep vein thrombosis) than this therapy would be reasonable but developing a clot like this would be unlikely if he were already on anticoagulants for his brain coils related to treatment of his first aneurysm. You could read more about this here.

I’m not aware of any blood pressure medicines that are given SQ or IM (into the muscle). There are several given IV in the emergency/ICU setting but these would not be appropriate for home use. Patients are transitioned to home oral medications.

The only medication that could be given consistently SQ on a home basis with any regularity that I could see would be insulin for diabetes.

I did find this pamphlet on-line about SQ meds given in palliative care (hospice) but I don’t think any would fit your scenario. They are mostly anti-anxiety, anti-nausea, or drying agents for secretions given this way because the patient can’t swallow anymore. In fact, most of the links about SQ meds given at home were in conjuction with hospice care.

Also, SQ and IM sites and the angle at which they are given are different as well.

Probably best to find an alternative to this scene.

Author Question: Is There a Drug that could Mimic Death?

Toni Asks:

I’m writing a contemporary retelling of Snow White. I was wondering if you have any suggestions on how the stepmom could intend to poison her but is not successful. Instead, maybe just paralyzes her or slows her respiratory system down to where it seems she’s dead. Any suggestions?

Jordyn Says:

I brainstormed this with a co-worker pharmacist and these are our thoughts.

There isn’t a current paralyzing agent that will work for this scenario. A couple of problems with paralyzing agents is that they never just slow down respirations— they knock them out totally. Plus, in the absence of a sedative, the person is very much awake and panicked because they can’t breathe. Giving this drug alone could not mimic death and would rapidly cause death from hypoxia unless medical intervention was given post haste.

The drug we came up with for you is called Donnatal and can be given as an elixer. It has four medications: Hyoscyamine, Atropine, Scopolamine, and Phenobarbital. The hyoscyamine actually helps with intestional disroders like irritable bowel syndrome. It is the other three components that will help with your scenario.

The atropine and the scopolamine both act to dilate pupils and could mimic fixed and dilated pupils that you get upon death.

Phenobarbital is a barbiturate and can be used to treat anxiety and seizures. Overdosing on phenobarb will cause slow and shallow breathing.

Here is a patient teaching sheet for further information.

Hope this helps and best of luck with your story!

Author Question: How Long Before a Teen Diabetic Gets Sick Without Insulin?

Megan Asks:

I’m so glad I found your website. I would love it if you would answer this on your blog. Thanks for reading and I look forward to your answer.

My YA manuscript has scenes with two sixteen-year-old teenage boys on a  twelve hour adventure race in the mountains. One of the boys has Type 1 diabetes. He consistently tests his glucose and knows what to eat/drink and he has an insulin pump. All is going well until his insulin pump malfunctions and he realizes he has left his back-up insulin in a cave they had sheltered in earlier in the story.

My specific medical question: What would happen to him if he has to wait approx. one to two hours for the other boy to retrieve his insulin and return to him? What symptoms would he show? And, after taking the insulin (1 – 2 hours past his regular schedule), would he be able to function well enough to walk to the finish line area without further medical assistance?

Jordyn Says:

Hi Megan!

Thanks for sending me your question.

I don’t think your character would be affected dramatically by a one to two hour delay in getting his insulin.

Insulin works to transport sugar from the outside of your cells to the inside. In the absence of insulin, his blood sugar will start to rise but how fast it rises depends on a lot of factors. For instance, what is he eating and drinking? How vigorous is he exercising? Considering he is stopping to rest and wait for his friend will help.

The rise in blood sugar is problematic, but is actually not the most concerning issue. What usually causes the emergency is a build up of acids in the blood due to the body’s inability to use the sugar inside the cells. Because the body still needs energy to run, it begins to break down fat for energy leading to a rise in ketones in the blood— hence the name diabetic ketoacidosis (or DKA).

If he were to continue to exert himself, I could see a situation where this process could be hastened, but though he might not feel awesome— I don’t think he would be incapacitated. Also, if he’s not eating or drinking, his blood sugar could also get too low depending on what type of insulin his pump was delivering.

I found this article that gives some tips on what the patient might be feeling. In my experience, I haven’t seen anyone using the blood based ketone testing— just urine test strips.

Some sites say DKA can develop in one to two hours. That might be true, but I would be doubtful a patient would be incapacitated in that time frame. They may not be feeling great, but can function. How severe DKA is really depends on how acidic the blood is when they seek treatment. Some people have ketones in their urine, would be considered in DKA, but their blood is not that acidic. People like this can usually be rehydrated with fluids in the ER, an insulin correction given, and sent home.

The more acidic the blood— that determines the course for a pediatric DKA patient. We measure this by the pH of the blood via a blood gas. Diabetics who have very acidic blood generally end up in the ICU for many reasons I won’t outline here.

Hope this helps.

Author Question: Law Enforcement Shooting with Vest in Place

Carol Asks:

I have a cop who is involved in a shooting. She’s wearing a vest and is hit outside the vest’s protective area. I need her hospitalized long enough that the shooter (who she killed— they shot simultaneously, more or less) to have been claimed post autopsy. I can’t have her debilitated for months— just a week or two. Where would I shoot her? Hip? Leg seems hard to hit and shoulder does too. I don’t want her disabled, nor do I want a months long rehab.

Jordyn Says:

What I would recommend is a shot coming through the side, under the armpit, causing the lung to collapse. I would pick the right side over the left— there’s just a lot more vasculature on the left that could prove deadly/problematic. If her right arm was raised and she was say . . . turning into the shot . . .  it could leave her vulnerable.

She would have difficulty breathing. How difficult would depend on how quickly the pneumothorax (air moving into the chest and deflating the lung) expanded. She would be transported to the ER via ambulance and receive an IV, oxygen, and vital sign monitoring.

A chest tube would be placed, likely after a quick chest film, unless she is in significant distress to re-expand the lung. If in significant respiratory distress or cardiovascular compromise then she would get a rapid needle decompression to buy some time or some facilities will go straight to chest tube placement. For a “simple” pneumothorax she would be admitted into the hospital (regular floor— not ICU) and observed.

Generally, depending on the size of the pneumothroax, it’s a few days to get the lung to re-expand, a day or two with the tube to “water seal” to make sure it stays up without suction, and then the tube would be removed. Maybe one or two more days after that to make sure all was well.

If she’s young and healthy she should recuperate pretty quickly, but would still be winded, perhaps easily fatigued for another week or two.

Hope this fits your time frame.

Dear Medical Thriller Author: Please, Ask a Nurse

I just got done reading a recently released medical thriller by a well known author. The novel, overall, was really enjoyable. Truly a captivating story line. However, there is one medical scene that continues to bug me because of the medical inaccuracies that could easily be solved by having a nurse with expertise in the area read over the scene.

In the last three medical thrillers I’ve read, the author always notes the doctors that helped with the novel, but I honestly don’t think I’ve ever heard a nurse mentioned. Trust me, they needed a nurse. Our expertise is in delivering the medical care as ordered by the physician so we know what makes sense and what doesn’t.

In the scene, the patient is suspected of ingesting the poisonous mushroom Amanita Phalloides also known as the Death Cap. The patient has potential political fallout so our hero, a family practice physician, is designated as team leader for this code over two ER physicians. I’ll discuss some of the things I find problematic with the scene.

The hero admits he’s not an expert on mushroom toxicity, but doesn’t phone a friend. One of the first things that should be done in addition to providing for the patient’s medical needs is consulting a toxicology expert (a poison control center is a great place to start). In toxic ingestions of any kind, the medical team needs to know how to counteract the poison. This targeted therapy may be the only thing that will save the patients life. Even if the patient is provided stellar medical interventions, if they’re not given the antidote, it will all be in vain and the patient can proceed to death. That being said, not every poison has an antidote, which then means supportive care.

Let’s discuss these two statements from the novel:

“BP is sixty over palp,” said a nurse, taking the measurement by palpating with her fingertips.
“Pulse one forty-eight by monitor. I can’t even feel a carotid pulse.”

First of all, taking a palpated blood pressure is not usual in the hospital setting. This is typically done by EMS as a quick and dirty measure for obtaining a BP because it is really hard to hear through a stethoscope with sirens blaring above you. Next thing is, one of these two people are wrong. A carotid pulse is considered a central pulse so if it can’t be palpated then the patient is pulseless, has no BP (because you need a palpable pulse to have a BP), and therefore requires CPR no matter what is seen on the monitor. This rhythm is called pulseless electrical activity (PEA) and is treated medically like the patient is asystolic or flatlined. Treatment is high-quality CPR and IV epinephrine, but our hero calls for a central line.

Then there’s this statement:

“Right now, D-five normal saline at two hundred an hour. Wide open.”

D-five normal saline is an IV solution. This is typically not given in a code situation which I won’t highlight here. In reading about this mushroom’s toxicity, I get why the author chose this IV solution, but the reader doesn’t know and so it should be spelled out what the doctor is worried about clinically for this ingestion and how he’s going to treat it.

However, what’s really wrong with this statement is that it is a contradiction in terms for the nurse. Either the rate is 200 ml/hr or the rate is wide open which means the IV bag is let to run into the vein via gravity as fast as it will go. In an adult patient, the IV bag could be delivered in as little as five minutes depending on the size of the IV catheter that’s been placed.

Lastly, this gem:

“Compressions at ten per minute.”

There is a lot wrong with this medical scene (too much to blog about here), but this is by far the most egregious. I read this to my accountant husband and even he knew this was not medically correct. In fact, I googled, “How fast should you do CPR?” and it gives the correct answer without having to click into a web site which is 100-120/minute. This can’t even be a typo because one hundred and ten— can you really mistype that?  Flat out, this is an easily researched aspect and there is prolific information out there on doing CPR.

Dear Medical Thriller Author: Please, Ask a Nurse Click to Tweet
What’s Wrong with this Medical Scene? Click to Tweet

Just as I ask doctors about the medical accuracy of my scenes, so should nurses be asked. Particularly those who are actively practicing in the area.

C-section Primer for Writers

Today, Heidi Creston gives some nursing insight into the world of obstetrical nursing.

Welcome, Heidi!

STAT Sections, TOLAC, VBAC, Let’s think about all that . . .

STAT C-sections definitely give your story drama, critical hysteria in some cases, just what you need to keep your readers turning pages except . . .

The patient who has had only one prior cesarean section for an indication that no longer presents itself in her next pregnancy may ask the physician for a trial of labor termed trial of labor after cesarean section or TOLAC. For example, if her first baby was breech but the second baby is not. These patients that deliver vaginally are then referred to as successful VBAC (vaginal birth after cesarean section). The patient, however, will undergo a TOLAC for each succeeding pregnancy thereafter.

Midwives, physicians assistants, and nurse practitioners cannot manage the care of these patients alone. There must be a physician present during the labor process. It is important to note that the physician has to agree to the TOLAC. If the doctor does not agree to it then it is the patient’s responsibility to find another physician who will. Some physicians do not carry the insurance for TOLAC or VBAC. There are some states and countries that do not offer TOLAC or VBAC option regardless. Some hospitals do not carry TOLAC or VBAC insurance due to the maternal risks and expenses associated with these procedures. If you’re writing a novel set in a real life state, city, and or hospital with this type of scenario then it would be important to check out these specifics for those locations.

The first thing writers should keep in mind is that cesarean sections are major abdominal surgeries. There is nothing lackadaisical about it. Given that information, any time a muscle in our bodies is cut, torn, or otherwise altered, that muscle is weakened permanently. During a cesarean section the abdominal muscles are both cut and then torn. The uterus is also a muscle. The physician cuts into the uterus in order to remove the baby.

There are two commonly used incisions: Lower Transverse (aka the bikini cut) and the Classical Incision (aka the T-cut). Lower Transverse is the preferred, most common and least damaging of the incisions.

The uterus can develop a uterine window, a fragile site on the uterus that can lead to medical emergencies for the mother and baby. Partial and full abruption of the placenta and ruptured uterus are the most lethal and common complications associated with TOLAC and VBAC procedures.

An abruption is when the placenta dislodges from the uterine wall prior to delivery. In this case, without emergency intervention (imminent birth or emergency cesarean section), the baby will die.

A ruptured uterus is a breakdown of the uterine wall, in which case both mother and baby are at risk for sudden death. Cesarean sections leave the uterus in a compromised state. The more c-sections a patient has, the more compromised the uterus is, which leaves the patient more at risk for abruption and or rupture.

In my experience, patients having had two or more cesarean sections, regardless of the indication, a TOLAC or VBAC are not an option. At this point the risks outweigh the benefits. This risk is so prevalent neither the hospital nor the physicians are willing to accept that responsibility. The physician and hospital will go to great lengths to explain the risk associated with a TOLAC to the patient.

Ultimately the decision is up to the patient. The patient can go against medical advice. Proper paperwork must be filled out indicating that the patient is cognitively aware of their decision and understands the risks involved. The physician and hospital can also file a legal petition to a judge concerning the patient’s decision.

What plot scenario can you think of using these guidelines that will still have a lot of conflict?

C-section Primer for Authors. Click to Tweet.

*Originally published 4/25/2011.*

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Heidi Creston is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

The Lyme Wars: Part 2/2

Today, I’m concluding my interview with author Brandilyn Collins. You can find Part 1 here. Today, we focus on healing and what medical professionals can do to improve the care for those affected by chronic illness.

Jordyn: You’ve been open about God healing you during your first Lyme infection. Did your feelings/attitude toward God change when you were reinfected? Are some of these attitudes reflected in Janessa’s attitude toward God as displayed in the novel?

Brandilyn: When I was reinfected with Lyme in 2009, I couldn’t believe it! I gave God a hard talking-to. What are you doing? We’ve been here, done this. And aren’t you worried about your reputation—so many people know you cured me once? What if they doubt you now?

Well first, God informed me that He’d been dealing with the reputation thing since He brought the Israelites out of Egypt, so thank you very much, but He had that under control. Second, I can see now in hindsight that if I hadn’t experienced round number two of Lyme, I wouldn’t have written Over the Edge. As it turned out, six months of antibiotics cured me of that round.

Regarding Janessa, her spiritual journey is similar to mine. When I had Lyme the first time, I learned how to pray the psalms, both as petition and in praise—whether I felt like praising God or not. Most of the time I didn’t. It was a wonderful lesson that has changed me to this day.

Jordyn: Any words of wisdom for doctors/nurses in dealing with patients who have chronic pain/illness?

Brandilyn: Please, please don’t tell them it’s “all in their head” or some form thereof. Just because you can’t diagnose an illness—that doesn’t mean the patient simply wants attention or is a hypochondriac. It’s bad enough facing chronic illness. Worse still to be invalidated by the medical community. And please—educate yourself about Lyme. Admittedly, this is hard to do, because typical education would be in the form of reading published articles in esteemed medical journals. Unfortunately, these articles are based on the old, wrong assumptions about Lyme (or the authors simply ignore other research altogether). Google “lyme wars” to start online research. And—I have to get in that plug—read Over the Edge. It will alert you to the symptoms and issues involved in the Lyme wars—and how those wars came about.

Secondly, I want to talk to you doctors/nurses who do know about Lyme but are afraid to diagnose it. I understand your dilemma. I understand you don’t want to get into a battle between treating a patient long-term as he or she needs and your medical board. The political climate for you regarding Lyme is very bad. But please don’t send that patient away, saying, “I don’t know what’s wrong with you.” At least admit to the patient that he may have Lyme and refer him to an organization that can help find a Lyme doctor. (Googling “find a Lyme literate doctor” is easy.)

Leaving a possible Lyme patient completely in the dark opens him up to extended, further debilitating disease—if he does indeed have Lyme. I’ve seen this happen. I’ve seen Lyme patients lose all quality of life and become bedridden because their doctors didn’t want to admit Lyme, even when those doctors recognized the signs. I’ve even seen doctors refuse to test for Lyme when the patient requested it.

Jordyn: Any final thoughts?

Brandilyn: Good health and blessings to all. ~ Brandilyn

Thank you so much, Brandilyn, for your time. Blessings to you in your writing and to the continued success of Over the Edge.

Even in writing fiction, it’s a must to be factual for the story to ring true. Brandilyn also started a web-site for Lyme patients to discuss their experiences as well as some additional education regarding Lyme disease. These are great resources for research.

Blog Note: This interview with Brandilyn was originally published in May, 2011. Still, there appears to be confusion on how to deal with these patients as evidenced by just one recently published news piece called Defining Lyme: Medical community struggles with treatment.

Do you know anyone who suffers from chronic Lyme disease? Have you ever incorporated a disease into a story line?

Help spread the word about Brandilyn’s interview and Lyme Disease!

Brandilyn Collins’ insight into Lyme Disease: Part 1/2. Click to Tweet.
Brandilyn Collins’ insight into Lyme Disease: Part 2/2. Click to Tweet.