Five Things This Is Us Got Right About Medical Care

Usually, when I write these blog post, it’s a scathing review of something a television show or movie got wrong. However, in a recent episode of This Is Us entitled The Waiting Room, there were several things that the show got startlingly right for a change. Chrissy Metz’s character, Kate, was in preterm labor leaving the family to dwell in the waiting room. Here’s what the episode got right.

1.  People use Google all the time to question medical professionals. In the episode, one of the family members pulls up the drug Kate is on to quell her contractions and begins to question its side effects. Listen, I’m all for informed family members, but as many medical professionals know, the information on Google can be less than accurate.

It does become frustrating as a medical person to take Google’s word for a medical treatment over a trained medical professional. I’m also all for questioning a provider in a respectful way. A better way to approach this question with your provider is to ask, “What side effects are common with this medication?” and “Do you feel like those side effects are worth the benefits of the treatment?” Any provider worth their salt should easily be able to answer these questions. If not, then you may have a problem on your hands. This will tell you more than Google will be able to tell you.

2. Often times, people think that waiting equates to poor medical care. In one part of the episode, Kevin begins to question the delay in hearing any news, and openly questions if his sister should be moved to another facility, insinuating that she’s not getting proper care. The truth is, few things are fast in medicine. I think the culture and patient expectations haven’t benefited from these one hour television shows.

Nowadays, everyone wants to be seen within an hour and discharged home shortly after. In reality, especially in units where you don’t have an appointment, triage happens all the time based on how life threatening a patient’s condition is. Also, sometimes patients need to be watched for lengthy periods to see if their condition will resolve to a point where they could go home, or see if they’re appropriate for admission. If needing to be admitted, where to? Does that unit have capacity and staff to take care of the patient? Just because you’re waiting doesn’t mean anything necessarily bad is going on or that your loved one is getting bad medical care. A lot is probably happening behind the scenes that you’re not aware of.

3. Threats to staff happen a lot more than you might think. Maybe a better term for this would be microaggressions. Threatening to leave. Threatening to transfer. Threatening to call the patient care representative to file a complaint. Threatening to sue.  Using profanity directed at the medical staff and not just expressing frustration at the situation. Unfortunately, medical professionals hear variations of these every day and often without merit. They are designed, generally, to force medical care to happen more quickly. Using threats or aggression to speed up medical care is not necessarily wise for a variety of reasons. The largest reason is that stressed out healthcare workers tend to make more mistakes— the one thing you don’t want to have happen.

4. Waiting rooms are pressure cookers. It’s not unusual for arguments and fights to happen in waiting rooms. The waiting room becomes a voluntary prison and all people can do is watch the clock ticking. The more time that goes by— the more frustration builds. We are all more likely to take out frustration on our loved ones most— probably after the staff. That frustration will bleed over into other people and families.

5. Healthcare workers respond to kind and courteous over anger a lot better. In the episode, Kevin and Randall both approach the nurses’ station asking for information. Randall does it with more kindness and respect and gets more of what he’s asking. We are normal humans and it’s true what they say about honey.

This Is Us used truth and reality to make a very effective episode. Well done.

Author Beware: Good Example of BAD CPR

Sometimes, blog posts are very easy to write. I was tagged on this CPR video by a respiratory therapist friend of mine. It comes from a FB page called Enfermagen. Since I don’t speak the language, I’m not sure if they’re using this as a good or bad example of giving a patient CPR, but I’m here to confirm this is bad CPR and here’s why.

1. The patient has purposeful movement. As you can see, several times in the video the patient reaches up and attempts to move the mask from his face. Any time a patient crosses their midline, it’s purposeful movement. It definitely appears that he is sick, but he has enough of a perfusing blood pressure (and therefore pulse) for his brain to be getting blood flow in order to make these movements. Therefore, he does not need CPR.

2. The compression rate should be 30 compressions to 2 breaths. The compression depth is two inches. When the patient does not have a breathing tube in his throat (called intubation), the compressor should pause in order for the person to be able to deliver breaths. This compressor doesn’t really pause in order for the rescue breaths to be delivered. Luckily, for this gentleman, his compressor gives relatively shallow compressions and not the two inches they should be.

3. No one checks a pulse. What might help these rescuers is that when the patient starts moving, is to check his pulse. This might confirm for them that he has one and they can stop compressions.

4. Patients should not need to be restrained for CPR. CPR is for unconscious patients without a pulse. If you’re retraining the patient, they likely don’t need CPR.

I’m not sure the medical nature of this gentleman’s illness. Clearly, it looks like he does need some sort of medical assistance. It’s just not CPR.

Can you see anything else wrong with the way this team is delivering CPR?

All the HIPAA Posts in One Place

This post will simply be a reference tool for authors. Since I have so many posts about HIPAA, the patient privacy act, I decided to put links all in one place for your convenience. This would be a great link to bookmark.

General Information Regarding HIPAA:

HIPAA Part One
HIPAA Part Two
HIPAA Part Three

Specific HIPAA Topics:

Law Enforcement and HIPAA
Disclosing Protected Health Information Under HIPAA
Disasters and HIPAA
HIPAA and Identity Thefts
Author Beware: Proof’s Problem with HIPAA
Modern Family: Disclosing Pregnancy Results
Author Beware: HIPAA— It’s no April Fools

Remember, in a novel it’s perfectly okay for a character to violate HIPAA. In fact, in might be preferred to increase the drama/conflict in your story. Just remember, they need to face consequences for their actions, or it should be made clear that other characters are aware that the action did violate this law. This ensures the reader knows that you’ve done your research.

Author Beware: HIPAA– It’s No April Fools

Image by Gerd Altmann from Pixabay

One of the biggest errors authors make in regards to writing about something medical is that their character violates HIPAA. HIPAA is a law that outlines a patient’s rights regarding their protected health information (PHI). I’ve blogged extensively on this topic and you can find these posts by following these links:

Author Beware: The Law: HIPAA  Part 1/3
Author Beware: The Law: HIPAA Part 2/3
Author Beware: The Law: HIPAA Part 3/3

HIPAA and Law Enforcement
Author Beware: Proof’s Problem with HIPAA
Disasters and HIPAA
Modern Family: S10/E7 Disclosing Pregnancy Results

The simplest way to explain a HIPAA violation is that someone accesses a patient’s information when they are not directly caring for that patient and/or discloses protected health information about a patient publicly.

Two recent stories have highlighted each of these scenarios.

The first involves actor Jussie Smollett and several dozens of hospital employees accused of viewing his medical information at Northwestern Memorial Hospital in Chicago, Illinois. They were all fired, reportedly some didn’t even open the chart, but just “scrolled by” it. The point is, with today’s technology and electronic medical records, it is very easy to determine who has accessed someone’s health information. It’s basically tracked electronically. Unless you are directly involved in caring for a patient, it is illegal for you to look at their information. I can’t even access my own children’s medical charts at the hospital where I work unless I go through the proper channels, which is signing a release for them through medical records.

The second, and perhaps more frightening case, is of the nurse who disclosed a toddler was positive for measles in the pediatric ICU where she worked and then posted about it to an anti-vaxxer group she belonged to on social media.

She didn’t give the patient’s name, sex, or exact age so she should be okay, right? Many times, people think this is a way to get around HIPAA and sometimes they can be right— it depends on the volume of such a diagnosis. For instance, if my ER sees 5,000 patients a day (which is insane– I don’t know any ER that can even possibly do this) and I say we saw a patient with a rash (and that’s it) then that doesn’t necessarily signify the one I might be talking about because there were probably dozens of patients seen with a rash that day with that volume of patients. However, I will also say this could still be considered a HIPAA violation, but let me further illustrate my point.

The more unique and rare a medical diagnosis is, the more easily it would be to identify a patient even without disclosing name, sex, or age and that is this nurse’s first problem. There was probably only one patient in the PICU that had a medical diagnosis of measles. It had likely been in the news that there were measles cases in Texas (this is frequently disclosed for the public good to encourage vaccinations), but the nurse’s information narrows down the hospital, the general age group, and just how sick he was. Then neighbors can start thinking, “Hey, we live close to Texas Children’s and I haven’t seen Billy (totally made up name) in a while and he’s a toddler—” and then phone calls go out to Billy’s mom asking if he has measles. See?

The frightening aspect of the scenario, from a purely pediatric standpoint is, that even after seeing how sick this child was, she remained an anti-vaxxer and even mused about taking a swab from the ill child’s mouth and attempting to give wild measles to her own child! For one, I consider this child abuse. I truly cannot fathom in my mind how this nurse believes giving her child the real thing is preferred over a vaccine that can prevent the entire illness.

**The safest thing for ANY healthcare worker is to not discuss their patients at home or on social media no matter how vague they try to make the scenario.**

It is also the safest thing for authors who are writing these scenarios. As I’ve always said, you can have a character that violates HIPAA in your novel, but they must face repercussions for it. The positive side of this is that it increases the conflict in your story automatically. It also shows the reader that you’ve done your research.

Author Beware: Doctors Cannot Do Everything

I was recently reading a YA novel (that I did really enjoy BTW) when I came across this passage. For a quick background, this young girl has just woken up screaming after being involved in a car accident so it’s presumed she has a head injury.

The passage is as follows from the novel:

The room fills up with people. Two nurses and a doctor appear as quickly as if I’d pushed the little red call button on my bed. 

“Sophie, I’m Dr. Langstaff. You’re in a safe place and I’m here to help you.” The doctor holds a syringe and a container, measuring out a clear liquid. “I’m going to give you some medicine to calm you down and help you sleep.” He inserts the syringe so the medicine flows into my IV. It drains the screams right out of me, like he’s pulled the plug on my lungs.

Interestingly, there are quite a few problems with this small passage.

1. There is a process to giving medications in the hospital. The doctor orders the medication, the pharmacy double checks and approves the dosage, and the nurse draws it up and gives it to the patient. This patient is on a medical surgical floor— this is the process that would take place.

2. Doctors generally don’t have access to sedatives or narcotics. There are only a few areas in the hospital where a doctor would have direct access to these types of medications that they could pull themselves and that would be anesthesia. Narcotics are very tightly controlled. Doctors generally can’t even access narcotics or sedatives via the medication dispensing machines on the floor— even those medications that only they can give (such as perhaps Ketamine for a sedation). This is not the “old” days where a doctor carried around a stock of medications he could dispense. Nowadays, they likely can’t even access them.

3. Sedatives generally aren’t the first choice for a distressed patient.  I think for writers, this idea comes from watching too many bad television hospital dramas, but in real life is rarely done. The first step in handling a patient that first wakes up from a traumatic event is to orient them to where they are and what’s happened. Involve the family in helping them feel safe. If the distress continues, evaluate if there is a medical reason behind it. Is there some undiagnosed medical problem? Does she need a repeat scan of her head? It really is unusual that you can’t calm a person down— even one with a head injury. Patients are generally only given sedation if they become physically harmful to themselves or others. We do use sedation in some of these situations, but not as a first line and not as often as you might think and most likely not in the head injured patient.

What are some other things you’ve seen in books that aren’t accurate as far as a hospital setting goes?

Someone Please Rescue 911: Teach Them to do CPR Correctly

I’ve been teaching CPR for almost thirty years. Can you believe that? I hardly can.

I’m pretty passionate about CPR because time after time studies have shown that this is the patient’s best path for survival— high quality CPR given as soon as the patient needs it. It’s not rocket science and it’s pretty easy to research. Here’s a Google link to a bunch of images that show the algorithm for CPR.

What you want to be sure of is that you’re using the most recent guidelines. For the American Heart Association (AHA), their most recent set came out in 2015. The AHA reevaluates their CPR guidelines based on research every five years. Next update will probably happen next year, but the educational materials likely wouldn’t be released until 2020.

In episode nine of this season’s 911, Hen and Howie rescue a boy from a submerged vehicle. He is unresponsive and pulseless once he reaches the shore. They begin CPR (just compressions) and after every set of compressions they do a pulse check. After about a minute, they revive the patient.

Did you know that even healthcare providers are not that great at determining whether or not there is a pulse? It’s true. On top of that, imagine trying to do a pulse check with cold hands, in the dark, in the rain. Not easy to be sure.

The reason the pulse shouldn’t be checked that much is that it ultimately delays compressions and we don’t want to do that. Every time compressions are stopped, the blood perfusion to the heart also stops and it takes several compressions to reperfuse the heart. Some fire departments have gone to doing two hundred uninterrupted compressions for this very reason.

In lieu of this issue, I did like this episode quite a bit. It’s Hen’s origin story and I do think it highlighted some of the issues minorities face in the fire service.

911— let’s just stop messing up the little things.

New Amsterdam and The Law: Real or Not Real?

In Episode Two of the new NBC show New Amsterdam, there are some pretty amazing claims about two specific laws. Keep in mind, I’m not a lawyer, and this blog is for fiction writers so you might be interested in doing your own research, but these are my thoughts on these “two laws”.

Law #1: In one scene, a man is standing outside his room complaining that he must choose between his wife’s care and a car— eluding to how expensive the medical care will be and that the hospital won’t tell him how much it is. Dr. Goodwin says in passing, “Congress actually made it illegal for hospitals to disclose prices to you.”

Having worked in health care for twenty-five years, I understand how frustrating this can be and there definitely needs to be reform in this area. However, let me give some insight into why it is hard for hospitals to give you an exact price up front. Simply, humans are not machines and often do not medically act the same in every situation.

Let’s say your child comes in for stitches and we tell you it costs “X” amount. This assumes your child only needs a topical numbing agent for the procedure. However, your child is not on board with the medical plan and won’t hold still for his stiches so a decision is made to give them some sedation— and the topical medication isn’t enough to numb the site so we then have to inject a medication. Since the child received sedation, now there’s increased monitoring time to make sure the child is okay to be discharged home. Things like this happen every day in healthcare.

The problem is when you quote someone a price, they want to (rightly so) hold you to it. When you can’t, then it creates dissatisfaction for both the patient/family and the hospital.

Despite this, I could not find any such law that congress has passed that prohibits a hospital from disclosing prices. I think the reluctance is on the side of the hospital for the reasons I mentioned above. In fact, there seems to be movement legislative wise, in the other direction for more transparency. You can read the American Hospital Associations thoughts on it here.

Law #2: A young boy is brought in for psychiatric treatment and the psychologist on staff believes he’s being overmedicated and wants to wean him off all his meds. Quick note on that— not sure why a neurologist would be involved in this process. A psychiatrist, yes.

There’s a statement made regarding the Prohibition of Mandatory Medication Amendment of 2004. As from the link, this law does exist. Put very simply, a school cannot force a child to take medication to receive educational services. However, in the show, it’s stated that the school can force a child to take meds for educations purposes if the mother has signed an IEP otherwise known as an individualized education plan.

I could not find any source to support this statement. This blog post written by a mom who seems familiar with this issue would be a good one to read. Do I believe that schools try to “strongly suggest” that kids are medicated. Yes, I do. However, I don’t think it’s supported by law.