Author Beware

HIPAA and Law Enforcement

/ Jordyn Redwood / Leave a comment

I had a phone consultation with an author who wanted to discuss HIPPA.

As you know, HIPAA is a set of laws designed to protect patient privacy.

Here’re links to a previous series I did on HIPAA: Part I, Part II, and Part III.

His question centered around whether or not law enforcement was privy to medical info.

In the pediatric ER– we will readily discuss medical issues with law enforcement because it usually deals with us reporting child abuse. Police also need information so they know the degree of serious bodily injury (or SBI) to determine if charges should be pressed.

However, I didn’t know much about how my adult ER compatriots generally approached the issue. HIPAA is difficult to understand in its entirety and most healthcare professionals are apt to err on the side of providing no information rather than get in trouble for giving out information that they shouldn’t.

Keep in mind that the main crux of this law was also to give you the power to always view your medical information. A hospital or medical provider cannot keep your records from you. Even if you are in the hospital– you should be able to ask to see documents. What the hospital may do is have a representative sit with you to “watch” you so 1. you don’t tamper with the record and 2. they can explain the medical lingo.

Unfortunately, some places make it challenging for patients to get their information. You should absolutely have to sign a medical release form. But after that, I’ve known of hospitals to state it can be up to two weeks or more for records and that they may charge you for the copying of each page. That can be frustrating experiences for families.

Pertaining to this author’s question– come to find out through a little research for said author, that HIPAA does allow for discussions with law enforcement personnel.

Here is the particular section that pertained directly to the authors question from this link:

Law Enforcement Purposes. Covered entities may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if the covered entity suspects that criminal activity caused the death; (5) when a covered entity believes that protected health information is evidence of a crime that occurred on its premises; and (6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.34

Just goes to show you what you can learn whilst doing some research!

Editor’s Question: Consent for Rape Kit in Unconscious Victim

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During my blog tour for Proof I had an interesting question from fiction editor, Ramona Richards, in the comments section of the blog on this post that dealt with collecting a rape kit.

Ramona: If a sexual assault victim is stable but unconscious– will the medical team do a rape kit and if so– who do they get consent from?

Jordyn: This is an interesting question on many levels. As a nurse, I’m first an advocate for the patient but also as a nurse and woman– I want to see justice happen for this woman as a victim.

The central issue is that part of the rape kit is very invasive. Particularly the pulling of the hair from the head and groin area and well as the internal pelvic exam.

No one wants to put a victim through something more traumatizing– so generally– permission must be given by the victim in order for the exam to be done.

But say– the victim looks like she is not going to wake up to give that permission?

Part of the exam can be done. External evidence and swabs can be collected. An external exam of the vaginal area could also be done. Pictures can be taken.

Likely– we’ll wait to see if the patient wakes up. Nothing should be disturbing the internal presence of the evidence if the patient is hospitalized. Exams should be done within 72 hours and one nurse practitioner I work with said semen could be preserved on the cervix for 10 days.

But what if it looks like the victim is never going to wake up?

Then it becomes an issue for the courts. They would have to issue an order for the exam to be done. So either the victim has to give permission (and no– not next of kin)– or the court would order the exam to be done.

Author Beware: Delusional Diagnosis (2/2)

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Last post, I discussed the issue of heart palpitations and how, in isolation, they can be benign and not representative of heart disease.

The line in this particular published novel that did get my ire up is shortened as follows: “Any experience terrifying enough to cause a panic attack, in extreme circumstances, causes an arrhythmia. That’s a heart attack.”

Really? No. There’s a lot medically wrong with this sentence.

First, in very general terms, a heart attack is caused from lack of oxygen to the heart muscle, generally from a clot in an artery that feeds blood to the heart– your coronary arteries. When the heart muscle is not getting oxygen, it becomes irritable. One interesting thing about your heart is that each cell can generate an electrical current that will contract heart muscle. It generally does not do this due to the over-riding normal pacemaker. However, when oxygen is cut-off and the heart cells become irritable, they can begin to fire outside the normal conduction system.

When this happens, the medical team begins to see aberrant beats. But see, the heart attack itself generally causes the arrhythmia, not the other way around.

Let’s stay on track with this character. A healthy, college age woman. The incidence of actual heart disease is going to be low. What causes chest pain during a panic attack? Generally, the heart rate may be faster than usual. However, the truly rapid heart beat of SVT (more on that later) I would say is rare and would point away from the mind and more to the conduction system in the heart.

The last thing to consider is that people who have true heart arrhythmias, may have structurally fine hearts. Meaning the muscle, valves, and coronary arteries are good. Just the conduction system is a little funky.

My advice for authors– don’t make blanket medical statements. Just like they taught you in school– sentences that have all, every, etc… are likely the wrong answer.

Author Beware: Delusional Diagnosis (1/2)

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There’s nothing I hate more as a reader than to be happily reading along a novel that I really like and come across a medical issue that begins to pull me out of my snow globe of a story bubble. It’s even worse when it begins to keep me up at night and I dream up a whole blog series about this issue.

That means things are really bad.

This happened recently. The story is actually quite good. Solid, interesting premise. Had it not been for this medical issue that was a thread through the entire story, I’d easily give it a five star rating. But, because of this medical issue and how it was painted, I downgraded my review just for that reason.

It made me wonder if the author had talked to someone in the medical field. And if they did, who it was. I mean, the 125 year-old retired dermatologist may not be the best resource. For dermatology– yes, absolutely. Otherwise, just sayin…

And I love dermatologists by the way. But if I’m dying– please find me a cardiologist!

The issue surrounded palpitations. The author began to write about how the lead character was having palpitations and how she was concerned this represented a major heart issue that would ultimately lead to her not being able to pursue her ultimate career goal. The author painted it as a major event in her life.

I’m going to ease off a little here as patients are often this way. They worry that a minor symptom represents a major life-ending disease. Happily, this if often not the case. So, it’s okay to do that… in the beginning. I’ll cover the major down side of this book next post.

Let’s cover what we know. What are palpitations?

Palpitations are merely the sensation of your being aware of your heart beating. Normally, you can’t feel that muscular pump busily working in your chest. Is doesn’t keep you up at night with its never-ceasing beating nature.

Palpitations are often skipped beats. When your heart skips a beat, sometimes blood doesn’t flow out as it naturally would and this fullness can be felt. Normally, these skipped beats aren’t anything too concerning if they happen every so often. More worrisome is if it is happening all the time and/or associated with chest pain and/or shortness of breath.

Palpitations can also represent rapid heart beats or irregular heart beats. These can be a little more worrisome.

However, some people with palpitations do not have heart disease or an arrhythmia. This character happened to be a young, healthy college student which makes these diagnosis more unlikely.

Come back for Part Two of Delusional Diagnosis next time.

Author Question: Refusing Medical Treatment

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Carrie Asks:

My novel is set in the US and my MC, who’s eighteen, is injured. He’s suffering from concussion, blood loss, and hypothermia, and is very weak and quite disorientated. He is, however, conscious and responding, and adamant that he does not want to be treated or taken to a hospital (and the plot requires him not to be). I understand that he’d be able to refuse treatment if he signed a form saying so. My question is, is there a standard procedure that an EMT would follow before letting him sign?

Jordyn Says: Thanks for e-mailing me your question. You have an interesting scenario here.

I’m going to come from the standpoint of this person presenting to the ER. Put simply, we are not going to let this patient sign out AMA. A couple of things in your statement about his condition will prevent this. Almost everything you’ve listed as far as his medical condition makes it impossible for him to make a reasonable decision regarding his care–concussion, disorientation, hypothermia. Even though he can talk, it doesn’t mean he has enough medical capacity to make an appropriate decision regarding his care until these issues are straightened out.

We would do everything in our power to keep him in the ED. Considering that– you have a couple of options. Make him a lot less sick. Maybe just a few bumps and scrapes. Or, he could elope from the ED somehow, but if we were really concerned about his medical condition we might send the police to fetch him back. Of course, this could add conflict into your story.

I did verify this through an EMS friend of mine as well. The issue is not whether or not they can talk, it’s whether or not they are medically competent to make a decision about refusing care. This character’s condition precludes that.

Author Beware: Unsecured Narcotics

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I was happily reading along one of my favorite best-selling authors when I stumbled upon a troubling set-up. Now, this author makes a lot of money which is why I’m not sure the reason for his not picking up the phone to consult me on his manuscript.

One character had been beaten up fairly well. He was in the hospital on a Valium drip. Huh? That’s right, just a bag of Valium hanging and dripping into his veins.

Issue One: Valium is not a pain medication per se. It is a muscle relaxant which can relieve pain from a muscle spasm. However, if you have had the snot beat out of you, let me introduce you to my friends the opiates: Morphine, Fentanyl, etc. These are likely what we would give first for pain.

Issue Two: Valium is not given in a bag as a drip. In fact, I can think of few instances where Valium would be given as a continuous medication. Some shorter acting friends of Valium are– but you generally have to be in the ICU on a ventilator to get some. This character was not.

Issue Three: Narcotics need to be secure. If a patient needs a continuous amount– this is what PCA (patient-controlled analgesia) pumps were made for. They are locked IV pumps so that no one can steal the drug from the bag and so that the patient cannot manipulate how much they receive.

Pediatric ICU’s do run a lot of continuous drips that are not locked. In these instances, usually a calculation is made at the end of a shift to look at the amount remaining. If the syringe is off by more or less one millimeter– then generally an incident report is filled out.

So bestselling, multi-million dollar author— really, just call me up. I’d be happy to help.

Have you read a scene with inappropriate use of narcotics?

Author Beware: Hallmark’s Christmas Magic

/ Jordyn Redwood / Leave a comment
There’s nothing more charming for me than a Hallmark Christmas movie. Several I loved this past Christmas season– particularly Trading Christmas written by Debbie Macomber. Hilarious if you’re a writer.
Some I didn’t like as much– and you guessed it– had to do with a medical reason.
Christmas Magic was a Hallmark movie where a young PR exec was involved in serious car accident.
Spoiler alert!
Most of the movie, you’re led to believe that she has died and is doing some angel work before going to heaven. At the end of the movie– you learn she has been in a comatose state and the climatic scene is where the man and daughter she was trying to help, come to her side at the hospital, to sing her back to life before her father “pulls the plug.”
My first issue: You should actually look injured if you’ve been in such a devastating car accident that you’ve been lying in a hospital bed for the better part of a week. In her “death” scene, her hair is clean and styled. Nary a scratch on her pretty face. Exactly what was her injury? Supposedly brain trauma. Well, she should at least have a bruise on her head.
My second issue: Pulling the plug generally denotes that you are on a ventilator. Discontinuing the ventilator– pulling the plug– means a patient’s breathing is no longer being assisted, they then cannot oxygenate their body, and the heart will stop beating when it doesn’t have oxygen.
In this scene, she was on a heart monitor (which is merely a monitoring device) and an IV bag of fluids hung at her bedside. She was not on a ventilator. Therefore, no “plug to pull”.
To denote discontinuing “life support” the nurse in the movie turned off the IV solution where then the heart began to slow down. Okay, you will die if you are in a comatose state from dehydration (think Terri Shiavo’s case) but it will not happen in a few minutes. It will take days.
But, this patient was able to comply and nearly died in a few short minutes.

Next season, Hallmark Channel, hire me as a consultant. You might be surprised at how inexpensive I am!

How to Write a Hospital Scene: Amitha Knight

/ Jordyn Redwood / Leave a comment
As a doctor, I don’t like reading books or TV shows about doctors. Not because I’m jaded and think I’ve heard it all before (quite the contrary) but because often, it feels like the writers just haven’t done their research. I’m not talking about highly involved medical research—it’s the basics that can trip you up.
Here are a few questions to think about when writing a character’s hospital scene (please note that some of this is for US hospitals only).
1. Is your character on the right floor?
As many people know, hospitals are set up with different patients in different areas of the hospital. There are pediatric floors, adult floors, surgical floors, maternity floors, ICU’s, etc. Knowing where your character/patient would be placed in the hospital depends a lot on the type of hospital you’ve chosen for your story. Is it a small community hospital in a small town? Or a large teaching hospital in a major metropolitan area? The smaller the hospital, the fewer wards there will be (and often the really serious cases would quickly be sent over by ambulance to a bigger hospital). In larger hospitals, the ward will be more specialized so you shouldn’t expect to see mixing of patient types (i.e., adult surgery patients in a medical ICU ward).
Why does this matter? It has to do with your setting details. For example: If your character is in the ICU, he/she won’t see a lot of patients walking around with IV poles in their hands. And the rooms in maternity ward have more privacy than in an ICU setting. If your character is the doctor rather than the patient—they won’t be wandering around random hospital wards. Your medical intern isn’t going to be regularly wandering around the pediatric wards and playing with kids there.
2. Who will be taking care of your character/patient?
This can be confusing and again, depends a lot on the type of hospital in your story. Let’s say you choose a teaching hospital. Who will be taking care of your character? I’m going to focus on the different types of doctors and doctors-in-training because that’s what I know the most about.
Medical students: These are students in medical school. They have not yet yearned their MDs so they are not “doctors”. Medical students are often allowed to see the patient first and ask questions—but not in an emergency situation. They do not make medical decisions for your patients.
Residents and Interns: These people have graduated from medical school and thus are “doctors”. They see their own patients and make some medical decisions, but are still in training and run major decisions by an attending physician (see below). Interns are what residents are called when they are in their first year of residency. In some specialties, residents have to do a separate intern year at a different program before beginning their specialty training. That’s why the distinction is made.
Fellows: These are people who have finished their residency but are doing further specialization and are also overseen by an attending physician, though less closely than a resident.
Attending Physicians: An “attending” is the doctor who is ultimately in charge of your patient during their hospital stay. All major decisions will have to be run by him or her.
This hierarchy can make a huge difference to the believability of your story. For example—a medical student or an intern will not be in charge of breaking bad news to a patient unless they have forged some strong bond with your patient. This is generally the role of the attending physician. Likewise, the attending physician will not be doing “scut work” (tedious hospital work, ordering tests) unless they are in a hospital where they don’t have interns and residents around.
3. Which patient will your doctor characters see?
This is one of the reasons I can’t watch Grey’s Anatomy. If you are a surgery resident, you will not be delivering babies. If you wanted to do that, you would have done ob/gyn. If you are an ob/gyn resident, you will not be taking care of babies in the neonatal ICU. If you wanted to that, you would have done pediatrics. And if you are a pediatric resident, you will not be doing surgeries. Please, get it right! Your doctor characters really can’t do it all!
Originally posted to the Guide to Literary Agents Blog. Reposted with author permission.

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 Amitha Knight is a former pediatric resident turned writer of middle grade and young adult fiction. She’s also a blogger, a book lover, an identical twin, and a mom. Follow her on twitter @amithaknight or check out her website: http://www.amithaknight.com/.

C.J. Lyons Interview: Part 2/2

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Today, I’m concluding my two-part interview with New York Time’s bestselling author C.J. Lyons. If you’re a fan of medical thrillers and haven’t read C.J.’s books, now is the time to start. The focus of today’s questions is on aspects of the writing craft.

Jordyn:  After reading through several of your past interviews, I discovered we’re really kindred spirits. I, too, started writing at a very young age. Do you still have these stories? Have you adapted any of them into your current novels?

CJ: LOL! No, they’ll never see the light of day. My stories when I was young usually involved a girl and her horse off fighting some form of injustice in history (I was fascinated by history as a kid, so my stories were set in the Wild West or Civil War or American Revolution).
Jordyn:  I think you’re one author who has successfully navigated both traditional and e-book publishing. What would you say are the best three ways to market a novel?
CJ:  Know your reader, know your story, know your strengths. Write a story your reader will love and use your strengths to connect with them and let them know it’s out there. Really, it’s that simple. Marketing is making a promise to your readers and keeping it. How you do that depends on where your strengths lie.
Jordyn:  Your novels are character driven. What are some strategies you use to develop imperfect heroes and sympathetic villains?
CJ:  It all starts with my character’s default action at the start of the story. What they think is their greatest strength on page one, I slowly make their greatest weakness by the end of the story until they sacrifice that old default action and learn a new one. Villains are on their own hero’s journey (no one wakes up one day deciding to be the bad guy, we all think we’re heroes of our own lives) so I do the same with them, only in the end they don’t make that sacrifice and learn from their mistakes, allowing the hero to defeat them.
Jordyn:  I was sad to learn of the tragic murder of a friend of yours during your residency. How did writing serve to help manage the chaos in your life during that time?
CJ:  After Jeff’s death I wrote my first crime fiction story, Borrowed Time. I think I needed to switch from the SF/F I had been writing before then because suddenly I needed to know that justice could be served and that good guys could win, despite the forces rallied against them. I’ve been writing thrillers ever since.
Jordyn:  What was it like co-authoring a novel with Erin Brockovich? How did you divvy up the writing?   
CJ:  Erin and I have never actually met in person—her travel and work schedule is crazy! We spoke on the phone and via email. It was so amazing to work with a personal hero of mine and I love it that we were able to create a character that embodies the philosophy that both she and I share: that heroes are born everyday.
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As a pediatric ER doctor, New York Times Bestseller CJ Lyons has lived the life she writes about in her cutting edge Thrillers with Heart.  
CJ has been called a “master within the genre” (Pittsburgh Magazine) and her work has been praised as “breathtakingly fast-paced” and “riveting” (Publishers Weekly) with “characters with beating hearts and three dimensions” (Newsday).
Learn more about CJ’s Thrillers with Heart at http://www.cjlyons.net/

CJ Lyons Interview: Part 1/2

/ Jordyn Redwood / Leave a comment

I’m honored to have had the chance to interview CJ Lyons, past pediatric ER doctor and now full-time author extraordinaire. If you haven’t checked out CJ’s books, now is time time, particularly if you’re a fan of medical thrillers.

Today we’re going to focus on aspects of medicine in writing. On Wednesday, we’ll focus just on the writing craft.

Jordyn:  Thanks so much for stopping by. It’s my great honor to have you here. Redwood’s Medical Edge is all about dispelling medical myth. Along those lines, what do you see as the most common medical mistakes perpetuated in fiction writing?
CJ:  The most common (and irritating) mistakes I see deal with the characters. For instance, the popular TV show Grey’s Anatomy has interns, who’d be maybe 25 years old, sleeping with “world renown” surgical attendings…well, to be a “world renown” neurosurgeon you’d have to have 12 years of primary education, 4 years of college, 4 years of medical school, 7 years of residency, probably another 3 year fellowship, and then be in practice a long time, at least 5-10 years…so the 25 year old intern’s love interest would be old enough to be her father! Gross!
Not only that, a surgical intern doesn’t have time to sleep or bathe (interns eat on the run) so sex isn’t the first thing you think of doing when you finally do make it to a call room.
Don’t even get me started on stories where a “doctor” can do everything from take x-rays (99.9% of us wouldn’t even know where the “on” button is) to diagnose rare diseases from glancing into a microscope to doing brain surgery one minute and heart surgery the next…while I love the idea of doctors being heroes, let’s at least make us human.
Oh, and I’ve only met two physicians who drove Porsches, both orthopedic surgeons, freshly divorced and shopping for new wives. At the community pediatric practice where I worked, the guys who plowed the snow were paid more than we were. So just because a character is a doctor doesn’t mean they’re rich.
Jordyn:  What about the most common medical myths?
CJ:  Those magical “blacked out” incidents. Where the character is hit on the head and wakes eight hours later in perfect condition, ready to chase after the bad guys…or the Taser hit that instead of lasting the five seconds it does in real life, knocks someone out for a prolonged time.
Sorry. In real life, your guy with the head injury would probably be dead or dying of a brain bleed and people who are Tasered don’t black out at all (although they might wish they did)—in fact some of them stay perfectly functional while being Tased, much to police officers’ dismay.
Jordyn:  I read with interest that you had worked with a community group of pediatricians that served an Amish community. Amish books are selling briskly on the inspirational market. Do the Amish have any medical beliefs that differ from western medicine? What are some of the unique aspects of working within the Amish community as a doctor?
CJ:  We had a variety of patients when I was working at a community pediatric practice in Pennsylvania, including Amish. But also Chinese, Russian, Pakistani, Turkish….and every demographic from the very poor to millionaires who kept their family home in our idyllic mountain setting and flew their privates jets to and from their offices in DC or NYC every week. It was a great experience, because like the ER, you learned very quickly not to judge anyone because of their appearance or accent or attitude.
Jordyn:  You spoke once about how you had a fascination with ghost stories. Speaking as a physician, do you have any thoughts on near-death experiences and what they might mean?
CJ:  I think there’s more going on in the universe than we understand or can imagine. It’s hubris to think we have all the answers—or ever will. As for near-death experiences, I actually used one in Borrowed Time to set things up for the main character. She’s a cop, shot and killed in the line of duty on page 3, and brought back to life by a trauma surgeon. But she’s now seeing things, visions of other people’s deaths, and suddenly everything she once had faith in: her abilities as a cop, her trust in herself and her fellow officers, even her sanity is questioned.
Jordyn:  What are three things you’d like President Obama to know about the healthcare system after serving families for seventeen years as a physician.
CJ: Not just the president, but everyone. First, just because kids don’t vote shouldn’t mean that their health care is put last. It should be top priority along with education and feeding them. Without healthy kids energized to learn the skills they need to take us into the next century, we have no future.
Second, there is no universal formula doctors can follow. Yes, we need evidence based medicine to help us tailor our choices, but it can’t be about cost, it has to be about effectiveness, about what’s best for the patient in front of us here and now.
Third, from my point of view as a physician on the front lines, the HMOs already cut all the fat from the medical field and put that cash into their own pockets decades ago. The only place left to cut now is trimming the bureaucracy. Which would not only save money but improve health care quality because then doctors would have time to spend with patients instead of wasting it arguing with administrators.
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As a pediatric ER doctor, New York Times Bestseller CJ Lyons has lived the life she writes about in her cutting edge Thrillers with Heart.  
CJ has been called a “master within the genre” (Pittsburgh Magazine) and her work has been praised as “breathtakingly fast-paced” and “riveting” (Publishers Weekly) with “characters with beating hearts and three dimensions” (Newsday). You can find out more about C.J. by visiting her website: http://cjlyons.net/