Can You Fake an Ultrasound in Real Time?

Gerard Asks:

I came across your blog as I was googling my question. This week, I was watching Grey’s Anatomy (Season 14, episode 18) in which an unscrupulous (or maybe it he was just a fraud?) doctor was giving false diagnoses for breast cancer through ultrasound—I think to sell treatment?

Knowing a little about computers, I wondered how that could be possible. Can an ultrasound store the millions of images or 3d imaging from another patient to be “played” on another patient? Of course, I wrecked the show for my wife by questioning the episode she was enjoying.

So, in case I’m all wet in my assumptions, is it possible to fake an ultrasound in real time?

Jordyn Says:

Hi Gerard! Thanks for submitting your question to me. The perfect person to answer your question is Redwood’s resident medical expert, Shannon Moore Redmon.

Shannon Says:

Today’s ultrasound technology does offer the ability to record video clips that an extremely unethical doctor could replay while pretending to scan a patient with a probe. Most patients would not know the difference between normal breast tissue compared to a malignant mass and the shape of the entire breast isn’t really a factor on the ultrasound screen, since we’re only scanning a small section at a time.

With that said, the hoax displayed in the Grey’s Anatomy episode – Hold Back The River, would be difficult to achieve in real medical life.

Gold Standard

First, ultrasound is not the Gold Standard for detecting breast cancer. That role belongs to mammography (x-rays of the breast). Highly trained technologists position and complete several different mammography views. Ultrasound simply supports suspicious lesions first detected on these images. Doctors use the scan to provide more information and ultrasound should never be used alone to detect malignancy. I hope most patients would not simply take a doctor’s word based on an ultrasound alone when determining whether they have breast cancer or not.

When a mass is identified on a mammogram and followed up with ultrasound, these images or video clips do not give a complete diagnosis of cancer. We can suspect cancer by the appearance of the mass we see, but the only way to know for sure if the mass is malignant, is through a biopsy. Stereotactic breast biopsies are often performed at imaging centers or hospitals. A large needle is used to take samples of the mass and then send them off for pathology testing. Those results tell if a mass is cancerous or not. If the patient is not a candidate for stereotactic breast biopsy, then the mass can be removed in surgery and sent to pathology for testing.

Appearance

When a sonographer finds a suspicious mass on ultrasound, we look for several factors in the appearance. Is it solid or fluid filled? Does is have smooth borders or finger-like spiculations extending into normal tissue? Does a shadow present posterior to the mass? The mass shown during the episode did not meet the specified criteria for malignancy. Let’s break the moment down:

The doctor shows the female character a mass on the screen. There was no shadowing posterior. The borders were smooth and looked like the normal tissue adjacent to it. The area the physician suggested was solid but had a Cooper’s ligament running through the tissue which is typical for a normal lobe of the breast. I’ve included an ultrasound image of a true malignant mass, so you can see for yourself what a true breast cancer might look like on ultrasound. I think you’ll find the video clip played in the scene looked nothing like the true cancer below.

 

 

 

Exam Inaccuracies

During the scene, a swishing heartbeat noise can be heard in the room. Grey’s Anatomy seems to think that when an ultrasound is being used, every machine creates this noise. Let me assure you, that’s unrealistic.

The noise heard in the background is created by a Doppler sample of a vascular structure, such as an unborn baby’s heartbeat or blood flowing through an artery. Neither of these were being scanned during our breast exam.

When no Doppler is activated on the screen, this sound cannot be heard. But yet, we have the heartbeat noise once again. I wish someone at Grey’s Anatomy would update their sound effects team.

After the blond female doctor goes back to Seattle Grace, she has her doctor friend scan her breast to make sure there is no cancer. The doctor who performs the scan and supposed to be knowledgeable enough to detect breast cancer, is holding the wrong probe. She should be holding a linear transducer used in high frequency imaging and provides a rectangular footprint on the screen. Instead, her probe is curved and used for abdominal and pelvic scanning because of the lower frequency range.

Another flaw in the episode is how all these doctors are experts at performing scans in every area of the body. In real life, trained, registered sonographers and technologist work in these modalities. They would be the ones to execute the imaging. Then a radiologist would read the exam and communicate with the surgeon or other physicians. But once again on TV, we see the Grey’s Anatomy doctors performing all the imaging exams. No sonographers or technologists around anywhere. So unrealistic and a little insulting.

I think it is time for the Grey’s Anatomy team to hold back more than the river— they need to hold back on performing any more ultrasounds until they consult a living breathing registered Sonographer.

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Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.

Author Question: Treatment of Teen Suicide Victim (2/2)

Today, we’re continuing our discussion of the medical treatment of a fifteen-year-old male suicide victim who slit his wrists at school. You can find Part I of the discussion here. In this post, we’ll focus on more of the mental health aspects over the medical treatment.

Pink Asks:

Upon examining a patient, and if sexual abuse is suspected, what is the hospital protocol? How do the hospital staff work with police and the victim’s family?

Jordyn Says:

If outward physical exam of the skin shows injuries concerning for sexual abuse, this can be handled several ways. In order to answer this best, I’d need to know what kind of hospital your patient/character is at in order to give advice as to how that community would likely respond but I’ll give thoughts as to how my institution would handle it—which is a large, urban pediatric medical center. A rural hospital would likely handle it much differently.

One thing I want to say is that no sexual assault exam would be done without the patient’s consent (or parental consent—a court can order if needed)—so this would not be done on an unconscious person. What you can see from the outside would be the limit. For instance, in girls and women no internal vaginal exam.

There might be an extreme outlying caveat to an internal exam if the patient were near death, concern for loss of evidence, or other victims were at risk, but it would have to be VERY PRESSING circumstance and likely the courts/law enforcement would be involved in order to move forward.

Regarding the suicide attempt, the next thing to keep in mind is that the patient’s medical needs are always addressed first. In fact, the patient must be “medically cleared” by a physician before they can participate in a mental health evaluation.

If there is a concern for sexual abuse, we would first contact social work through our hospital to develop a game plan. If a sexual assault exam needs to be done, we have health care professionals that are very experienced in doing these with kids/teens and we want the most experienced professional to do the exam and collect any evidence. Social work will do a couple of things if they think the concerns are valid. One, report it to the state (Department of Children and Family Services—something along those lines depending on the state) and second, report it to the police if they believe a crime has occurred. The incident is reported to the police jurisdiction where the crime took place and not the location of the hospital where the patient is receiving care.

As an example, if a woman is raped in Anchorage, AK, flies to Seattle and seeks treatment there, the hospital in Seattle is going to have to call Anchorage, AK police to report the crime. Local police can help determine the appropriate jurisdiction if it’s not clear.

The timing of the sexual assault is important in collecting evidence. If a person was just raped, we’d be very anxious to encourage the person to have a sexual assault exam done ASAP. If they are reporting something that happened more than three days prior (it’s 72 hr for us)—it’s not as pressing that an exam should be done immediately but plans can be made with the patient and family for follow-up exam and care.

Larger police departments typically have victim advocates that can help families through processes like this, but it is up to them to call that person in. Contrast this with a more rural hospital that may “hotline” the concern for abuse to the state, call the police, and depend on state social workers to determine the course of action.

Pink:

Are patients who attempt suicide always sent to a mental health facility for treatment? I know patients speak with a crisis counselor, but what if the attempt wasn’t caused by being under the influence of drugs, or a mental illness, but due to a desperate situation (domestic violence)?

Jordyn:

The most important determination about whether or not someone will receive psychiatric care is whether or not they are a current danger to themselves (and/or others) and how likely are they to act on it. This is determined by a mental health professional and not the medical staff. The reason for the attempt doesn’t necessarily differentiate potential lethality—it’s what the patient is thinking about in their mind and how at risk they are to act on it.

I think you’re trying to make a distinction that a desperate situation caused by domestic violence leading to a person’s suicide attempt would be seen as less lethal and it wouldn’t. If a person is trying to kill themselves because their home situation is driving them to do that—that is very significant and taken as seriously as someone who swallows pills, or slits their writs, or is having a psychiatric break. Someone attempting suicide due to domestic violence will likely have other co-existing mental health issues like anxiety and depression.

This is a very serious topic and definitely worthy of fiction to help foster discussion of suicide. Good luck with this novel.

Author Question: Treatment of Teen Suicide Victim (1/2)

Pink Asks:

Hi there! I’m so glad I’ve found your site and thanks for taking the time to read this. Ok, here goes.

I’m writing about a fifteen-year-old boy who is being abused physically and sexually by his father. One day at school, he tries to commit suicide by slitting his wrists. He becomes scared by the amount of blood, so he leaves the restroom to try to find help. He is found by his teacher and passes out. Now, I know with any kind of suicide attempt, the police are always contacted, and given the all clear for the paramedics.

Jordyn: I think it would depend on the city, county, school district (and whether or not there was a school resource officer) as to the level of police involvement if he just really needs medical attention. I would advise that if this is written about a real place you ensure they have co police response because a paramedic team would be able to handle this call.

Pink: What will the ED staff do to stabilize a patient who has slit their wrists? Is surgery necessary if the wound is pretty deep?

Jordyn: We always look at airway, breathing, and circulation first. If the patient is talking to us then we can quickly check off the first two as at least functional for the time being. As far as circulation the priority is to stop all active bleeding first by direct pressure. Also, does the patient exhibit any vital sign measurements that show he’s suffering from blood loss—which in this case could be increased heart rate, low blood pressure, and also low oxygen levels.

After that, the medical priority for this patient is to further control the bleeding and determine how much blood he’s already lost. Direct pressure is the method used to control the bleeding. Blood work would be done to look at his blood counts to see if he needs any blood replacement. Next would be to look at if he damaged any arteries, tendons, ligaments or nerves during the attempt. Generally, an exam of the function of the fingers can reveal if there is a concern there. For instance, do his fingers have full range of motion? Do any fingers have areas of numbness? Arterial bleeding is very distinct so it’s usually obvious if an artery has been severed. If he has damaged anything that would limit the function of his hand then he would need follow-up evaluation by a hand surgeon for surgery. If there is no damage to the structures as listed, there is a possibility the wound could be closed in the ER as a simple laceration repair.

Pink: Upon discharge, what will the patient be given to take home for treatment of their wound (the slit wrist)?

Jordyn: If the patient gets a simple laceration repair (merely closing the skin even if it takes a lot of stitches) then pain could be managed at home with over-the-counter pain relievers like Tylenol or ibuprofen. If the patient requires surgery, a short course of a narcotic may be given for pain control,    but we also have to look at other factors to determine if this would be wise for the patient (are they a current drug addict or is there continued concern for suicide attempt). If the patient has surgery, then it is up to the surgeon to determine the patient’s home pain relief.

Pink: If a nurse or doctor notices any bruises on the patient’s body, can they examine an unconscious patient?

Jordyn: Yes, an unconscious patient’s skin can be externally examined. In fact, it is often protocol to do so because we are looking for clues as to why the person is unconscious.

Well continue this discussion next post.

Author Question: Tawse Hand Injuries

Anonymous Asks:

I’m really glad I found your blog! I don’t know whether this is the sort of question you’ll answer on the blog, since it’s “injury to order”, but I very much hope so as I try to be scrupulous about my research and want to get this right.

I have a male character in his mid-30s. He’s right-handed, and his left hand is permanently damaged. It can be either a birth defect or something that occurred when he was young (before the age of ten). I’m completely open to what the injury is— I would like him to have at least limited use of his hand, and it would be a bonus to have a childhood surgery and/or to have him use a splint or brace in adulthood (even only occasionally), but none of this is required.
However, what’s fixed is that he believes the injury was caused by parental abuse— specifically, being whipped across the palm with a leather strap known as a tawse.
Because he’s mentally conflating his actual injury with the abuse, those two things don’t have to match up. It might even be better if someone in his adult life said “could being hit with a strap really cause that damage?”, but I do want to know exactly what the issue is so I can depict it accurately.

Many thanks for anything you can suggest!

Jordyn Says:

Thanks for sending me your question.

I love “injuries to order”. Sometimes it’s easier to fit an injury into what the writer wants than framing the writing to a particular injury the author wants to write about.

I’ve never heard of a tawse and its use in corporal punishment. For readers, a tawse is a piece of leather with split end. You can find some representative images by following here. Just reading about this device being used– it would easily cause soft tissue damage– bruising (even though they were seemingly designed to not bruise), swelling, and if used with enough force– fractures. I think continued, persistent use could potentially even cause nerve damage. I looked specifically for articles dealing with “tawse hand injuries” and really didn’t have much luck.

The reason I list these potential injuries is so that you can “pick your own” injury within these guidelines. I’m including a couple of links to websites that list several congenital malformations of the hand. Read through them and see if any connect with you and the goals of your story.

http://emedicine.medscape.com/article/1285233

http://www.hopkinsmedicine.org/healthlibrary/conditions/plastic_surgery/congenital_hand_deformities_85,P01120

https://my.clevelandclinic.org/health/articles/congenital-hand

Hope this helps and best of luck with your story.

Author Question: Scythe Wound to the Chest (1/2)

Sue Asks:

The year is 2006 and a seventeen-year-old male gets stabbed through the right side of his chest all the way through to the back, but the blade (a hand scythe) that could potentially stop him from bleeding out gets removed. Naturally, he starts bleeding out.

I already know a lot about what goes into stabilizing him: Checking the ABCs, IVs for blood and fluid replacement, intubation (an endotracheal tube), but my question is, what is the exact treatment for this type of injury in a surgical theatre? What are the indications that he may need a thoracotomy or a lobectomy? Or is it as simple as a chest tube to treat the hemopneumothorax, connecting him to a ventilator, and then suturing the lacerations in his lung?

Jordyn Says:

Thanks so much for sending me your question, Sue. Very intriguing scenario you have here!

Let’s first clarify some of these medical terms for readers. A thoracotomy is a surgery that involves removing the lung. Lobectomy can be removal of any lobe of organs such as your thyroid, liver, or lung. In this case, you’re referring to the lung. A hemopneumothorax is a collection of blood and air inside the chest wall that is usually relieved by placement of a chest tube. Pneumothorax is an abnormal collection of air in the chest between the lung and the chest wall– also typically relieved by placement of a chest tube (though some very small ones may just be watched).

I asked a physician friend (thanks, Liz!) her thoughts on your questions.

She says the following:

Since the patient is unstable, he needs a thoracotomy by default. Other indications for surgery would be blood draining from the chest tube at greater than 100 milliliters per hour. The lungs cannot be sutured. Generally, bleeding vessels are either tied off or cauterized and the bronchi (the larger breathing tubes) are repaired. If the lobe is severely damaged then it does get removed.

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.

Questions:
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.

Care of the Burn Patient

Linda Asks:

In my middle grade novel my main character’s dad was a fireman in NY.
He was present during the collapse of the World Trade Center buildings.
He was burned severely and is in the hospital – near death.

My main character remembers his last conversation with his Dad in the hospital right before he dies.

The dad is hooked up to all kinds of beeping machines and is wrapped in white gauze.
After he talks to his son for the final time, he pushes a button for more morphine.

Questions:

Do they still wrap burn patients in gauze?
Is morphine used on severely burned people?

Jordyn Says:

From the point of view of your character– yes, burns are wrapped in gauze. They are specialized dressings, but a character aged 10-13 could perceive it as gauze only.

Yes, morphine is still used for pain.

My only concern is this character having a conversation with his dad. You don’t describe the nature of how he was burned, but a severely burned patient, particularly one close to death, is likely on a breathing machine and, therefore, unable to speak to his son.

You could change the scene to be that he’s so sick that they are getting ready to intubate the character’s father, and the medical team gives them a few moments to talk before they put the father on the breathing machine. He could still die quickly after from his injuries.