This Is US: Jack’s Needless Death

This television episode caused more people to reach out to me over any other. This Is Us has been building up to Jack’s death for eighteen months. It needed to be big. It needed to be dramatic. Can you tell I’ve been watching the show? It was really none of those and medically— well, just weird to be honest.

If you haven’t watched the episode then don’t read this post because it will reveal his cause of death . . . like right now.

Jack’s ultimate demise? A heart attack called the widow maker caused by the stress of the fire.

Jack is in intense smoke and heat for several minutes. He emerges and is first checked by EMS. He is being given oxygen and a dressing to his arm for “2nd degree burns”. The EMS person says she can’t treat the burn and he is seemingly refusing transport, but she does encourage him to be seen. Also, giving oxygen is correct, but it is not the right type of mask. A note on burns. Burns will evolve over the next several days so you don’t really know how severe a burn will be for a while.

Jack does eventually go to the hospital to get his burns checked. The doctor is initially giving him instructions on burn care.  The doctor says, “I’d like your heart rate to come down.” and glances at the monitor— which doesn’t have any readings on it. No waveforms. No numbers. He then says, “There’s soot in your airway so we’ll have to run some tests. The swelling is minor.”

That’s about it. The doctor tells Jack he basically dodged a bullet and seems none too concerned about his potential airway damage.

Just as I mentioned above, airway burns from smoke inhalation are similar to skin burns in that they evolve over time. Smoke inhalation and the potential for upper airway swelling is taken very seriously. There is a nice overview here. At the very least, there should be discussion of admitting Jack to the hospital. As quoted from the article, “Studies have shown that initial evaluation is not a good predictor of the airway obstruction that may ensue later secondary to rapidly progressing edema.” If there is concern about significant injury to the airway then the patient is electively intubated until the airway injury heals. It’s VERY difficult to intubate someone with a lot of airway swelling.

Shortly after this consultation, Rebecca decides to make a phone call and get a candy bar from the vending machine. In that, perhaps under two-three minutes passage of time, Jack codes and dies. Even though she is just outside the ER nurses station, she never hears a code being called. Doesn’t see the commotion.

The doctor approaches her and says, “One of complications of smoke inhalation is that it puts a terrible stress on the lungs and therefore the heart. Your husband went into cardiac arrest. It was catastrophic and I’m afraid we lost him . . . Mrs. Pearson, your husband has died.”

After a few exchanges she goes to Jack’s room where there is a spotlight shining on his chest with a cursory ambu bag at the head of his bead . . . but no other equipment. I’m telling you in two minutes, a code has barely just begun and is never called so hastily . . . like ever. Later, explaining the event to Miguel, Rebecca says he had a widow maker’s heart attack.

The widow maker is a real term for a heart attack. It generally refers to occlusion of the left main coronary artery that feeds the left side of the heart. It is the same heart attack celebrity trainer Bob Harper had and survived. The reason the widow maker can be so devastating is that the left ventricle is the largest, strongest pumping chamber. If it dies . . . well, you’re hosed.

There would be no realistic way the doctors would know it was specifically this kind of heart attack as shown in the episode without an autopsy. Presumably, Jack went into one of the lethal heart rhythms, v-tach or v-fib, at the time of his code. In the time frame given on the show, the medical team would have barely started CPR and given the first line treatment which is electricity. A 12-lead ECG can be a strong diagnostic tool for this type of heart attack, but they never did one. Had they done that early on, they probably would have seen the changes.

Also, he would likely have some signs and symptoms. Chest pain. Nausea. Left arm pain. Sweating. Demonstrating these might make the scenario seem more believable. Having Rebecca witness the code would have been more dramatic.

Also, it would make more sense that he would suffer this cardiac event while he is actually under duress— such as during the rescue of the children and the dog.

The only way to truly know that this is the type of heart attack Jack suffered as presented in the show would be to conduct an autopsy.

This Is Us— thanks for killing off a beloved character in a totally lame way— at least from a medical standpoint.

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.

Authors Question: Treatment of Burns in Children

I got this question in my blog comments and thought I would also provide the answer here.

Latedra asks:

How would they treat burns in children? I imagine as they grow the burn scar would shrink right? My heroin received a burn as a child and I write it like she still has this big burn that is a part of her life. Is that possible? Maybe I’m over thinking it. I’m just now taking her burn seriously.

Jordyn Says

Hi Latedra!

Thanks for leaving a question. It depends on what kind of burn you’re talking about. Burns that need a higher level of care would be those that would inhibit function. We get concerned about burns that cover a large portion of the feet, hands, face or genitalia (including breasts). The larger the burn area or the deeper the burn– the more it may require skin grafting to heal.

Let’s take a simple burn. Red with some blisters but covers maybe a palm size of the thigh. We would wash it with mild soap and water. Apply a copious layer of triple antibiotic ointment. Then we put something over top that won’t stick to it– we use a Vaseline impregnated gauze called Adaptic– then it won’t stick as the dressing comes off. More extensive burns would be referred to a burn center.

Scars generally stay the same size. They don’t grow as the child grows so it may appear that they are shrinking because the child is bigger but really they are the same size.

Hope this helps!

Author Question: Burn and Crush Injuries

Amitha Knight returns to give her medical insight in this reader question.

Welcome back, Amitha!

Q:

I am writing a novel and understand that you give medical information online which I would be really grateful for.  The two main characters in my current book are hurled out of a burning bus which has smashed into a building after going out of control.  They land on concrete.  One of those characters has been in the smoke-filled bus about 15 minutes.

I would appreciate it if you could tell me the following;
1) What type of injuries would they have received, burns, fractures, concussion etc and what procedures are followed by medics who turn up at such accidents. What equipment would they use? 
2) I want one of the characters to be in intensive care for about 3 days and then be allowed onto the ward, what type of follow up treatment could she receive, what machines would she be attached to etc.
3)I want the second character to be unconscious for about three weeks and then wake up with temporary amnesia.  Is this plausible and what treatment would he receive while he’s
unconscious …. what machinery would he be attached to.
  
Thank you in advance for your help!!!
M.G.
Amitha says:
I will help you the best that I can. My specialty was pediatrics and not intensive care or emergency medicine, so keep that in mind.
1) What type of injuries would they have received, burns, fractures, concussion etc and what procedures are followed by medics who turn up at such accidents.  What equipment would they use. 
The types of injuries sustained could range from anything from a few bruises to severe cranial fractures and multiple broken bones. When medics show up, they will place a neck collar in case there are spinal injuries and basically follow the “ABC” rules for emergency medicine. (some links to read more about this: http://en.wikipedia.org/wiki/ABC_(medicine)) This means if the patient isn’t breathing, they’ll make sure there is no obstruction, then they will intubate the patient as necessary. They will also start IV fluids and take them immediately to the hospital. What they would do *exactly* would depend on the extent and severity of the injuries. For fiction purposes, I would think hard before going into too much medical detail.
2) I want one of the characters to be in intensive care for about 3 days and then be allowed onto the ward, what type of follow up treatment could she receive, what machines would she be attached to etc.
This depends on the type an extent of the injuries. if there was a perforation to the lung, they may have a chest tube. They probably can’t get up and thus would need a foley catheter for urine. they would definitely have some kind of IV fluids attached. This website has some good information about smoke inhalation injuries: http://www.emedicinehealth.com/smoke_inhalation/article_em.htm
3)I want the second character to be unconscious for about three weeks and then wake up with temporary amnesia.  Is this plausible and what treatment would he receive while he’s
unconscious …. what machinery would  he be attached to.
This person who is unconscious might be intubated for at least some of that time, which means they would have a ventilator machine in the room in addition to everything I said in #2. As far as amnesia, there is a blog post on Jordyn Redwood’s blog that may help with this: http://jordynredwood.blogspot.com/2011/08/remember-me-use-of-amnesia-in-fiction.html 
Her website is a great place in general for information like this!
I hope this helps.

*************************************************************************

 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/. 

Burn Injuries

One thing that has changed recently is how medical professionals talk about burns or burn terminology.

Burns used to be classified as follows:

  • First Degree: Skin is pink, but no fluid-filled blisters.
  • Second Degree: Skin had fluid-filled blisters of varying sizes.
  • Third Degree: Multiple layers of the skin are involved. There may be charring of the wound. The picture would denote, at the very least, a third degree burn.
  • Fourth Degree: Charring and burning that involves muscle and bone.

Now, we refer to burns as partial thickness or full thickness. Partial thickness would include first and second degree burns. Full thickness would be considered third and fourth degree burns.

Here is a good resource that discusses the difference. 

Treatment of burns depends on location, size and depth. 

Very simply, localized burns are usually treated by cleaning, leaving blisters intact, slathering them with triple antibiotic ointment and then dressing them.

Not all burns need to be followed up by a specialist at a burn clinic but burns that involve the hands or feet (because of functionality), the face (for cosmetic reasons or if they could hinder the senses), or genitalia (including nipples) are usually referred for further care.

Also, burn injuries need to be estimated on what percentage of the skin is involved. Based on the percentage– a patient can be referred for follow-up or flat out admitted if the burn injury is severe. You may have heard this referenced to as the “Rule of Nines”. Pediatric patients have different ratios so keep that in mind.

Here are a few links that help estimate burn percentage based on skin area:
  
 http://www.medstudentlc.com/page.php?id=85
  
http://www.emedicinehealth.com/burn_percentage_in_adults_rule_of_nines/article_em.htm:

http://www.ncbi.nlm.nih.gov/books/NBK27240/

Most patients with significant burn injuries have significant pain. We do tend to give something that has a narcotic to help their pain. Also, based on the percentage of burned skin, some patients will also need fluid resuscitation, ICU admission, intubation— etc, to manage the injury.

So, if you’re writing about burns and your POV character is a medical professional, keep these things in mind so your character can be treated the right way with the medical professional using the right language.